Editor ial
Editorial
ar Layar
Inadequate pain control versus opioid abuse: It is time for the pendulum to swing
W
hile pain is an unfortunate component of illness and injury, the ability to alleviate pain has been an essential part of the practice of medicine. Initial efforts in pain management focused on acute necessities such as surgical anesthesia and the easing of childbirth, with more recent advances addressing chronic problems such as cancer and palliative care. Naturally occurring drugs like willow extract, cocaine, and opium gave birth to a myriad of pharmaceuticals with diverse mechanisms of action and potencies, ranging from aspirin and nonsteroidal antiinflammatory drugs to local anesthetics and opioids. Clinicians, though limited by their inability to cure all disorders, took refuge in their capacity to alleviate pain and suffering and provide comfort to all in need with an expanding array of analgesics. However, around the late 1980s, reports of indifference to pain added a new and distasteful term to the medical lexicon: oligoanalgesia (the use of analgesics too infrequently or at doses insufficient to relieve pain).1 There were reports not only about overall physician insensitivity to patients’ pain but also about disparities in pain management related to race, sex, and age.2,3 The corrective action taken by the medical community was to enforce a more rigorous approach to the assessment, documentation, and treatment of pain. Pain became recognized as the “fifth vital sign”—a fundamental part of every patient encounter, requiring assessment and treatment as frequently as pulse, blood pressure, temperature, and breathing.4 Although entirely well-meaning, this paradigm shift was not without consequences. By 2004, unintentional poisoning— largely driven by an increase in the number of opioid-related deaths—surpassed firearms to become the second leading cause of injury-related fatalities (exceeded only by traffic accidents) in the United States.5 The trend continued, still driven by opioidrelated deaths, and by 2009 the number of poisoning fatalities approached the death toll from motor vehicle accidents, with poisoning deaths outnumbering traffic fatalities in the subgroup of adults between 34 and 56 years of age.6,7 The inappropriate prescribing of opioids, opioid diversion, opioid abuse, and opioid-related deaths have clearly reached epidemic proportions. In 2010, it was estimated that enough opioids were sold in the United States to administer 5 mg of hydrocodone to every adult every four hours for one month.5 Reversal of this trend will take a multidisciplinary effort among doctors, pharmacists, nurses, public health experts, and regulatory bodies. Efforts underway include detoxification programs, maintenance therapy with methadone and buprenorphine, prescribing limits, prescription monitoring programs, and prosecution of offending practitioners. Soon pharmacists will be faced with a new challenge. The Food and Drug Administration has just approved a spring-loaded naloxCopyright © 2014, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/14/0902-1537.
one delivery device.8 Like currently marketed devices for epinephrine administration, this new product will help facilitate the growing trend of naloxone delivery by nonmedical personnel.9-11 While still controversial,12,13 the use of naloxone in the community provides a safety net to help save lives when other efforts to curb opioid overdoses fail. Countless cases of the reversal of opioid toxicity by nonmedical personnel are reported in both the medical literature and the lay press, and naloxone distribution models are growing in many states. Pharmacists will be challenged to provide medication and educate in a way they have never considered before. In this issue of the journal, Cobaugh and colleagues14 provide a comprehensive overview of the use of opioids in clinical medicine and discuss the critical role of the pharmacist in helping to reverse the devastating effects of opioid misuse and overdose. This article is an indispensable reference for pharmacists in retail, hospital, administration, and policy-focused practice settings, as it highlights areas where each can have an impact on a problem that affects the entire nation. 1. Wilson JE, Pendleton JM. Oligoanalgesia in the emergency department. Am J Emerg Med. 1989; 7:620-3. 2. Goldfrank LR, Knopp RK. Racially and ethnically selective oligoanalgesia: is this racism? Ann Emerg Med. 2000; 35:79-82. 3. Sobel RM, Todd KH. Risk factors in oligoanalgesia. Am J Emerg Med. 2002; 20:126. 4. Lanser P, Gesell S. Pain management: the fifth vital sign. Healthc Benchmarks. 2001; 8(6):68-70, 62. 5. Increases in age-group-specific injury mortality—United States, 1999–2004. MMWR. 2007; 56:1281-4. 6. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR. 2011; 60:1487-92. 7. Motor-vehicle traffic and poisoning death rates, by age—United States, 2005–2006. MMWR. 2009; 58:753. 8. In brief: a naloxone auto-injector (Evzio). Med Lett Drugs Ther. 2014; 56(1444):45. 9. Clark AK, Wilder CM, Winstanley EL. A systematic review of community opioid overdose prevention and naloxone distribution programs. J Addict Med. 2014; 8(3):153-63. 10. Davis CS, Ruiz S, Glynn P et al. Expanded access to naloxone among firefighters, police officers, and emergency medical technicians in Massachusetts. Am J Public Health. 2014; 104:e7-9. 11. Doe-Simkins M, Quinn E, Xuan Z et al. Overdose rescues by trained and untrained participants and change in opioid use among substance-using participants in overdose education and naloxone distribution programs: a retrospective cohort study. BMC Public Health. 2014; 14:297. 12. Goodloe JM. Not so fast on naloxone? There’s growing support for non-paramedic use, but keep these cautions in mind. EMS World. 2014; 43(5):51-2. 13. Zuckerman M, Weisberg SN, Boyer EW. Pitfalls of intranasal naloxone. Prehosp Emergency Care. Epub ahead of print. 2014 May 15. 14. Cobaugh DJ, Gainor C, Gaston CL et al. The opioid abuse and misuse epidemic: implications for pharmacists in hospitals and health systems. Am J Health-Syst Pharm. 2014; 71:1539-54.
Robert S. Hoffman, M.D., FAACT, FACMT, FRCP Edin, FEAPCCT, Professor of Emergency Medicine and Medicine and Director, Division of Medical Toxicology New York University School of Medicine New York, NY [email protected] The author has declared no potential conflicts of interest. DOI 10.2146/ajhp140470 Am J Health-Syst Pharm—Vol 71 Sep 15, 2014
1537
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Editorial
ar Layar
Inadequate pain control versus opioid abuse: It is time for the pendulum to swing
W
hile pain is an unfortunate component of illness and injury, the ability to alleviate pain has been an essential part of the practice of medicine. Initial efforts in pain management focused on acute necessities such as surgical anesthesia and the easing of childbirth, with more recent advances addressing chronic problems such as cancer and palliative care. Naturally occurring drugs like willow extract, cocaine, and opium gave birth to a myriad of pharmaceuticals with diverse mechanisms of action and potencies, ranging from aspirin and nonsteroidal antiinflammatory drugs to local anesthetics and opioids. Clinicians, though limited by their inability to cure all disorders, took refuge in their capacity to alleviate pain and suffering and provide comfort to all in need with an expanding array of analgesics. However, around the late 1980s, reports of indifference to pain added a new and distasteful term to the medical lexicon: oligoanalgesia (the use of analgesics too infrequently or at doses insufficient to relieve pain).1 There were reports not only about overall physician insensitivity to patients’ pain but also about disparities in pain management related to race, sex, and age.2,3 The corrective action taken by the medical community was to enforce a more rigorous approach to the assessment, documentation, and treatment of pain. Pain became recognized as the “fifth vital sign”—a fundamental part of every patient encounter, requiring assessment and treatment as frequently as pulse, blood pressure, temperature, and breathing.4 Although entirely well-meaning, this paradigm shift was not without consequences. By 2004, unintentional poisoning— largely driven by an increase in the number of opioid-related deaths—surpassed firearms to become the second leading cause of injury-related fatalities (exceeded only by traffic accidents) in the United States.5 The trend continued, still driven by opioidrelated deaths, and by 2009 the number of poisoning fatalities approached the death toll from motor vehicle accidents, with poisoning deaths outnumbering traffic fatalities in the subgroup of adults between 34 and 56 years of age.6,7 The inappropriate prescribing of opioids, opioid diversion, opioid abuse, and opioid-related deaths have clearly reached epidemic proportions. In 2010, it was estimated that enough opioids were sold in the United States to administer 5 mg of hydrocodone to every adult every four hours for one month.5 Reversal of this trend will take a multidisciplinary effort among doctors, pharmacists, nurses, public health experts, and regulatory bodies. Efforts underway include detoxification programs, maintenance therapy with methadone and buprenorphine, prescribing limits, prescription monitoring programs, and prosecution of offending practitioners. Soon pharmacists will be faced with a new challenge. The Food and Drug Administration has just approved a spring-loaded naloxCopyright © 2014, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/14/0902-1537.
one delivery device.8 Like currently marketed devices for epinephrine administration, this new product will help facilitate the growing trend of naloxone delivery by nonmedical personnel.9-11 While still controversial,12,13 the use of naloxone in the community provides a safety net to help save lives when other efforts to curb opioid overdoses fail. Countless cases of the reversal of opioid toxicity by nonmedical personnel are reported in both the medical literature and the lay press, and naloxone distribution models are growing in many states. Pharmacists will be challenged to provide medication and educate in a way they have never considered before. In this issue of the journal, Cobaugh and colleagues14 provide a comprehensive overview of the use of opioids in clinical medicine and discuss the critical role of the pharmacist in helping to reverse the devastating effects of opioid misuse and overdose. This article is an indispensable reference for pharmacists in retail, hospital, administration, and policy-focused practice settings, as it highlights areas where each can have an impact on a problem that affects the entire nation. 1. Wilson JE, Pendleton JM. Oligoanalgesia in the emergency department. Am J Emerg Med. 1989; 7:620-3. 2. Goldfrank LR, Knopp RK. Racially and ethnically selective oligoanalgesia: is this racism? Ann Emerg Med. 2000; 35:79-82. 3. Sobel RM, Todd KH. Risk factors in oligoanalgesia. Am J Emerg Med. 2002; 20:126. 4. Lanser P, Gesell S. Pain management: the fifth vital sign. Healthc Benchmarks. 2001; 8(6):68-70, 62. 5. Increases in age-group-specific injury mortality—United States, 1999–2004. MMWR. 2007; 56:1281-4. 6. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR. 2011; 60:1487-92. 7. Motor-vehicle traffic and poisoning death rates, by age—United States, 2005–2006. MMWR. 2009; 58:753. 8. In brief: a naloxone auto-injector (Evzio). Med Lett Drugs Ther. 2014; 56(1444):45. 9. Clark AK, Wilder CM, Winstanley EL. A systematic review of community opioid overdose prevention and naloxone distribution programs. J Addict Med. 2014; 8(3):153-63. 10. Davis CS, Ruiz S, Glynn P et al. Expanded access to naloxone among firefighters, police officers, and emergency medical technicians in Massachusetts. Am J Public Health. 2014; 104:e7-9. 11. Doe-Simkins M, Quinn E, Xuan Z et al. Overdose rescues by trained and untrained participants and change in opioid use among substance-using participants in overdose education and naloxone distribution programs: a retrospective cohort study. BMC Public Health. 2014; 14:297. 12. Goodloe JM. Not so fast on naloxone? There’s growing support for non-paramedic use, but keep these cautions in mind. EMS World. 2014; 43(5):51-2. 13. Zuckerman M, Weisberg SN, Boyer EW. Pitfalls of intranasal naloxone. Prehosp Emergency Care. Epub ahead of print. 2014 May 15. 14. Cobaugh DJ, Gainor C, Gaston CL et al. The opioid abuse and misuse epidemic: implications for pharmacists in hospitals and health systems. Am J Health-Syst Pharm. 2014; 71:1539-54.
Robert S. Hoffman, M.D., FAACT, FACMT, FRCP Edin, FEAPCCT, Professor of Emergency Medicine and Medicine and Director, Division of Medical Toxicology New York University School of Medicine New York, NY [email protected] The author has declared no potential conflicts of interest. DOI 10.2146/ajhp140470 Am J Health-Syst Pharm—Vol 71 Sep 15, 2014
1537
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
