Book Review: A Useful Guide for New Pain Practitioners
A review of the 2018 Oxford University Press Book: Prescription Drug Diversion and Pain: History, Policy, Treatment, edited by John F. Peppin, Kelly K. Dineen, Adam J. Ruggles, and John J. Coleman.
The opioid crisis has been tragic for both patients and clinicians, but understanding the history leading up to it and knowing how to mitigate risk going forward may rebalance the pendulum. For today’s clinicians, it is not uncommon to be caught in a conflict of mixed messages regarding pain management and the use of prescription opioids for chronic pain. Over the past several years, there has been a drastic shift in the literature regarding the safety and efficacy of long-term opioid therapy for chronic pain. John F. Peppin, DO, FACP, and colleagues developed the book Prescription Drug Diversion and Pain: History, Policy, Treatment in hopes of informing healthcare professionals as well as other audiences about the fundamental aspects of pain management and substance abuse in an era of changing perceptions regarding opioids. Dr. Peppin is an established pain management physician and scholar who brings a wealth of knowledge and expertise to the field of medicine. As stated in the Preface, the book explores the “many facets of modern pain management,” but “also includes the dark side of drug diversion and abuse.”
Various disciplines are apparent in the contribution of this book, ranging from physicians, pharmacists, nurse practitioners, and clinical psychologists, thereby offering diverse clinical experiences and perspectives.
Content Overview
In Prescription Drug Diversion and Pain: History, Policy, Treatment, Peppin and colleagues provide readers with detailed yet succinct descriptions of myriad issues within the realm of pain management and substance abuse. They describe the landscape of pain and substance abuse leading up to the US opioid crisis while providing strategies on how to appropriately address it. Informative chapters begin with a brief history of opiates, exploring the legal and regulatory establishment pertaining to prescription opioids, and then delve into government implementation of Prescription Drug Monitoring Programs (PDMP), as well as the role of pharmacy benefit managers in addressing prescription opioid abuse.
The latter half of the book includes approaches for evaluating and managing chronic pain, including: approaches to interdisciplinary pain management; the role of sedative-hypnotics and stimulants; strategies for appropriate urine drug monitoring (UDM); the significance of a patient’s mental status; and pain in special patient populations, such as those with comorbid substance use disorder.
Among these informative chapters, perhaps best aimed at new practitioners, clinicians will find several topics which may be applicable to daily practice. Liability is always a concern, for instance, so understanding the laws and regulations, as described in the book, may help lessen those fears. For instance, Chapter 2 addresses aspects of the law that prescribers may find reassuring—that is, opioids may be safely and appropriately prescribed “for a legitimate medical purpose” and that any conviction must be treated fairly by due process while cautioning against “willful blindness” and mens rea.
One part of the book that may have benefitted from further elaboration was on prescriptive authority, which inopportunely left out any mention of pharmacists, who share this same privilege (in certain states). Clinical Pharmacy Specialists with prescriptive authority may, in fact, increase patient access to care when assisting physicians with medication management as well as perform risk-mitigation strategies that range from UDM to reviewing PDMP reports.
Chapter 5 on evaluating the chronic pain patient provides a solid overview of assessment techniques and therapeutic modalities using a “wholistic” approach and individualized care. Since many non-opioid medications used in pain management may be abused or misused, Chapter 6 is devoted to abuse potential, including an overview of various medications beyond prescription opioids that may potentiate risk.
A section in Chapter 8 on medication-assisted therapy (MAT) provides a brief summary of buprenorphine and methadone with regard to their role in therapy and their pharmacokinetic and pharmacodynamics effects. Unfortunately, a stigma remains attached to the use of methadone despite its long history of treating opioid use disorder (OUD). If the authors had elaborated on methadone’s pharmacotherapeutic role in chronic neuropathic pain, it may have helped to dispel the substance’s negative reputation and further highlight its pharmacology as a viable option to treat pain. A table comparing the differences between buprenorphine and methadone use for MAT versus chronic pain management, including dosing, may have been useful to clinicians—the authors of this book review have, therefore, provided one herein (see Table I).
Commentary
Overall, the book provides insight into uncertain areas of pain management and substance abuse. The primer-type publication is likely to assist clinicians as they address patient-specific pain management needs, oversee safe prescribing, and perform appropriate monitoring and risk-mitigation strategies. Although the book is not a traditional clinical reference guide for review material and could have further detailed certain areas, its intention to provide historical aspects and current understanding of what led to the opioid epidemic is appropriately insightful.
The book may be ideal for new practitioners, policymakers, and regulatory officials seeking further clarification of the myth that continues to cast a shadow over prescription opioids. The book may also enable clinicians to practice with confidence as they address the opioid epidemic head on, every day, one patient at a time.
This review appeared online first in affiliation with the PPM September/October 2019 issue and appeared in print in the November/December 2019 issue.
