Pain Control Advances Leave Troublesome Legacy

The beginning of the new millennium brought unprecedented focus to the issue of pain control.

In 1997, the American Academy of Pain Medicine and the American Pain Society teamed up to promulgate guidelines on the use of opioids for the treatment of chronic pain; the American Society of Anesthesiologists introduced their guidelines for chronic pain management that year as well. In late 2000, Congress passed and President Clinton signed into law a measure that declared the period that began January 1, 2001, as the Decade of Pain Control and Research. Also in January 2001, the Joint Commission presented pain-management standards for ambulatory care facilities, behavioral health care organizations, hospitals, and other medical care settings. In 2004, the Federation of State Medical Boards published its model policy for the use of controlled substances for pain treatment.

Advocates of pain control hailed the results of these events, saying they've led to heightened awareness, improved treatment, and more funding for pain-control efforts and research. But as the "Decade" ended, it left behind a less desirable legacy of unintended consequences: that of a spectacular rise in the diversion and abuse of opioid pain-control medications.

Nowhere has that been more evident than in West Virginia, where the nation's most substantial increase in drug overdose mortality rates—a 550 percent jump—occurred from 1999 to 2004. In 2006, 295 West Virginia residents suffered unintentional overdose with prescription pharmaceuticals, the majority of which were due to nonmedical use and diversion of opioid analgesics, according to a report in the December 10, 2008, Journal of the American Medical Association (JAMA).

And West Virginia is by no means alone. Statistics from the Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Administration are equally alarming:

• Drug treatment admissions related to pharmaceutical opioid use from 1998 to 2008 increased five-fold.

• Emergency department visits related to pharmaceutical opioid use increased from 144,644 in 2004 to 305,885 in 2008.

• Unintentional opioid-related overdose deaths increased from 3,000 in 1999 to 12,000 in 2007.

• In 2007 the number of deaths involving opioid analgesics was 1.93 times the number involving cocaine and 5.38 times the number involving heroin.

• Opioid overdose is now the second-leading cause of unintentional death in the United States, second only to motor-vehicle crashes, prompting the CDC to label pharmaceutical opioid overdose a national epidemic.

In the April 6 JAMA, Amy Bohnert, Ph.D., of the Department of Veterans Affairs Health Services Research and Development Center of Excellence, and the Serious Mental Illness Treatment Resource and Evaluation Center in Ann Arbor, Mich., and colleagues described their efforts to see if there is an association between the maximum prescribed daily opioid dose and dosing schedule ("as needed," regularly scheduled, or both) and the risk of opioid overdose death. "Among patients receiving opioid prescriptions for pain, higher opioid doses—those equivalent to 50 mg/day or more of morphine—were associated with increased risk of opioid overdose death," the researchers found.

Physicians Not Barriers to Abuse

Indeed, physicians appear to be a failed first line of defense against this pharmacoepidemic. In the online February 24 Journal of General Internal Medicine, Joanna Starrels, M.D., M.S., of the Division of General Internal Medicine at Albert Einstein College of Medicine and Monteflore Medical Center, and colleagues found that primary care physicians' adoption of opioid risk-reduction strategies is limited, even among patients at increased risk of misuse.

"Well-meaning, thoughtful primary care physicians face many obstacles to implementing monitoring strategies for these patients," said Starrels in an interview with Psychiatric News. "Primary care physicians lack the tools that could help to make this easier, such as written agreements or policies that can help them provide routine, structured care." Starrels and her colleagues also said in their report that lack of time with each patient plays a part: "This lack of face-to-face encounters represents missed opportunities for physicians to examine responses to treatment, propose alternative treatments when the response is inadequate, detect side effects, and assess for misuse."

Nora Volkow, M.D., director of the National Institute on Drug Abuse, and A. Thomas McLellan, Ph.D., director of the Center for Substance Abuse Solutions of the University of Pennsylvania School of Medicine, and colleagues further characterized the problem in a research letter in the April 6 JAMA. Overall, they pointed out, the main prescribers of opioid analgesics were primary care physicians, followed by internists, dentists, and orthopedic surgeons. For patients aged 10 to 19, dentists were the main prescribers followed by primary care and emergency medicine physicians.

Physician Education Needs Bolstering

Expressing her concern, Volkow told Psychiatric News, "Education for health professionals about pain management has not kept pace; thus physicians may not be properly trained on best prescribing practices for opioids, their potential for abuse and addiction, and other adverse consequences. To balance benefits while mitigating risk is a key challenge to physicians and other prescribers and calls for targeted education and training to improve the screening and management of pain and the use of opioid medications" (see Physicians Key to Strategy for Reducing Opioid Abuse).

NIDA has developed information for practicing physicians and physicians in training. "We hope this information will result, for physicians, in their greater engagement in drug-abuse screening and help guide thoughtful and informed prescribing practices without depriving patients of needed pain relief," said Volkow.

NIDA's information for physicians about prescription opioid medication is posted at <www.drugabuse.gov/coe>.