Editorials

Opioid Abuse and Pain Management



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Am Fam Physician. 2012 Oct 1;86(7):600-602.

  See related article Rational Use of Opioids for Management of Chronic Nonterminal Pain, the AFP By Topic module on chronic pain, and information and resources on pain management and opioid abuse from the AAFP.

Chronic nonmalignant pain affects a significant number of Americans. In addition to physical discomfort, chronic pain leads to work absenteeism, family disruption, and impairment of activities of daily living, resulting in secondary depression, social isolation, and low self-esteem, among other consequences.

Concurrent with the increased need for pain management is a considerable increase in the use of prescription pain relievers for nonmedical purposes. Nonmedical use of prescription pain relievers is now the second most common form of drug abuse (not including alcohol), exceeded only by marijuana use.1 The most recent statistics indicate that in 2007, an estimated 5.2 million individuals older than 12 years reported nonmedical use of prescription pain relievers during the preceding month (2.1 percent of the general population, which is unchanged from 2002).2

In 2008, there were an estimated 36,450 deaths in the United States secondary to a drug overdose, with prescription drugs involved in 20,044 of those deaths and opioid pain relievers identified in 14,800 deaths.3 This makes drug overdose the 11th leading cause of death in the United States.

The Food and Drug Administration Amendments Act of 2007 gave the U.S. Food and Drug Administration the authority to require drug manufacturers to develop risk evaluation and mitigation strategies for products under review.4 Manufacturers were also asked to financially support the development of continuing medical education (CME) from accredited providers to be offered on a voluntary basis to prescribers of these products.4,5

The American Academy of Family Physicians (AAFP) has been helping to organize and develop a proposal for an opioid risk evaluation and mitigation strategy in conjunction with CME development. The AAFP, together with the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, and the Society of Teachers of Family Medicine, has developed a suggested guideline for teaching residents how to care for patients with chronic pain.6

The issue of opioid prescribing remains contentious for many family physicians, including those in training. Studies have indicated that primary care physicians’ attitudes on patients with chronic pain are often negative,7 with such attitudes forming as early as medical school8 and reinforced during residency training.9 The reasons for the development of negative attitudes are complex, and include difficult patient interactions, compliance issues, and diversion and regulatory scrutiny.10 Despite these attitudes, primary care physicians are central to effective pain management, including the prescribing of opioid analgesics and adjunctive therapies for large segments of the U.S. population.

The AAFP Commission on Health of the Public and Science recently developed a position paper on pain management and opioid abuse. Some of the Commission’s major recommendations are outlined in Table 1.11 Through advocacy, collaboration, and education, the AAFP continues to actively work toward a solution to America’s pain management and opioid abuse epidemics.

Table 1.

American Academy of Family Physicians’ Stance on Pain Management and Opioid Abuse

Advocacy

Urge all states to obtain physician input when considering pain management regulation and legislation

Urge all states to implement prescription drug monitoring programs and the interstate exchange of registry information

Oppose mandated continuing medical education as a prerequisite to the U.S. Drug Enforcement Administration or other licensure because of the limitations on patient access to legitimate pain management needs that may occur

Strongly advocate for increased national funding to support research into evidence-based strategies for optimal pain management and their incorporation into the patient-centered medical home model

Urge all payers to recognize the increased visit requirements that are needed to perform the proper assessment and treatment of patients with chronic pain and calls for the appropriate payment for those services

Clinical practice

View the goal of pain management to be primarily improvement and maintenance of function

Urge family physicians to individualize therapy based on review of the patient’s potential risks, benefits, adverse effects, and functional assessments, and to monitor ongoing therapy accordingly

Continuing education for family physicians

Support development of evidence-based physician education to ensure the safest and most effective use of long-acting and extended-release opioids, and to reduce the problem of opioid abuse

Collaboration with other organizations

Collaborate with The Partnership at Drugfree.org (formerly Partnership for a Drug-Free America) on projects aimed at patients and patient education

Continue to work with appropriate government agencies to ensure policies are in place to allow effective and safe opioid prescribing; one such project is the U.S. Food and Drug Administration’s Safe Use Initiative

Form or join a coalition of medical organizations to address opioid management and abuse in a coordinated manner

Work closely with chapters to synergize efforts to assist members with opioid management and abuse in their patients


Information from reference 11.

Table 1.   American Academy of Family Physicians’ Stance on Pain Management and Opioid Abuse

View Table

Table 1.

American Academy of Family Physicians’ Stance on Pain Management and Opioid Abuse

Advocacy

Urge all states to obtain physician input when considering pain management regulation and legislation

Urge all states to implement prescription drug monitoring programs and the interstate exchange of registry information

Oppose mandated continuing medical education as a prerequisite to the U.S. Drug Enforcement Administration or other licensure because of the limitations on patient access to legitimate pain management needs that may occur

Strongly advocate for increased national funding to support research into evidence-based strategies for optimal pain management and their incorporation into the patient-centered medical home model

Urge all payers to recognize the increased visit requirements that are needed to perform the proper assessment and treatment of patients with chronic pain and calls for the appropriate payment for those services

Clinical practice

View the goal of pain management to be primarily improvement and maintenance of function

Urge family physicians to individualize therapy based on review of the patient’s potential risks, benefits, adverse effects, and functional assessments, and to monitor ongoing therapy accordingly

Continuing education for family physicians

Support development of evidence-based physician education to ensure the safest and most effective use of long-acting and extended-release opioids, and to reduce the problem of opioid abuse

Collaboration with other organizations

Collaborate with The Partnership at Drugfree.org (formerly Partnership for a Drug-Free America) on projects aimed at patients and patient education

Continue to work with appropriate government agencies to ensure policies are in place to allow effective and safe opioid prescribing; one such project is the U.S. Food and Drug Administration’s Safe Use Initiative

Form or join a coalition of medical organizations to address opioid management and abuse in a coordinated manner

Work closely with chapters to synergize efforts to assist members with opioid management and abuse in their patients


Information from reference 11.

editor’s note: Dr. Houston is chair of the AAFP Commission on Health of the Public and Science, and Dr. Rich is chair of the Commission’s Opioid Abuse/Pain Management Work Group.

Address correspondence to Thomas Houston, MD, FAAFP, at tphdoc@aol.com. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations to disclose.

REFERENCES

1. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Results from the 2007 National Survey on Drug Use and Health: national findings. September 2008. http://www.oas.samhsa.gov/NSDUH/2k7NSDUH/2k7results.cfm. Accessed August 20, 2012.

2. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. The NSDUH report: trends in nonmedical use of prescription pain relievers: 2002 to 2007 February 2009. http://www.samhsa.gov/data/2k9/painRelievers/nonmedicalTrends.htm. Accessed August 20, 2012.

3. Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487–1492.

4. U.S. Food and Drug Administration Food and Drug Administration Amendments Act of 2007. http://www.fda.gov/regulatoryinformation/legislation/federalfooddrugandcosmeticactfdcact/significantamendmentstothefdcact/foodanddrugadministrationamendmentsactof2007/fulltextoffdaaalaw/default.htm. Accessed August 20, 2012.

5. U.S. Food and Drug Administration. Post-approval REMS notification. http://www.fda.gov/downloads/Drugs/DrugSafety/InformationbyDrugClass/UCM251595.pdf. Accessed August 20, 2012.

6. American Academy of Family Physicians. Recommended curriculum guidelines for family medicine residents: chronic pain management. June 2011. http://www.aafp.org/online/etc/medialib/aafp_org/documents/about/rap/curriculum/chronicpain.Par.0001.File.tmp/ResidentsGuidelinesReprint286.pdf. Accessed August 20, 2012.

7. Potter M, Schafer S, Gonzalez-Mendez E, et al. Opioids for chronic nonmalignant pain. Attitudes and practices of primary care physicians in the UCSF/Stanford Collaborative Research Network. University of California, San Francisco. J Fam Pract. 2001;50(2):145–151.

8. Weinstein SM, Laux LF, Thornby JI, et al. Medical students’ attitudes toward pain and the use of opioid analgesics: implications for changing medical school curriculum. South Med J. 2000;93(5):472–478.

9. Chen JT, Fagan MJ, Diaz JA, Reinert SE. Is treating chronic pain torture? Internal medicine residents’ experience with patients with chronic nonmalignant pain. Teach Learn Med. 2007;19(2):101–105.

10. Matthias MS, Parpart AL, Nyland KA, et al. The patient-provider relationship in chronic pain care: providers’ perspectives. Pain Med. 2010;11(11):1688–1697.

11. American Academy of Family Physicians. Pain management and opioid abuse: a public health concern. http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/painmanagement/painmanagementopioids.html. Accessed August 14, 2012.


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