May 9, 2008 As controversy swirls about proper clinical use of opioids and other potent pain medications, research reported at the American Pain Society annual meeting shows that, contrary to widespread beliefs, less than 3 percent of patients with no history of drug abuse who are prescribed opioids for chronic pain will show signs of possible drug abuse or dependence.
In his plenary session address, Srinivasa Raja, MD, professor of anesthesiology, Johns Hopkins University Medical School, urged clinicians and policy makers not to allow the small percentage of abused pain prescriptions to prevent legitimate pain patients from getting the care they need.
"Physicians today face a dilemma in trying to balance the needs of their patients with demands from society for better control of opioid medications. We also are dealing with unfounded accusations in the media that increased prescribing of opioids for severe chronic pain is responsible in large part for reported upswings in the abuse of pain medications," said Raja.
"We do need stronger evidence about which patients will benefit most from these medications to help make better prescribing decisions," he added. "But for most chronic pain patients, drugs are not the sole solution. More and more studies are showing that multi-faceted treatment involving physical and cognitive-behavioral therapies and appropriate interventional strategies lead to the most favorable outcomes."
According to Raja, the problem of prescription drug abuse can best be attacked and hopefully solved through collaborations involving care givers, regulatory and law enforcement agencies and the pharmaceutical industry.
"First, I believe physicians should be diligent is communicating with their patients about the benefits and risks of opioids and also screen them for drug-seeking behavior and other warning signs of potential abuse," said Raja. "Also, we must monitor patients carefully to determine when doses can be lowered over time as they improve their pain control and overall functioning."
The message for law enforcement and federal and state regulatory agencies, first and foremost, is to strive for state-to-state consistency in regulating controlled substances and crack down on illegal internet pharmacies and prescription thefts and forgeries.
"Progress is being made as there is increased awareness of the source of prescription opioids being diverted into the illicit market," said Raja, "and states and municipalities are stepping up their teen drug awareness education programs."
For pharmaceutical manufacturers, Raja said the key challenge is to match clinical needs for less addicting pain medication with drug development priorities. "There are novel analgesic formulations in various stages of development that we hope can be prioritized and expedited for clinical use," he said.
Raja noted that fifty years ago, a commentary published in the Journal of the American Medical Association recommended that opioids should be avoided in treating cancer pain because of possible addiction, and 20 years ago it was believed infants didn't feel pain and shouldn't receive anesthesia.
"We abandoned such faulty beliefs as scientific evidence proved otherwise," he said. "Now I hope history repeats itself in changing professional and public attitudes as we now know opioids are effective for treating chronic non-cancer pain and that very few legitimate pain patients abuse their medications. Hopefully, the evidence will foster a middle-ground approach that protects the rights of patients and clinicians while upholding society's right to control medication abuse and diversion."
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