__________________________________ Prescription Opioids: Risk Management and Strategies for Safe Use dents stated their medical board was the agency most likely to investigate improper controlled substance prescribing in their state [29].
These iatrogenic addiction figures were disseminated through communications to specialists, general practitioners, other providers, administrators, regu- lators, and the lay public. “Less than 1%” became the message that opioids posed little risk of addic- tion in patient with pain without substance abuse histories. Substantial support for compassion-based efforts to broaden opioid use for pain control also came from the 1990 opinion paper by the co-author of the landmark paper describing gate control theory that revolutionized the concept of pain [39]. In 1988, the Federation of State Medical Boards (FSMB) released a policy explicitly reassuring physicians they would not face regulatory action for prescrib- ing even large amounts of opioids, assuming it was medically warranted [30]. Physician awareness of the new FSMB policy was promoted by widely circulated publications. For example, the Joint Commission published a guide, supported by Purdue Pharma, stating, “Some clinicians have inaccurate and exag- gerated concerns about addiction, tolerance, and risk of death,” and “This attitude prevails despite the fact there is no evidence that addiction is a significant issue when persons are given opioids for pain control” [30]. During the 1990s, the American Pain Foundation endorsed more aggressive treatment of chronic pain, while the American Pain Society (APS) promoted the position that pain should be considered a fifth vital sign. The APS and the American Academy of Pain Medicine (AAPM) published a landmark con- sensus statement in 1997 that stated long-term opi- oid analgesic use for chronic noncancer pain posed minimal risk of overdose or addiction [30; 40]. The pharmaceutical industry was also instrumental in the movement toward loosening opioid prescribing con- straints and broadening the indications for opioid use in managing chronic pain [30; 41]. Professional pain societies wrote consensus statements claim- ing little risk of addiction or overdose in patients with pain and that long-term opioids were easy to discontinue. In 1997, Congress passed SB402, also known as The Pain Patient’s Bill of Rights [42]. In 2001, the Joint Commission issued new standards requiring hospitals to make pain assessment routine and pain treatment a priority. The now familiar pain scale was introduced, with patients asked to
Against this backdrop, some pain physicians began to re-examine and challenge the intense physician reluctance to prescribe opioids. Observing the extent that suffering was relieved by opioids in cancer patients with severe pain and the apparent lack of euphoria that differed from the responses of opioid abusers, it was suggested that opioids could also be used to relieve suffering in many patients with intense, persistent noncancer pain, with little risk of addiction. This was followed by an effort to destigma- tize the use of opioids, with the objective of easing access to opioids by the large number of patients with severe, persistent noncancer pain. While widely viewed as driven by good intentions, this crusade for acceptance of opioid use in noncancer pain was also accompanied by the regular tendency to minimize the inherent potential risks that accompany opioid prescription drug use, despite the absence of valid evidence to support the assumption [30]. Results from a 1986 chart review study of 38 patients with chronic noncancer pain receiving long-term opioid therapy were cited to support the assertion that long-term opioid use in patients with intractable nonmalignant pain was effective and safe with little risk of addiction. Of the 38 patients in the study, the 2 who developed opioid problems had histories of drug abuse [31]. This paper was followed by several other publications on opioids for chronic noncancer pain [32; 33; 34; 35]. Each paper cited the prevalence rates of iatrogenic opioid addiction reported by three earlier pain studies [36; 37; 38]: • Of 11,882 hospitalized patients with a negative substance abuse history who received ≥1 opioid dose, 4 developed addiction. • A national survey of roughly 10,000 patients treated for burn pain found no cases of addiction. • Of 2,369 patients treated at a headache center who had access to opioid analgesics, 3 developed problems with their prescribed opioid.
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MDMS1526
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