Excerpt from the Book Avoiding Opioid Abuse While Managing Pain
Prescription drugs are newsworthy, particularly when they are abused in violation of their intended medical purpose. Conservative radio commentator Rush Limbaugh grabbed many headlines when he admitted his own misuse of the painkilling opium derivatives known as opioids. Limbaugh is only one of many famous abusers of prescription drugs, although he is perhaps the most surprising example, because his proposed solution to the widespread abuse problem before his own arrest was to convict drug abusers and “send them up the river.”2 The nonfamous are similarly afflicted, according to a study from Columbia University in New York, which found that prescription drugs (including opioids, stimulants, and depressants) had attracted 15.1 million admitted abusers by 2003.3 That figure is double the number from only a decade earlier, and it includes more people than the total population of Tokyo. Today, only marijuana, alcohol, and tobacco are more popular than prescription agents as drugs of abuse. Of all prescriptions, opioids attract the most new abusers.4
However, opioids, which are so dangerous in the hands of abusers, are beneficial or even lifesaving for millions of people who otherwise would live with intractable pain. Nearly everyone seeks medical treatment to control pain at some point. Some will be unlucky enough to experience chronic pain that does not respond to treatment; about 70 million people live with chronic pain in America today.5 In a world with few alternatives, opioids remain the best treatment available for many chronic pain conditions and are the first choice of therapy for acute and postoperative pain.
Clinicians who prescribe opioids to treat chronic pain are often caught between their professional obligation to relieve suffering and their desire to avoid contributing to the nonmedical consumption of controlled substances. Many medical practitioners fear becoming a source of medications that can be diverted for sale on the black market. They also dread the possibility of regulatory scrutiny or even prosecution that results from their patients’ misuse of medication.
Thus the medical community is faced with a conundrum: Opioids offer safe, effective treatment for many chronic pain conditions and pose little risk for addiction for most patients who take them to control pain. However, some patients treated with opioids do display behaviors consistent with addiction. The challenge is to curtail the abuse and diversion of prescription opioids while ensuring their availability for patients who benefit from their use. The first step in resolving those seemingly conflicting interests is to acknowledge that they exist. Patients who suffer pain are often treated with prescribed painkilling drugs that can be abused. Because a certain segment of the opioid-treated pain population exhibits an active substance-use disorder, steps should be taken to minimize the very real potential for the abuse of such medications. The obligations to battle pain and addiction are not mutually exclusive, they are mutually inextricable.
This complex dilemma is summarized in the following list of the rights and responsibilities of healthcare professionals who prescribe opioids to treat pain (Box).6 Although the task of safeguarding against substance abuse appears (and is) daunting, patients are not at equal risk for opioid addiction or abuse. The key to managing a patient’s opioid intake lies in screening for abuse potential and carefully monitoring the progress of treatment. Those skills are within the capability of every caring, committed healthcare professional, even given the time constraints of practicing medicine in today’s clinical settings.
Primary care physicians, nurse practitioners, and other first-contact clinicians are uniquely positioned to make a difference at the beginning of medical treatment. Research indicates that a patient with chronic pain is far more likely to seek treatment from a family doctor or other healthcare professional than from a pain management specialist. Likewise, an individual struggling with a substance-use disorder is more often treated by a primary care physician than by a physician certified in addiction medicine. Those realities create an opportunity for first-contact clinicians to maximize the chances for success when patients begin opioid therapy.
“The bottom line is that there will never be enough [pain] specialists to deal with the problem,” said Scott Fishman, MD, during his time as president of the American Academy of Pain Medicine, “so we have to train primary care physicians at the front lines to be able to do this as part of the basic care that we give patients.”7
Treating pain adequately in all patients.The medical obligations of physicians include:
- Screening new patients for potential drug abuse or addiction.
- Monitoring patients’ progress and addressing any harmful effects as they participate in opioid therapy.
Clinicians may receive little support in those endeavors. Medical schools provide scant training in either managing pain or treating addiction; most curricula are focused instead on teaching future doctors to recognize and eradicate disease. In a survey of physicians conducted by the Columbia University National Center on Addiction and Substance Abuse in New York, only 40% of the respondents had received any medical school training to help them identify prescription drug abuse or addiction in patients. Almost half of respondents said that they have difficulty discussing prescription drug abuse with their patients.’ Pain management, which is a subject similarly neglected in many medical school curricula, consisted of only a few hours of instruction for the less than half of physicians who received any training. Even though some recent graduates of medical school indicate that training has improved in recent years, many physicians are still failing to diagnose active substance abuse, and medical students frequently graduate without having taken a single course on the treatment of pain. Furthermore, medical textbooks that address opioid abuse and chronic pain often refer to the topics separately—the complex interplay between substance abuse, mental disease, and chronic pain is rarely grasped or explored. In this book, we acknowledge the danger posed by the misuse of prescription opioids—a danger often downplayed by pain control advocates. At the same time, we affirm the right of all people to be treated for pain. The latter perspective is sometimes ignored by addiction-treatment specialists.
We also assert with vigor that at no time should the guidelines presented here be taken as license to refuse to treat (or to undertreat) the pain of someone with a substance-use disorder. People who have problems managing drug intake experience acute, postsurgical, and chronic pain as often as do any other patients, and they are no less deserving of pain relief. The goal of providing good medical care is to improve the quality and duration of life for every patient. That goal is within reach; it simply requires a high level of professional concern and a strong commitment to monitoring patients’ progress.