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NEWS & VIEWS |
The document will be distributed to law enforcement personnel as well as physicians who are registered to prescribe opioids, and is also available online at http://www.stoppain.org/faq.pdf.
The goal, developers said, is to help physicians and law enforcers strike a balance between providing effective pain relief to people who need it without contributing to the growing problems of prescription drug diversion and abuse.
"We have two serious societal problems—the undertreatment of pain, and drug abuse and diversion—that are intertwined through prescription pain medications. We address both problems in this document, and hope it will bring some clarity to the issue," said Russell Portenoy, MD, chairman of the Department of Pain Medicine and Palliative Care at Beth Israel Medical Center in New York, and lead pain expert on the project.
Studies suggest that more than 40% of patients with cancer aren’t getting enough pain relief, Portenoy said. In part, the problem stems from concerns about becoming addicted to opioid drugs; some patients and doctors are simply afraid to try them.
More recently, though, burgeoning prescription drug abuse and high-profile prosecutions of doctors prescribing opioids illegally have had a chilling effect on the medical community, said David Joranson, MSSW, another member of the group that developed the new guidelines.
"We already knew that for years physicians have been concerned about being investigated if they prescribed controlled substances," said Joranson, who is Director of the Pain and Policy Studies Group at the University of Wisconsin Comprehensive Cancer Center. "But now we hear that patients can’t find a physician who will prescribe opioids."
Some pharmacies, he added, won’t even stock these medications because they fear being robbed by drug dealers or addicts.
The new guidelines should help address that situation by providing "some clarifications about what does or does not constitute questionable activity in the eyes of the DEA," said Patricia Good of the DEA’s Office of Diversion Control. It also helps law enforcement officers understand what is considered sound medical practice, she said.
The endorsement of the DEA is "truly significant" said Mary Simmonds, MD, a medical oncologist and immediate past president of the American Cancer Society. She was not involved in developing the guidelines.
If doctors feel more confident prescribing opioids, patients are more likely to get the relief they need, she said.
In addition to describing the steps doctors should take when assessing pain and determining whether opioids are appropriate, the new document gives doctors some advice on spotting a person who is likely to abuse or divert drugs. It also clarifies the differences between true drug addiction, and drug tolerance or physical dependence.
The distinction is important, said Joranson, because fear of addiction keeps so many people from getting proper pain relief. People who use opioids may well become physically dependent over time—if they quit the drugs abruptly, they will experience withdrawal symptoms. Or they may develop a tolerance to the drug, requiring higher doses to achieve pain relief. But those conditions aren’t the same as addiction.
"Addiction is a much more complex disease that occurs in vulnerable people due to genetics, biology, environment," he said. "It involves maladaptive behaviors and a compulsive need to continue using [these drugs] for nonmedical purposes."
The World Health Organization and major national and international scientific organizations have recognized the difference between addiction and physical dependence, Joranson said. Yet misperceptions persist.
"Every clinical panel has always said the risk of addiction is so low in patients with cancer that it really shouldn’t be a consideration, yet people continue to be concerned and the reason for that is they don’t understand addiction," he said.
Simmonds agreed. "People think if they become tolerant they will eventually become addicted, or that there won’t be a sufficient dose to relieve their pain," she said, "and that’s not true.
"All these myths are in everybody’s mind and they’re fearful of taking medication. But for moderate to severe pain, a nonopioid is not going to be potent enough and there’s no need to suffer."
Cancer pain is complex, Simmonds said. It can involve multiple types of pain in the same person for different reasons, and may even be combined with pain from other conditions. A patient may need to try different dosages or different medications, or combine medications to achieve relief.
The document encourages patients to talk openly with their physician about their level of pain, and to seek out a doctor who takes these concerns seriously. Patients should tell the doctor if the medication isn’t working or if it causes problematic side effects.
People seeking pain relief must also understand that doctors have certain procedures they need to follow in order to stay within the law.
"Doctors act in ways that patients may see as capricious or idiosyncratic," Portenoy said, "when really it’s that the doctor needs to be sure he’s acting with the right documentation and within the parameters of the law."
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