Many physicians are not adequately trained to recognize and manage patients at high-risk for, or suffering from, prescription opioid misuse: only 19% of physicians report receiving training in opioid misuse in medical school and only 34% report receiving training in residency.1 In addition, nearly 50% of physicians find it difficult to discuss prescription drug misuse with their patients.1 This may have grave implications as, left untreated, prescription opioid misuse is associated with significant morbidity and mortality from non-fatal and fatal overdose. 2-4
It is estimated that 80% of prescription opioids misused come from actual physician prescriptions.5Some physicians, unaware of the risk, may prescribe opioids without conducting appropriate monitoring for benefits and risks. Others, fearful of the medico-legal risk that will ensue if patients overdose, develop an addiction, or divert (i.e. sell) their pain medications, refuse to prescribe opioids for any condition, even if required for adequate pain relief.6, 7
Recently, an expert panel formulated new guidelines for the use of opioids in the treatment of chronic, non-cancer pain.8 It was concluded that, in spite of limited evidence, chronic opioid therapy can be safe and effective for certain patients with chronic, non-cancer pain.8 However, it was cautioned that adequate patient risk assessment and risk management for opioid abuse, addiction, and diversion is essential.8
For Primary Care Providers (PCPs), prescribing opioid therapy for patients with chronic, non-cancer pain may be challenging because of differing messages about prescribing. 8 Pain specialists advocate adequate pain treatment for all patients, yet addiction specialists caution about the risks associated with treating patients with chronic opioid therapy. The PCP is ultimately left to weigh the risks and benefits of treating patients with opioid therapy, often times without the clinical skills and knowledge necessary to safely manage opioids.8
Clinicians also report dissatisfaction with the training they receive in the use of opioid therapy,9 suggesting that appropriate continuing medical education can increase clinicians’ comfort level in prescribing opioids and in managing any potential issues with abuse, addiction, adverse effects, tolerance, and medication interaction.10
1. Califano JA. Under the Counter: The Diversion and Abuse of Controlled Prescription Drugs in the US. The National Center on Addiction and Substance Abuse, Columbia University, July 2005.
2. Crane E. The Dawn Report, Narcotic Analgesics: Substance Abuse and Mental health Administration; 2003.
3. Drug Abuse Warning Network. Substance Abuse and Mental Health Services Administration, 2008. (Accessed at http://dawninfo.samhsa.gov/.)
4. Novak S. The New Dawn Report, Emergency Department Visits Involving Nonmedical Use of Selected Pharmaceuticals: Office of Applied Studies (OAS), Substance Abuse and Mental Health Services Administration (SAMHSA); 2006.
5. Substance Abuse and Mental Health Services Administration (SAMHSA), Office of Applied Studies (2007). Results from the 2006 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-32, DHHS Publication No. SMA 07-4293). Rockville, MD.
6. Longo LP, Parran T, Jr., Johnson B, Kinsey W. Addiction: part II. Identification and management of the drug-seeking patient. Am Fam Physician 2000;61:2401-8.
7. Trescot AM, Boswell MV, Atluri SL, et al. Opioid guidelines in the management of chronic non-cancer pain. Pain Physician 2006;9:1-39.
8. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009;10:113-30.
9. Upshur CC, Luckmann RS, Savageau, JA. Primary care provider concerns about management of chronic pain in community clinic populations. J Gen Intern Med 2006 Jun;21(6):652-5.
10. Bhamb B, Brown D, Hariharan J, et al. Survey of select practice behaviors by primary care physicians on the use of opioids for chronic pain. Curr Med Res Opin. 2006 Sep;22(9):1859-65.