MDNews - Minnesota

"We were misled by a very effective marketing campaign to believe that the compassionate way to help people with chronic pain was aggressive opioid prescribing, and that turned out not to be true." — Andrew Kolodny, MD, Director of Physicians for Responsible Opioid Prescribing, Chief Medical Offi cer at Phoenix House and past president of the American Academy of Pain Medicine. "[Pain patients] tend not to manipulate but take in excess of what was prescribed in order to get pain relief, and the new forms will not prevent that from happen- ing," Dr. Webster says. "These forms will not prevent the most common method of abuse." THE NOMENCLATURE PROBLEM When indicated — commonly for end-of-life analgesia and cancer-related pain — opioid pain relievers are excep- tionally effective, but marketing these powerful medications as potentially "safer" versions of themselves carries possibly catastrophic consequences, some observers say. "The problem with calling them 'abuse-deterrent pills' is that it gives people — including prescribers — the impression that the pill is safer and maybe less addictive," Dr. Kolodny says. "If physi- cians think [an opioid] is somehow a less addictive pill because it's being marketed as abuse-deterrent, they prescribe it for low-back pain when they really shouldn't be giving an opioid for low-back pain." Perceiving the medications as safe, providers may lean on them to treat a number of chronic pain conditions because of their notable analgesic qualities, he adds. But for many chronic pain conditions, such strategies are fruitless. "Opioids are lousy drugs for low-back pain, fi bromyalgia and chronic headaches, not only because of the risk for addiction, but because they're unlikely to work," Dr. Kolodny says. Tennessee Health Commissioner John Dreyzehner, MD, MPH, FACOEM, says the medical evidence supporting opioid treatment for chronic conditions doesn't add up. "Despite what many were led to believe, there was never suffi cient evidence — and still isn't — for use of these highly addictive opioid medications for chronic benign pain," Dr. Dreyzehner says. "For many patients, other modalities or medication such as a combination of acetaminophen and ibuprofen is a more effective and less abuse-prone pain reducer. By focusing on pills, we missed opportunities to better study pain itself and the use of other modalities to relieve it." THE PHYSICIAN'S RESPONSIBILITY The underlying issue of the prescription drug problem is addiction, and opioid abuse should be treated similarly to any other addiction. But when opioid pain relievers are indicated, responsible prescribing can reduce the likelihood of addiction. "Opioids have significant risk, but in a subset of patients, the benefi ts do outweigh the risks," Dr. Webster says. "It's an assessment of needs and balancing that risk/benefi t ratio to determine whether an opioid should be prescribed, and once prescribed, then patients need to be monitored very closely." Several screening mechanisms can help providers monitor patients for signs of drug abuse: + Urine testing reveals the presence of other drugs in the system, potentially identifying patients with addiction problems, and also identifi es whether patients are using their prescriptions. + Close monitoring by a committed physi- cian can help prevent addiction, but that is effective only if patients cooperate. + Consulting a state's prescription drug-monitoring program can identify "doctor shoppers" and drug seekers. But because addiction, not drug abuse, is the public health issue, these mechanisms won't stem the tide of the prescription drug epidemic, according to Dr. Kolodny. Instead, the key to curbing opioid abuse is stopping it before it begins. When it comes to addictive drugs, "instead of supply reducing demand, sup- ply creates demand," says Dr. Dreyzehner. "We have steadily increased the supply of these legal, highly regulated and controlled medications. We should not be surprised that demand has risen in virtual lockstep. This current epidemic will end when supply is constrained, current users stop and new users are not recruited." ■

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