Drug and Alcohol ReviewVolume 30, Issue 3 p. 233-235 Free Access Pharmaceutical drugs: The delicate balance between reducing pain and reducing harm Correction(s) for this article ERRATUM Volume 30Issue 6Drug and Alcohol Review pages: 693-693 First Published online: September 29, 2011 SUZANNE NIELSEN, SUZANNE NIELSEN Turning Point Alcohol and Drug Centre, Melbourne, Australia. NIDA Clinical Trials Network INVEST Fellow, UCLA, Los Angeles, USA. E-mail: SuziN@turningpoint.org.auSearch for more papers by this authorRAIMONDO BRUNO, RAIMONDO BRUNO School of Psychology, University of Tasmania, Hobart, AustraliaSearch for more papers by this author SUZANNE NIELSEN, SUZANNE NIELSEN Turning Point Alcohol and Drug Centre, Melbourne, Australia. NIDA Clinical Trials Network INVEST Fellow, UCLA, Los Angeles, USA. E-mail: SuziN@turningpoint.org.auSearch for more papers by this authorRAIMONDO BRUNO, RAIMONDO BRUNO School of Psychology, University of Tasmania, Hobart, AustraliaSearch for more papers by this author First published: 04 May 2011 https://doi.org/10.1111/j.1465-3362.2011.00326.xCitations: 7AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Non-medical use of pharmaceuticals is an international issue, with a seven-fold increase in global morphine consumption over the past 20 years, and concurrent concerns about opioid availability and under-treatment of severe pain in regions such as Africa [1] , [2] . Currently, in the US, the economic costs of non-medical use of prescription opioids is more than $50 billion a year [3] , and deaths from pharmaceutical opioids exceed deaths from all other drug classes, constituting the majority of both fatal and non-fatal overdoses [4] , [5] . This year, the Australian government has commissioned a National Pharmaceutical Drug Misuse Strategy, signalling broad recognition that pharmaceuticals, as a group of substances, require consideration within illicit drug use policy. It is therefore timely to be presenting this special issue, consisting of papers covering many aspects of the multifaceted issues relating to problematic use of pharmaceutical drugs. This special issue brings together the latest research on pharmaceutical misuse covering epidemiology, treatment implications and harm reduction. The special issue begins with an article by Larance et al. addressing the importance of using precise and consistent terminology to describe behaviours relating to pharmaceutical use in the context of opioid treatment [6] . Such precision is far from simply an academic interest – the authors argue that lack of specificity in describing the problems that may occur during opioid treatment can hinder appropriate responses, create communication barriers between prescriber and patient, and undermine progress in this arena. A series of epidemiology papers addresses pharmaceutical use in South East Asia, New Zealand and the United States [7] -[9] . A particularly salient point is raised by Larance et al. in the case of South East Asia, where there is both a dramatic under-treatment of pain and significant diversion of opioid pharmaceuticals, demonstrating that the problem of ‘misuse’ is not simply removed by constricting the supply of opioids for legitimate medical applications, and instead judicious regulatory processes that can support medical practice are required [8] . Patterns of increasing use and non-medical use of prescription pain medication in the US are described by Maxwell [7] . In New Zealand, Wilkins et al. describe pharmaceutical use amongst distinct subpopulations of illicit drug users, demonstrating different patterns of use among injection drug users, ecstasy and methamphetamine users, suggesting different intervention approaches may be needed depending on the substance in question and the population engaging in the extra-medical use [9] . In the provision of pain management, development of iatrogenic dependence is an important concern. However, excessive fear of dependence can similarly interfere with successful treatment. ‘Opioiphobia’ has been described amongst prescribers, especially in settings such as emergency rooms [10] . It is likely that these fears are heightened when prescribing for those with a history of substance abuse. Examining this issue, Ling et al.[11] highlight some of the challenges in treating concurrent opioid dependence and pain, discussing the need to find the balance between minimising risks and negative consequences of opioid use whilst not reducing effective pain treatment. As noted by Brogan and Kelsall [12] , with an aging population on chronic opioid substitution treatments who may increasingly require pain treatment, this is an important area with a need to prevent stigma and minimise the under-treatment of pain in this population. Attempts to dichotomise patients into pain patients and ‘abusers’ is identified as an oversimplification of the very complex issues that face many who are dependent on pharmaceutical opioids [12] , [13] . Harm, and reducing harm, in relation to pharmaceuticals is addressed in a number of papers in this special issue. There are a range of harms particular to pharmaceutical misuse. Where tablets are injected, insoluble tablet components may enter the bloodstream and damage organs. Currently, despite the fact that some pharmaceuticals are known to be likely to be injected, there is no responsibility for the manufacturer to ensure potentially damaging insoluble ingredients such as talc are not included in these products. Emerging work to investigate effective particle filtration procedures is presented in this issue by Roux et al.[14] , providing important directions for harm reduction for injecting drug users who use pharmaceuticals. Outside of injecting subgroups, another further contributor to harm arises from the formulation of some opioid products. One example is products containing the opioid codeine, in combination with other ingredients such as paracetamol or ibuprofen that are toxic in the high doses that are often consumed where dependence develops [15] -[17] . Similarly, harms may inadvertently arise from the perception of safety associated with taking a medically prescribed substance: in a review of the effects of prescription medications on driving by Leung, it is apparent that there is a link between benzodiazepines and opioids and accidents, even at therapeutic levels, however more experimental evidence is required to inform policy and to allow medical professionals to best advise their patients about safety when driving if they are using these medications [18] . Within this theme of harms, in their commentary Hallinan et al.[19] discuss some of the complexities relating to pharmaceutical opioids, raising the challenging point that, in some respects, non-prescribed use of pharmaceuticals may in fact be less harmful than use of illicit opioids such as heroin. This presents a novel and thorny dilemma for harm minimisation policy relating to opioid use [19] . Evidence is emerging that the populations experiencing problems with pharmaceutical use are demographically broader than the traditional injecting drug use populations seen in drug and alcohol treatment services [20] . For example, an over-representation of females and the largest number of attendances in relationship to benzodiazepines was found by Lloyd and McElwee from an examination of ambulance attendances in Melbourne, Australia [21] . Research is required to understand the treatment needs, and to develop interventions for these populations of pharmaceutical users that are currently under-represented in the treatment system. In an examination of drug treatment entrants, Nielsen et al. found that most pharmaceutical opioid users appear similar to heroin users on many characteristics [22] . Few non-injecting opioid users are entering treatment, despite growing evidence that this is a population that exists, and are at considerable risk of harm. There is a need to establish if there are alternative treatment types, modalities or processes that would be particularly effective in these populations. There may be a place for novel therapies including web based treatment, which Parr et al. have found to show promise in benzodiazepine users [23] . However, the question remains as to how these populations can be better identified and engaged. There are a number of unique elements to pharmaceutical use and challenges in responding to their problematic use at the health systems and policy level. Firstly, the availability of these agents for therapeutic use is essential, so clearly any measures to prevent abuse or dependence must be mindful of this. Ensuring that patients are not denied therapeutic medications whilst at the same time minimising diversion of potent medications for non-medical use is a delicate balance. Secondly, the ‘suppliers’ of these substances, at some point in the supply chain, tend to be medical professionals, largely doctors and pharmacists. Finally, the ‘users’ of these substances, while often meeting criteria for dependence, may not even themselves recognise that they are using a substance with a dependence liability. Sproule [13] and Holliday [24] make clear that detection of problematic pharmaceutical use needs to improve at both the prescriber and the pharmacist level. While much can be done to better utilise the role of these health professionals, both authors note that doctors and pharmacists respectively currently do not have the resources (including real-time information) nor are they remunerated to conduct the range of activities required to reduce pharmaceutical misuse. Further concerns are raised by Dunlop [25] , about just how little we know about the magnitude of problems with pharmaceuticals in Australia, and limitations with access to addiction and pain services. While it is clear there is a problem to address, when we consider policy responses, such as those involving monitoring and prescribing restrictions for pharmaceuticals, we need to remain mindful that these drugs do indeed have beneficial clinical effects and that it is highly likely that the majority of medications that are prescribed are used within therapeutic guidelines. In the debates around this issue, those coming from an addictions perspective must take care not to cause a ‘moral panic’, as this may increase problems such as opiophobia and create barriers to the access of indicated and effective treatments. For example, some prescription monitoring systems have been reported to reduce use of appropriate medications among cancer and cardiac patients [26] . There is also evidence showing that doctors switch to less restricted but also less effective medications for their patients in response to increased prescription scrutiny [27] . We also need to consider other potential unintended consequences of possible policy responses. What will we do when we have better e-records? Is the treatment system ready to respond to the estimated 1 500 000 prescription opioid dependent people in Australia [28] when their prescribers become aware of dependence, and can no longer supply these medications? What is the duty of care if an identified individual does not comply with treatment recommendations and displays aberrant behaviours? Does refusal to supply further prescriptions push dependent individuals into the illicit market? With rapid developments in information technology and e-health access, we are at a pivotal point in responding to the issue of problem pharmaceutical use. This special issue contributes important information better describing populations that use pharmaceuticals whilst also identifying some populations that we need to know much more about. Treatment approaches are considered, with examples of the complexity of this patient group, as well as potential treatment options for pharmaceutical users. We are left with food for thought with some interesting discussion on the place of harm reduction with pharmaceutical use. Carefully considered responses are required which engage all the stakeholders in this drug problem, including the patients and illicit consumers, the pharmacists, prescribers, pharmaceutical companies, and government regulatory agencies. The supply chains in this process are largely distinct from illicit drug markets, and hence previously developed responses may not translate well to pharmaceuticals. This is the time to develop considered and effective policy and treatment responses before morbidity and mortality further increase, tipping the scale to extreme regulatory responses which may see effective medications simply becoming unattainable.