Journal of Pain & Palliative Care Pharmacotherapy. 2014;28:2–3. Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 1536-0288 print / 1536-0539 online DOI: 10.3109/15360288.2014.880545
EDITORIAL
Perspective and Balance on Opioid Misuse Both the lay and professional media have increasingly focused on harm due to misuse of opioids in recent years. In the United States, we have seen the FDA implement a Risk Management and Mitigation Strategy (REMS) for long acting opioids,1,2 increasing numbers of reports of deaths from prescribed opioids,3 and calls for restraint in prescribing these strong analgesics due to mounting concerns about misuse.4 This journal has attempted to provide balanced discussions on these controversial issues for over a decade. The majority of media reports call for limiting the use of opioids, and this presents serious risks for undertreatment of patients for whom these drugs are clinically indicated. Many recommendations for limiting opioid use are based on assumptions and anecdotes. There have been tragic deaths due to opioid overuse and misuse. But some reports extrapolate worst case scenarios to the population making decreased opioid use appear to be a mandate.5 In the lay media and at public policy open meetings, parents of young people who overdosed on opioids have called for complete withdrawal of important medications. Indeed, when grieving parents argue that the drugs which caused their childrens’ deaths should be removed from the market, public sympathy is generated. While these calls are well intentioned, our heeding them would usually result in public harm, not good. Unquestionably, some overly zealous prescribing of opioid has led to tragic outcomes.6 Increased education and training in pain management is sorely needed in nearly all health professional schools,7 and the International Association for the Study of Pain (IASP) has developed balanced curriculum outlines for schools and students of medicine, dentistry, nursing, pharmacy, psychology, and physical and occupational therapy.8 These can be very helpful in establishing teaching courses on acute, chronic, and cancer pain at both the undergraduate and graduate level. While balanced research into safe and effective opioid use is increasing, too few objective data exist today. Prescription monitoring programs (PMPs) can
be useful in limiting inappropriate opioid prescribing and this journal has been reporting on such programs for nearly a decade.9 In this issue of the journal, we present a study on factors that influence emergency department physicians’ use of PMPs.10 We will continue to seek and publish well done studies on this important issue. Patients in much of the world have suffered greatly due to lack of opioid availability while Americans have had the luxury of ready access to clinically-indicated and legitimately prescribed opioid medications.11,12 We maintain that it is incumbent upon all pain clinicians to continually call for balance in opioid prescribing policy and practices. We must clearly refute calls for excessive limitations on opioid availability that would prevent patients from getting needed medications, while also working to minimize excessive and inappropriate opioid prescribing and use. As in most areas of medical care, balance is the key. Any call for extremes in medication access or limitation is usually dangerous. A fair balance between opioid use and control is needed. This must not be done in a manner that places patients with pain at risk of inadequate access to needed mediations. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Arthur G. Lipman, PharmD, Editor
REFERENCES [1] Gudin J. Risk Evaluation and Mitigation Strategies (REMS) for extended-release and long-acting opioid analgesics: considerations for palliative care practice. J Pain Palliat Care Pharmacother. 2012 Jun;26(2):136–43. [2] Craig DS.The Food and Drug Administration risk evaluation and mitigation strategy. J Pain Palliat Care Pharmacother. 2010 Jun;24(2):145–8. [3] Trevino CM, deRoon-Cassini T, Brasel K. Does opiate use in traumatically injured individuals worsen pain and psychological outcomes? J Pain. 2013 Apr;14(4):424–30.
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Editorial [4] Maurer MA, Gilson AM, Husain SA, Cleary JF. Examining influences on the availability of and access to opioids for pain management and palliative care. J Pain Palliat Care Pharmacother. 2013 Aug;27(3):255–60 [5] Sullivan MD, Howe CQ Opioid therapy for chronic pain in the United States: promises and perils. Pain. 2013 Dec;154 Suppl 1:S94–100. [6] Fischer B, Jones W, Rehm J. High correlations between levels of consumption and mortality related to strong prescription opioid analgesics in British Columbia and Ontario, 2005–2009. Pharmacoepidemiol Drug Saf. 2013 Apr;22(4): 438–42 [7] Kress HG. The importance of putting pain on the curricula in medical schools in Europe. J Pain Palliat Care Pharmacother. 2013 Jun;27(2):182–4 [8] http://www.iasp-pain.org/Content/NavigationMenu/General ResourceLinks/Curricula/default.htm
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2014 Informa Healthcare USA, Inc.
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[9] Barrett K, Watson A. Physician perspectives on a pilot prescription monitoring program. J Pain Palliat Care Pharmacother. 2005;19(3):5–13. [10] Fleming ML, Hatfield MD, Wattana MK, Todd KH. Exploratory study of emergency physicians’ use of a prescription monitoring program using a framework of technology acceptance. J Pain Palliat Care Pharmacother. 2014; 28(1):PRODUCTION DEPT PLEASE PUT IN PAGE NUMBERS FROM THIS ISSUE [11] University of Wisconsin Pain & Policy Studies Group. Do international model drug control laws provide for drug availability? J Pain Palliat Care Pharmacother. 2009;23(2):145–52. [12] Radbruch L, De Lima L, Bennett M, Cleary J, Currow D, Lipman A, Murray S, Pastrana T. Essential Medicines in Palliative Care. An Application for the 19th WHO Expert Committee on the Selection and Use of Essential Medicines. Houston Texas, IAHPC Press, 2013.
Copyright of Journal of Pain & Palliative Care Pharmacotherapy is the property of Taylor & Francis Ltd 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
Perspective and Balance on Opioid Misuse Both the lay and professional media have increasingly focused on harm due to misuse of opioids in recent years. In the United States, we have seen the FDA implement a Risk Management and Mitigation Strategy (REMS) for long acting opioids,1,2 increasing numbers of reports of deaths from prescribed opioids,3 and calls for restraint in prescribing these strong analgesics due to mounting concerns about misuse.4 This journal has attempted to provide balanced discussions on these controversial issues for over a decade. The majority of media reports call for limiting the use of opioids, and this presents serious risks for undertreatment of patients for whom these drugs are clinically indicated. Many recommendations for limiting opioid use are based on assumptions and anecdotes. There have been tragic deaths due to opioid overuse and misuse. But some reports extrapolate worst case scenarios to the population making decreased opioid use appear to be a mandate.5 In the lay media and at public policy open meetings, parents of young people who overdosed on opioids have called for complete withdrawal of important medications. Indeed, when grieving parents argue that the drugs which caused their childrens’ deaths should be removed from the market, public sympathy is generated. While these calls are well intentioned, our heeding them would usually result in public harm, not good. Unquestionably, some overly zealous prescribing of opioid has led to tragic outcomes.6 Increased education and training in pain management is sorely needed in nearly all health professional schools,7 and the International Association for the Study of Pain (IASP) has developed balanced curriculum outlines for schools and students of medicine, dentistry, nursing, pharmacy, psychology, and physical and occupational therapy.8 These can be very helpful in establishing teaching courses on acute, chronic, and cancer pain at both the undergraduate and graduate level. While balanced research into safe and effective opioid use is increasing, too few objective data exist today. Prescription monitoring programs (PMPs) can
be useful in limiting inappropriate opioid prescribing and this journal has been reporting on such programs for nearly a decade.9 In this issue of the journal, we present a study on factors that influence emergency department physicians’ use of PMPs.10 We will continue to seek and publish well done studies on this important issue. Patients in much of the world have suffered greatly due to lack of opioid availability while Americans have had the luxury of ready access to clinically-indicated and legitimately prescribed opioid medications.11,12 We maintain that it is incumbent upon all pain clinicians to continually call for balance in opioid prescribing policy and practices. We must clearly refute calls for excessive limitations on opioid availability that would prevent patients from getting needed medications, while also working to minimize excessive and inappropriate opioid prescribing and use. As in most areas of medical care, balance is the key. Any call for extremes in medication access or limitation is usually dangerous. A fair balance between opioid use and control is needed. This must not be done in a manner that places patients with pain at risk of inadequate access to needed mediations. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Arthur G. Lipman, PharmD, Editor
REFERENCES [1] Gudin J. Risk Evaluation and Mitigation Strategies (REMS) for extended-release and long-acting opioid analgesics: considerations for palliative care practice. J Pain Palliat Care Pharmacother. 2012 Jun;26(2):136–43. [2] Craig DS.The Food and Drug Administration risk evaluation and mitigation strategy. J Pain Palliat Care Pharmacother. 2010 Jun;24(2):145–8. [3] Trevino CM, deRoon-Cassini T, Brasel K. Does opiate use in traumatically injured individuals worsen pain and psychological outcomes? J Pain. 2013 Apr;14(4):424–30.
2
Editorial [4] Maurer MA, Gilson AM, Husain SA, Cleary JF. Examining influences on the availability of and access to opioids for pain management and palliative care. J Pain Palliat Care Pharmacother. 2013 Aug;27(3):255–60 [5] Sullivan MD, Howe CQ Opioid therapy for chronic pain in the United States: promises and perils. Pain. 2013 Dec;154 Suppl 1:S94–100. [6] Fischer B, Jones W, Rehm J. High correlations between levels of consumption and mortality related to strong prescription opioid analgesics in British Columbia and Ontario, 2005–2009. Pharmacoepidemiol Drug Saf. 2013 Apr;22(4): 438–42 [7] Kress HG. The importance of putting pain on the curricula in medical schools in Europe. J Pain Palliat Care Pharmacother. 2013 Jun;27(2):182–4 [8] http://www.iasp-pain.org/Content/NavigationMenu/General ResourceLinks/Curricula/default.htm
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2014 Informa Healthcare USA, Inc.
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[9] Barrett K, Watson A. Physician perspectives on a pilot prescription monitoring program. J Pain Palliat Care Pharmacother. 2005;19(3):5–13. [10] Fleming ML, Hatfield MD, Wattana MK, Todd KH. Exploratory study of emergency physicians’ use of a prescription monitoring program using a framework of technology acceptance. J Pain Palliat Care Pharmacother. 2014; 28(1):PRODUCTION DEPT PLEASE PUT IN PAGE NUMBERS FROM THIS ISSUE [11] University of Wisconsin Pain & Policy Studies Group. Do international model drug control laws provide for drug availability? J Pain Palliat Care Pharmacother. 2009;23(2):145–52. [12] Radbruch L, De Lima L, Bennett M, Cleary J, Currow D, Lipman A, Murray S, Pastrana T. Essential Medicines in Palliative Care. An Application for the 19th WHO Expert Committee on the Selection and Use of Essential Medicines. Houston Texas, IAHPC Press, 2013.
Copyright of Journal of Pain & Palliative Care Pharmacotherapy is the property of Taylor & Francis Ltd 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.
