A Letter Released to Medical Practitioners on
May 2, 2010

Opioids for Chronic Pain
Should We or Shouldn't We

Addiction and abuse of prescription drugs is on the rise in the US.¹ Some have used this fact to argue that opioids should not be prescribed for chronic pain.² On the other hand, undertreatment of chronic pain has been estimated to be as high as 50%.³ Undertreatment of chronic pain levies its own personal and societal costs including lost workdays, depression, anxiety, sleep disturbances, and relationship challenges. The Federation of State Medical Boards has made a clear statement that undertreatment of pain is “inappropriate”⁴ while the DEA has stated that physicians have a “responsibility” for preventing drugs from becoming a source of harm or abuse.⁵ How do physicians manage the balancing act between appropriate treatment of chronic pain and avoiding the potential for doing harm?

The answer to that question lies in the prescribing guidelines of the Federation of State Medical Boards, of the American Pain Society, and of the American Academy of Pain Medicine. Prescribing guidelines state that, before beginning any chronic pain patient on an opioid therapy, the patient should receive an assessment for risk of abuse and addiction. We now know of several risk factors that are predictive of opioid abuse. Family history is important, because genetics may account for 40% to 60% of the risk for developing addiction.⁶ The experience of cravings, cigarette usage, multiple opiate prescriptions, and certain psychological conditions, for instance, are each predictive of misuse to varying degrees.⁷ If patients are carefully assessed by their physician for risks, carefully managed in a plan of care that includes ongoing supervision, and prescribed a multi-factorial pain management plan, proper pain management may be achieved while minimizing the risk of addiction.^8,9 Prescribing opioids without performing an initial assessment to stratify the risk of addiction not only puts patients at extra risk but also contradicts practice guidelines while putting the physician at regulatory risk.

When you have patients requiring a carefully administrated pain management plan, please tell them about Dr. Neal Taub and The Center for Musculoskeletal and Pain Medicine. We manage complex pain cases, and this may include opioid therapy for carefully selected, appropriate cases. The Center for Musculoskeletal and Pain Medicine practices a 10 point opioid management program that includes thorough diagnostics, addiction risk assessment, treatment contracts, periodic review of the NC and SC prescription databases to check for doctor shopping, periodic drug screening, ongoing reassessment, and other measures meant to protect your patients from addiction.

References

1. Reuters Health. “Opiates a Leading Cause of Increased Mortality Rates Due to Drug Overdose.” Pharmacoepidemiol Drug Saf; July 25, 2006.
2. Collins T. Opioids for Noncancer Pain a Subject of Hot Debate: An Expert Interview with Pain Specialist Ajay Wasan, MD, MSc. Medscape Medical News. February 17, 2010.
3. Shurman J, Sack J, Shurman G, et al. Share the risk model. Pract Pain Manage. 2006; 6(5): 10-18.
4. Federation of State Medical Boards of the United States (FSMB). May 2004. Model policy for the use of controlled substances for the treatment of pain. Self published by the FSMB. Available at FSMB.org.
5. Drug Enforcement Agency (2001). Promoting pain relief and preventing abuse of pain medications: A critical balancing act. Joint Statement of DEA and 21 health organizations. Self published.  Available at www.ampainsoc.org/advocacy/promoting.htm.
6. Sartor C, Grant J, Bucholz K. Common Genetic Contributions to Alcohol and Cannabis Use and Dependence Symptomatology. Alcoholism: Clinical and Experimental Research. 2010; 34 (3): 545-554.
7. Datz G. Psychological assessment for the prevention of misuse in opioid therapy. The Pain Practitioner. 2009; 19 (3): 25-34.
8. Jan S. Landscape of opioid dependence. J Manag Care Pharm. 2010; 16(1-b): S4-S8.
9. Webster L, Webster R. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the opioid risk tool. Pain Medicine. 2005; 6 (6): 432-42.