Chapter 52 - PAIN IN THE SUBSTANCE ABUSE POPULATION

Abstract

The growing problem of prescription drug abuse has forced painmanagement practitioners to take a new look at opioid prescribing and to seek balance in its risks and benefits (Box 52–1). Whereas it is no doubt time to tone down the rhetoric, we should not abandon the use of these agents and return to trends of underprescribing. Although it is arguable that the dramatically expanded use of opioids was undertaken with a paucity of long-term data to justify it, it is also the case that the complete avoidance of these drugs was equally unsupported. Today, all practitioners involved in pain management have the dual mission of relieving suffering while avoiding contributing to drug abuse and diversion. If all practitioners can become better acquainted with the principles of addiction medicine as these apply to the world of pain management, pain management can be kept safe and available for all who need it. The assessment of aberrant behaviors in patients with chronic pain is one key aspect of mastering these principles. The problem of prescription drug abuse has grown by leaps and bounds since the late 1990s. Whereas initial reports were optimistic that the increasing production and use of opioids was not accompanied by a growth in the abuse and diversion of these drugs, as time has passed the growth of the problem has become more obvious. The media spectacle that has accompanied the misuse of sustained-release oxycodone has been only the most visible of the multitude of stories on misuse of opioids by well-known celebrities and others. There is little doubt that much of the reporting of the problem in the popular press has been inaccurate, sensationalized, and unbalanced. The result of this distasteful reporting has been that many physicians were initially dismissive of the problem because the seriousness of the problem was actually obscured for them by the media circus. However, it has become abundantly clear via numerous avenues of information (e.g., the Drug Awareness Warning Network, the Household Survey) that the problem is on the rise. Prescribers must recognize that there is a deteriorating environment around opioid use engendered by the substantial public concern and must follow guidelines carefully. The problem of prescription drug abuse nationally is only part of the issue, however. Prescribers must also know what drugs are being abused locally, follow the trends, and use medications carefully if these agents happen to be ‘‘hot’’ in their location. For example, we have studied prescription drug abuse in central and southeastern Kentucky, a locale especially hard hit by prescription drug abuse problems. In both a retrospective and a prospective set of studies, we learned a great deal about the abuse of pain medications in the area (e.g., hot ones like oxycodone and lesspopular ones such as fentanyl) and which patients are at particular risk for abuse or diversion. This understanding colors the decisions of physicians in the area about choice of agents and strategies to employ when the riskier agents are being prescribed. Thus, there is a duty not just to assess patients and treat them as individuals but also to assess and know the community and treat patients in the context of the specific flavor of drug abuse in their community.