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The World Health Organization states that undertreated pain is the number one health problem in America. The number of patients with chronic pain in the U.S. exceeds those with diabetes, heart disease and cancer combined. This data prompted the adoption of pain as the 5th vital sign. Along with checking a patient’s temperature, heart rate, blood pressure and respiratory rate with every assessment, the patient’s pain should also be addressed. This shift in paradigm, to be more proactive and aggressive in treating pain, along with more pain issues in the aging population, has resulted in significant increase in the amount of opioid painkillers that are prescribed. According to IMS health, sales of painkillers reached $8.5 billion last year, as compared to $4.4 billion in 2001.
While trying to address undertreated pain, another health crisis has emerged, that is the abuse of opioid prescription drugs. Opioid painkillers such as Oxycontin, Percocet and Vicodin are some of the most commonly prescribed and abused. Physicians were more liberal in prescribing higher opioid dosages to help treat patients suffering from chronic non-cancer pain (i.e. arthritis, back pain, multiple sclerosis). These chronic pain sufferers were then becoming tolerant to the opioid prescribed, as they needed more and more medication to achieve the same level of pain relief. Prescribers were essentially chasing the pain, without addressing the underlying disease state and not noting if the higher dosage of opioids was improving their patient’s condition/function. Patients become dependent on the high dose opioids, and if it was abruptly discontinued, life threatening withdrawal symptoms may ensue. Dr. Ballantyne from the University of Washington stated, “If doctors understood how hard it is to get patients off of these drugs, they would not prescribe them to begin with”. Many patients develop addictive behavior where they no longer utilize the medication for pain, and start exhibiting drug-seeking behavior.
To combat this growing health crisis of prescription drug abuse, a multitude of approaches need to be taken. Effective legislature is needed to allow law enforcement to shut down “pill mill” physician practices. Manufacturers of these painkillers are developing tamper proof pills, preventing the pills from being crushed and snorted or injected for a quick “high”. Educate the community, patients and prescribers on the appropriate use of opioids. The state of Washington has proposed that all physicians undergo a certification course during the licensing process and that physicians are required to refer patients taking high dosages of opioids, for an evaluation by a pain specialist. Furthermore, more than 40 states have implemented prescription monitoring programs, where prescribers can obtain reports of what controlled prescriptions their patients have received, even though they may have gone to different pharmacies or paid for the medication in cash. New Jersey’s Prescription Monitoring Program can be accessed by any prescriber with a DEA number at www.njxreport.com. One of the shortcomings of these state prescription monitoring programs is they do not communicate across state lines, but national integration is underway.
The epidemic of opioid prescriptions drug abuse has not only harmed the abusers, but can prevent chronic pain sufferers from obtaining the treatment they need. Pseudo addiction occurs in patients when their chronic pain is undertreated and therefore they exhibit addictive behavior. For example, patient may have a hard time finding a new physician to prescribe their high dose opioids once their physician has retired or moved.
Pain management specialists have a whole armamentarium of tools to help treat chronic pain and try to abate this prescription drug abuse epidemic. All patients are required to sign an opioid contract outlining the terms of opioid use (i.e. not obtaining opioid from any other physician, using only one pharmacy to fill the prescriptions, taking medications as prescribed, and undergoing randomized urine drug screens). Urine drug screening has been become a standard in monitoring patients to see if they are taking their medications appropriately and not utilizing additional non-prescribed or illicit substances. With the advent of instant urine drug screening, prescribers are able to see the results immediately, therefore adding another level of confidence in safely prescribing the appropriate medication. Furthermore, pain management specialists can utilize a multitude of interventional techniques to treat the underlying cause of pain, and thereby reducing or eliminating the pain and allowing a reduction or even discontinuation of the opioid painkillers.
In conclusion, the competing health crisis between undertreating pain and prescription drug abuse is a convoluted problem that our health care system is just starting to tackle. The Pain Management specialty is at the forefront of this battle, looking for safer ways to utilize opioids and alternatives to opioid treatment of chronic pain.
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