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April 6, 2011

Curtailing Diversion and Abuse of Opioid Analgesics Without Jeopardizing Pain Treatment

Author Affiliations

Author Affiliations: National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland (Dr Volkow); Center for Substance Abuse Solutions, University of Pennsylvania School of Medicine, Philadelphia (Dr McLellan).

JAMA. 2011;305(13):1346-1347. doi:10.1001/jama.2011.369

Opioid analgesics are among the most effective medications for pain management (including noncancer pain), but they are also associated with serious and increasing public health problems, such as abuse (ie, use for nonmedical purposes), addiction, and deaths from opioid overdose (excluding heroin). Both immediate and extended opioid release formulations, including methadone, are abused and contribute to overdose. For example, since 2002, the US prevalence of high school seniors reporting past-year nonmedical use of opioids has been 8% to 10% for hydrocodone and 4% to 5% for oxycodone.1 After excluding alcohol and tobacco, the prevalence of hydrocodone abuse is second only to marijuana abuse. Concurrently, there has been a 5-fold increase in drug treatment admissions for pharmaceutical opioids between 1998 and 2008, from 19 941 to 121 091.2 In addition, emergency department visits related to pharmaceutical opioids have increased from 144 644 to 305 885, between 2004 and 2008, and unintentional opioid-related overdose deaths have increased from about 3000 to 12 000 between 1999 and 2007.3 Opioid overdose is now the second leading cause of unintentional death in the United States, second only to motor vehicle crashes,4 which prompted the Centers for Disease Control and Prevention to label pharmaceutical opioid overdose as a national epidemic.

Some of the increased abuse of opioid analgesics likely reflects the misguided belief that, because these medications are prescribed by physicians, they are safer than illicit drugs. However, it is also likely that part of this increased abuse is due to much greater access to and availability of opioid analgesics.5 This is likely to reflect more aggressive management of noncancer pain, facilitated in part by the “regulatory” mandate from the Joint Commission to screen and manage pain, but also by the lingering concerns regarding the safety of nonopioid analgesics, particularly those classified as nonsteroidal anti-inflammatory drugs.

Given the escalation in the prescription of opioid medications; the recognition that some patients misrepresent genuine pain to obtain, misuse, and divert these medications; and the corresponding prevalence of serious or even lethal public health problems, suggestions should be considered for improving current noncancer pain management in primary health care settings that could decrease diversion, abuse, and overdose of opioid medications. The first general suggestion is to enhance and update clinical teaching and training practices for physicians, nurses, dentists, and pharmacists in the areas of pain management, opioid pharmacology, and abuse/addiction, perhaps through interactive Web-based training. Given that pain is among the most common diagnoses in medicine (with prevalence estimates for chronic noncancer pain ranging from 4% to 40% in primary care settings),6 that there have been significant research advances in understanding pain and addiction, that there are many new formulations and types of opioid and nonopioid analgesics, and that the current education of pain management for health professionals has been deemed insufficient, a more comprehensive and contemporary training curriculum for prescribers seems warranted.

Guidelines recently developed by the American Academy of Pain Medicine7 should be broadly adopted as a means to harmonize best practices among physicians and dentists regarding the initial prescription of opioids and the subsequent monitoring and management of patients with chronic noncancer pain. Harmonization of best-practice recommendations for the initiation of opioid medications should include the following: (1) standardized screening procedures and special provisions for managing pain in those most at risk for abuse and dependence,8 including adolescents and young adults, individuals with a current or previous substance use disorder (including nicotine and alcohol), and individuals with a family history of substance use disorders; (2) indications for when and for how long to prescribe nonopioid analgesics, nonpharmacological methods, or both for pain control vs when and for how long to prescribe opioid analgesics; (3) indications for when short- vs long-acting opioids should be prescribed; and (4) reasonable limits on the number of pills or amount of liquid prescribed, such that the prescribed amounts match the number of treatment days required.

Consensus on best practices for continuing opioid pain management of chronic noncancer pain should include the following: (1) when and how to use urine screening to manage risk of diversion, abuse, and addiction; (2) when and how to use patient contracts to manage risk of diversion through single-source prescribers and pharmacies; (3) proper use of state prescription drug monitoring programs to reduce doctor shopping; (4) criteria for deciding how long patients should receive opioid analgesics; and (5) criteria for deciding whether and under what circumstances to refill or discontinue opioid prescriptions.7

Patients and the general public also must become more aware and responsible for the use, storage, and disposal of opioid analgesics, because access to unused left-over medications has been reported as the main source for diversion among youth.9 Specifically, parents should learn the facts about pharmaceutical opioid abuse and counsel their adolescent and young adult children (those most likely to abuse) about the true risks of these medications; family members should not transfer opioid medications to other individuals or family members for self-diagnosed pain conditions; patients should store unused opioids in locked cabinets to prevent theft and diversion and should dispose of left-over opioids (and other abuse-prone medications) in an ecologically proper manner; and media should evaluate the influence of news reporting on the popularity of and misconceptions about psychoactive substances, particularly prescription opioids.

These recommendations for better education and harmonization of pain management should improve pain management and reduce diversion of opioid analgesics. This is an important and practical starting point. It is possible to reduce opioid abuse and diversion while preserving proper patient care, but a comprehensive effort will also require control of nonmedical sources of diversion (ie, stolen medications, illegal prescriptions, illegal pharmacies), clearer guidelines for disposal of unused opioid medications, and incentives for pharmaceutical firms to develop abuse-resistant formulations to prevent diversion.

These comments are not intended to jeopardize or even restrict proper physician prescribing of opioids, nor should there be reduced accessibility to opioid medications for patients who need them. These comments, building on the consensus of pain management experts,7 are intended to help improve the safety and benefits from these medications. Specifically, there is the need for better initial training of physicians, dentists, nurses, and pharmacists in pain management, opioid pharmacology, and principles of abuse and addiction; a review of contemporary best practices for assessing and treating pain patients10 to present more uniform guidance designed to minimize unnecessary confusion and the omnipresent fear of prosecution among law-abiding clinicians who provide treatment for pain; and better education of the public and policy makers to reduce public health risks while also improving the quality of care for patients with pain.10

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Article Information

Corresponding Author: Nora D. Volkow, MD, National Institute on Drug Abuse, 6001 Executive Blvd, Room 5274, MSC 9581, Bethesda, MD 20892 (nvolkow@nida.nih.gov).

Conflict of Interest Disclosures: Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Additional Contributions: We kindly acknowledge Ruben Baler, PhD, National Institute on Drug Abuse, who provided editorial assistance, and Dr Baler and Susan Weiss, PhD, National Institute on Drug Abuse, for their critical comments. Neither Dr Baler nor Dr Weiss received compensation other than that from their salaries.

Online-Only Material: The author interview is available here.

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