Current plans focused primarily on appropriate prescribing are a step in the right direction, according to the American Pain Society, but are just one aspect of what needs to be a multifaceted approach to turn this public health crisis around.

"We would like to see more emphasis on clinical practice improvement," society president Seddon Savage, MD, told Medscape Medical News. Her team sees prescriptions as just one piece of a very large and intricate puzzle.

A new Centers for Disease Control and Prevention report shows that the number of overdose deaths from opioid prescription pain relievers in the United States has reached epidemic proportions and is greater than fatalities from heroin and cocaine combined.

According to Centers for Disease Control and Prevention Director Thomas Frieden, MD, one of every twenty adults in the United States, or 12 million individuals, has a history of narcotic use — a problem that largely stems from inappropriate prescribing.

The US Food and Drug Administration has since released a draft blueprint to guide prescriber training modules for long-acting and extended-release opioid drugs.

The plan will include information on weighing the risks and benefits of opioid therapy, choosing patients, managing and monitoring prescriptions, and counseling on the safe use of these drugs.

One in Twenty Americans

The American Pain Society has issued a statement in support of renewed attention on prescription drug misuse.

"Powerful opioids are often used because they are effective and easily administered," Dr. Savage said during an interview. "Counseling patients, addressing core issues such as stress, diet, and exercise, take time, are more challenging, and don't reimburse well."

Many practices are not set up to address these problems, Dr. Savage explained, so there is a need for system changes. Approaches that combine the specialist care of physicians, physiotherapists, and other team members can be ideal, she noted, but require coordination. "We hope that healthcare reform will help, but this is clearly an area we need to be working on."

Data from the Drug Enforcement Administration show that sales of opioid prescription pain relievers to pharmacies and healthcare providers have increased by more than 300% since 1999.

According to the report, enough prescription painkillers were prescribed in 2010 to medicate every American adult around the clock for a month. Although most of these pills were prescribed, many were diverted and abused.

"The burden of dangerous drugs is being created more by a few irresponsible doctors than drug pushers on street corners," Dr. Frieden told reporters attending a press briefing when the report was released.

Dr. Savage pointed to the high-profile pill mill cases in Florida and acknowledged these criminal activities are contributing to the problem.

However, Dr. Savage told Medscape Medical News she is concerned about harsh statements blaming all prescribers. "The evidence strongly suggests that physicians are the source of these medications, but that doesn't necessarily mean there is intentional misprescribing involved in most cases. We don't have good data demonstrating how these drugs are being diverted."

Dr. Savage says there is a need to find the right balance between reducing misuse and abuse while safeguarding legitimate access to treatment. "Ultimately, we'd like to see Drug Enforcement Administration involvement."

Guidelines

In 2009, the society, in collaboration with the American Academy of Pain Medicine, published clinical practice guidelines to assist clinicians in prescribing opioids for patients with chronic noncancer pain.

Published in the Journal of Pain, the guidelines state that prescribers of opioid pain relievers should have clinical skills and knowledge in both the principles of opioid treatment and the assessment and management of risks associated with drug abuse, addiction, and diversion.

According to the guidelines, before prescribing an opioid medication, physicians must conduct a thorough medical history and examination and assess potential risk for substance abuse. The strongest predictor of possible drug misuse is a personal history of alcohol and drug abuse.

For patients at higher risk for drug abuse, physicians must provide more highly structured care that may include frequent visits, regular urine drug screens, regular contact with family members, smaller prescriptions, pill counts, counseling, or other interventions.

"Regular monitoring of chronic opioid therapy patients is critical because the therapeutic benefits of these medications are not static and can be affected by changes in the underlying pain condition, coexisting disease, or changing psychological or social circumstances," Dr. Savage said. "Weekly monitoring is justifiable for some patients at high risk for misuse and other adverse events."

Allison Shelley • Medscape Medical News © 2011 WebMD, LLC