Experts Confront Rx Painkiller Abuse

Better-Informed Doctors Help Patients Get Better Treatment

Aug. 11, 2004 -- Prescription painkiller use and abuse is a powder-keg issue. Doctors are often afraid to prescribe narcotic painkillers -- afraid of laws, afraid of drug abuse, afraid of addiction. But in a new report, the nation's pain experts provide some answers.

In collaboration with the Drug Enforcement Administration (DEA), these experts address important questions about narcotic pain prescriptions. It's to help doctors safely treat patients with chronic pain -- and to help both doctors and law enforcement officers get a better picture of the potential for abuse.

In a teleconference today, the report's authors shared their views.

"In the U.S. in the past decade, we have witnessed a large increase in prescription of opioid drugs to treat chronic pain -- a change that many pain specialists have welcomed. There's an epidemic of chronic pain, and opioids have been very much underused and stigmatized in the past," says Russell Portenoy, MD, chairman of pain medication and palliative care at New York's Beth Israel Medical Center.

However, the high rates of abuse and diversion of these opioid medications to the illicit drug market is a sizeable problem. "It has been a wake-up call to the medical community," Portenoy says. "We need to recognize that they are potentially abusable and take steps to reduce that risk."

Many doctors lack the information they need about prescribing opioids, which are well recognized as a gold-standard drug in pain control, says Portenoy. Other doctors are reluctant to prescribe these narcotic pain medications -- fearing that they will be accused of overprescribing them. "This leaves countless numbers of people with untreated pain."

Relieving Doctors' Fears

Doctors also have misconceptions about the laws involved. This leads "to unwarranted fear that doctors who treat pain aggressively are somehow singled out for law enforcement actions," says Patricia M. Good who is with the DEA's Office of Diversion Control.

"Our goal is not to eradicate [use of opioid painkillers] -- or even to limit their legitimate use -- but to prevent their illicit use," she explains.

Long-term legitimate use of these painkillers does not lead to addiction, Good says.

In many cases, a patient being treated for chronic pain may have an undiagnosed addictive disorder, she adds. "They may run into trouble when introduced to opioids in the course of medical treatment."

Other times, "drug abusers -- users of street drugs -- turn to safer, more potent, and often more profitable legal drugs and will go to great lengths to acquire these," she says. "They are not abusers because of their medical treatment. They already abuse drugs and misuse the medical system to get their drugs of choice."

Advice to Doctors

In their report, pain experts encouraged doctors to:

Investigate non-opioid pain therapies when appropriate, including acetaminophen, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDS), antidepressants, antiseizure medications, and others.
Recognize their own level of knowledge about pain medications, and refer patients to a pain specialist when necessary.
Understand that not all pain specialists are experienced in opioid therapy, so doctors must take care to identify the right specialist.
Take a careful medical history of the patient, looking for any signs of problematic drug-related behaviors.
Choose dosages and the type of opioid (whether "long-acting" drugs or "short-acting" drugs) to provide consistent pain relief, yet manage "breakthrough" pain.
Adjust medication if there are side effects; breathing problems are a rare side effect that require sensitive use of drug treatment.
Discuss opioid prescriptions with the patient, pharmacist, family members, and other health providers involved in the patient's care -- to allay any anxieties.
Consider having a written agreement between patient and doctor to reflect willingness to talk about the risks of opioid therapy.

"It might sound like good common sense, but doctors must act out of genuine concern for their patient's welfare -- using all the tools at their disposal, including opioid drugs, to control pain," says Good.

They must also have a healthy dose of respect for these painkillers, she adds. "By ensuring that the drugs have a therapeutic rather than a harmful effect, they will automatically do the right thing when confronted with the disease of addiction. They will find treatment for people who suffer from it. They will accept full responsibility for providing the right drugs for the right patients for the right reasons.

"The vast majority of [doctors] are operating with the best of intentions, and they have nothing to fear from the law enforcement community."

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SOURCE: Drug Enforcement Administration.