Prescription Opioids: Risk Management and Strategies for Safe Use _ _________________________________ rate their pain from 1 to 10 and circle a smiling or frowning face, and pain became the fifth vital sign [43]. Immediately following the release of the new standards, concern was raised that the standards would lead to the inappropriate use of opioids. By 2002, pain as a “fifth vital sign” in the standards was changed to “pain used to be considered the fifth vital sign,” and by 2004, this phrase no longer appeared in the Joint Commission’s Accreditation Standards manual [44]. The standard that pain be assessed in all patients also remained controversial for two reasons: It seemed inappropriate for some patients due to the nature of their medical condi- tion; and no similar standard existed requiring the universal assessment of other symptoms [44]. Thus, in early 2016, the Joint Commission began revising its pain assessment and management standards, with a focus on acute pain in the hospital setting. Draft standards were published in 2017, implemented in 2018, and revised in 2019 [45; 46].
2000, when Congress proclaimed 2000–2010 as the Decade of Pain Control and Research [47]. Shift- ing demographics also contributed to the changing attitudes toward opioid prescribing. With painful chronic illness rates increasing with the overall population age, there came growing awareness of the importance in providing effective pain relief [43]. Pharmaceutical companies began introducing new opioid formulations, and existing opioid products became more widely prescribed ( Table 5 ). The theme of minimal abuse liability was widely used in the marketing materials distributed to prescribers and pharmacists [48]. When the escalating rates of addiction, diversion, and fatal overdose involving prescribed opioids became apparent, the same pain specialists and organizations, pain advocacy groups, drug companies, and media reinforced the percep- tion of opioid legitimacy by primarily attributing the growing individual and public health hazard to improper Internet availability, illicit diversion, and the prevalence of societal drug addiction tenden- cies [49]. THE OXYCONTIN STORY: A CASE STUDY The story of extended-release oxycodone, marketed as OxyContin, is informative and unique. Although the United States has experienced several waves of widespread prescription drug abuse over the past 150 years, the rapid ascent of OxyContin from market entry to miracle drug for chronic pain to a demonized substance of abuse and diversion on a vast scale is without precedent. Multiple factors
The financial support supplied to professional soci- eties by drug companies helped influence members to change prescribing practices. Patient advocacy groups, often guided by physicians who felt con- strained by the prohibition of opioid prescribing and pain specialist organization consensus that chronic pain had been previously undertreated, worked to elevate awareness that pain was untreated and unrecognized [28; 40]. During this time, opioid prescribing for chronic noncancer pain dramati- cally increased across the country. The movement for more aggressive pain treatment culminated in
RETAIL PURCHASES a OF PRESCRIPTION OPIOIDS (GRAMS OF DRUG)—UNITED STATES, 2019–2021 Opioid 2019 2021 Change Methadone 15,080,444 g 13,866,600 g -8.01% Oxycodone 35,929,260 g 31,190,066 g -13.2% Fentanyl base 193,531 g 154,574 g -20.1% Hydromorphone 987,221 g 1,013,929 g +2.71% Hydrocodone 20,040,962 g 17,399,719 g -13.2% Morphine 11,966,623 g 9,728,577 g -18.7% Codeine 12,105,985 g 9,942,219 g -17.9% Meperidine 292,694 g 153,171 g -47.7% Total 96,596,720 g 83,448,855 g -13.6% a Purchasers include pharmacies, hospitals, practitioners, teaching institutions, and treatment programs. Source: [50] Table 5
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