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19 Articles in Volume 20, Issue #2
20/20 with Peter Staats, MD: The Future of Pain Medicine
Ask the APP: How useful and practical are pain assessment tools?
Ask the PharmD: What are the recommendations for preventing and treating pediatric migraine?
Axial Spondyloarthritis: Updated Medication and Imaging Recommendations
CGRP Monoclonal Antibodies for Chronic Migraine Prevention: Evaluation of Adverse Effects Using A Checklist
Chronic Low Back Pain: Can We Find a Treatment Consensus?
Correspondence: Are ESIs Still Worth It? Benzocaine for Orofacial Pain.
Could Pulsed RF Provide Lasting Chronic Headache Relief in Refractory Patients?
Diagnosis Is Everything: Low Back Pain As a Symptom of an Underlying Condition or Conditions
Editorial: From Just Say No, to Say Now and Say Know
Erenumab and Onabotulinumtoxin A Show Additive Effect in Refractory Chronic Migraine
Experts Roundtable: Finding a Bottom Line in Back Pain Care
Inside the Potential of RNAi to Target the Etiology of hATTR Neuropathy
Muscle Dysfunction in Head and Neck: Pain Causes, Osteopathic Options
New Migraine Medications: Oral Gepants, Ditan Tablet, and More
Root Cause of Sacroiliac Joint Dysfunction: Four-Step Exercise Protocol
The Emotional Impact of Chronic Low Back Pain
The Rise in Tianeptine Abuse: Our Next Kratom Problem?
The Sensory Component of Pain: Modifying Its Emotional and Cognitive Meaning

Editorial: From Just Say No, to Say Now and Say Know

Substances of abuse need to be part of clinical training and continuing education.
Pages 9-10

Perhaps the popular British band Coldplay says it best, “Am I a part of the cure? Or am I part of the disease?” Recommendations, advice, guidelines, and opinions come and go, especially in a digital age. However, as healthcare professionals, we must always remember that our recommendations can improve, save, change, or, sadly, hurt another life. Could there be a more impactful, yet controversial, topic than “substances of abuse” to deploy this knowledge?

First, it is of great importance to realize that approximately 2 million Americans struggle with opioid use disorder (formerly termed and more commonly known as opioid addiction), let alone issues with other substances of abuse.1 Addiction, misuse, and drug diversion have shown time and time again to drive an increase in crime, ranging from burglary to murder. The CDC estimates that the national “economic burden” of prescription opioid misuse totals $78.5 billion annually.2 Injection-based drug abuse greatly contributes to the spread of infectious diseases as well, including HIV and hepatitis C, adding to the indirect death toll.3

DEA’s 2018 report illustrated that approximately 80% of the time, people are misusing prescription medications due to pain, tension, emotions, and sleep concerns, rather than the stereotypical desire to “get high." (Image: iSTock)


Seventy-five percent of people who began abusing opioids in the 2000s stated with a prescription opioid,4 although there were no specifics provided as to the actual respective acquisition of those prescription opioids being legitimate or illicit. This point raises the question of where else people were obtaining their prescription opioids other than from a healthcare provider. Ironically, data from the 2017 DEA National Drug Threat Assessment shows a rather non-stereotypical answer to that very question: approximately two-thirds of people obtained their prescription opioids from a friend, relative, or drug dealer either for free or from illicit purchase.A further point to ponder lies within the DEA’s 2018 report, which illustrated that approximately 80% of the time, people are misusing prescription medications due to pain, tension, emotions, and sleep concerns, rather than the stereotypical desire to “get high.”6

On top of that, as of 2017, one person dies every 12 minutes from an opioid overdose in our country, yet one person dies every 7 minutes from any type of drug overdose in our country,6 which leaves many, many substances other than opioids at the forefront of overdose deaths. In fact, within the same year (2017), there was a 37% increase in overdose deaths involving psychostimulants such as methamphetamine,yet, little professional healthcare education is devoted to such substances. A long-standing death toll rival, ethyl alcohol, a legal substance across the globe, is not even accounted for in those staggering statistics, yet easily surmounts those numbers with an estimated 88,000 alcohol-related deaths annually, compared to the aforementioned 70,000 drug overdose deaths annually of recent years.8

So regardless of your profession or opinions, let’s all acknowledge that the cheese [heroin] has moved, pun intended, as we are all certainly well aware that cheese heroin is black tar heroin adulterated with diphenhydramine. Is there other valuable information regarding substances of abuse that we are lacking as healthcare professionals? Many times, as in the case of cocaine, ketamine, and methamphetamine, we need not look further than readily available legal prescription medications to understand the substances of abuse utilized across the globe. However, many other substances continue to prevail with no link to legal prescription medications whatsoever (read about tianeptine abuse and gabapentinoid abuse). This is where we as healthcare professionals enter the “danger zone.”

At some point, everyone ponders whether the “War on Drugs” will ever end. Didn’t the “Just Say No” campaign of the last millennium eradicate addiction, drug overdoses, and drug diversion? When should practicing clinicians expand their respective knowledge base on substances of abuse? In my opinion: Just Say NOW.

Ethyl alcohol and cannabis may change controlled substances classes again in the future but their respective pharmacology will not, and if we as healthcare professionals want to truly raise the bar on providing impactful patient care, we need to venture into the conversational area of substances of abuse. I recall one of the thousands of times I have asked a patient if any substances of abuse were being utilized, only to receive the response, “Sonny, I smoke up every day that ends in ‘y’!” His tone explained everything; he had never been asked the question before and, yet, was provided a multitude of pharmacotherapy for decades. We then proceeded to discuss drug-substance interactions and possible side effects.

To universally ask these questions and impactfully provide responses, we as healthcare professionals need to equip ourselves with the most updated, comprehensive, and unbiased information on substances of abuse possible. Professional conferences such as AAPM and PAINWeek and continuing education offer one such avenue. In addition, one can venture into online education with the folks at FreeCE (www.freece.com) who have collaborated with the author to develop a 17-hour certificate training titled “Substances of Abuse Specialty Pharmacist.” Other programs are available as well, including from PBI Education (https://pbieducation.com/courses/). This brings me back to my opening statement, are YOU part of the cure or part of the disease? Perhaps it’s time for the “Just Say Now” and “Just Say Know” movement. 

Last updated on: April 2, 2020
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Editorial: Why Haven’t There Been More Breakthrough Analgesics?
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