JOURNAL OF PALLIATIVE MEDICINE Volume 18, Number 9, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2015.0265
Notes from the Editor
The Pain Pendulum Swinging Again Daniel David Matlock, MD, MPH, Associate Editor
W
hen I began my medical training 20 years ago, there were major concerns about the undertreatment of pain. In response, I was taught to treat nonmalignant pain similarly to malignant pain. I even remember reading articles arguing that patients with true nonmalignant pain will not become addicted.2 These concerns about undertreatment were reiterated in the 2011 Institute of Medicine report Relieving Pain in America.1 Perspectives on pain have changed drastically since then. Important studies have questioned the long-term benefit of chronic opiates for nonmalignant pain.3 More importantly, the rapidly increasing rates of nonmedical opiate use are extremely alarming. The 2013 National Survey on Drug Use and Health demonstrates that 4.5 million persons aged 12 or older report current nonmedical use of prescription pain medications. In 2013 alone, two million people—or about 5500 per day—used psychotherapeutics nonmedically for the first time.4 These data have grabbed the attention of regulators, who are starting to impose restrictions such as daily dose and monthly pill limits. In my primary care practice I have recently made a conscious decision to monitor my patients more closely. As a palliative trained primary care physician, my practice has been enriched over the years with a host of patients on chronic opiates, often from internal referrals within my clinic. While I would have long discussions with patients about the safety of these medications and the importance of a multidisciplinary plan of care regarding pain, I still sometimes used opiates. Admittedly, I haven’t been as diligent as I could or should have been in using opiate agreements or urine toxicology screens for drugs of abuse, largely because these interventions, too, suffer from a paucity of evidence. Recently I discovered that one of my patients likely wasn’t taking the medications as prescribed. For years, even before I became his physician, he had been taking benzodiazepines for anxiety and opiates for pain. I randomly checked his urine and there were no benzodiazepines or opiates (there was marijuana, but this is Colorado). I learned in a quick literature search that the benzodiazepine should have been detectable in his urine for two to three weeks. I spoke to several primary care colleagues about how I should handle this. I received responses ranging from ‘‘continue to prescribe and repeat the testing’’ to ‘‘never fill them again’’ to ‘‘fire him from our clinic.’’ It turns out that the oxycodone he was taking was not detected in the traditional urine toxicology screen that I or-
dered. Instead, I was supposed to order a separate urine toxicology screen designated for ‘‘pain management’’ if I wanted evidence he was taking the oxycodone. However, the benzodiazepine should have been there. After a long and agonizing clinic visit, he left without further medication. I would characterize my personal attempt to improve the safety of these medications as clumsy. What does this mean for palliative care? This issue of the Journal of Palliative Medicine includes a small but provocative survey of academic palliative care programs across the country.5 The results demonstrate that perhaps some of us in palliative medicine are being naı¨ve. Half of the respondents recognized that substance abuse and diversion were potential problems, but the other half did not. More surprising, only about a quarter had any written policies related to screening for substance abuse or diversion. Given the abuse statistics cited above, this lack of concern among some programs is problematic. Another patient story illustrates the challenge of opiate prescription. One of my patients with end-stage metastatic prostate cancer experienced a significant increase in pain and took more of the short-acting opiate—at my encouraging. When I saw him in clinic, we increased his long-acting opiate and I gave him a prescription for another #120 short-acting opiate. I found out the next Monday that the pharmacy did not refill the medication because the insurance would not pay for the ‘‘early’’ refill. He suffered all weekend from severe pain. Once the insurance company realized that this was for cancer, they reluctantly agreed to the ‘‘early’’ refill. Which is the greater evil? Is it worse to give a patient opiates who intends to abuse or divert them, or is it worse to create a system where the undertreatment of pain is exacerbated? The sensitivity and specificity of our evaluation to distinguish between these two groups will never be 100%. There will always be false positives and false negatives— regardless of where you draw your line. The landscape of prescription pain medication is changing, and the trends of increasing abuse have to be stopped. Concerns about these trends will diffuse to malignant pain, if they haven’t already. We in palliative medicine must take the lead in these discussions. As the authors of the survey state in their articulate discussion, ‘‘Given the increasing regulatory concern about opioid prescribing, failure of palliative care and oncology programs to develop best practice guidelines and follow them voluntarily is likely to result in regulations being developed by outside agencies such as the DEA, which do not fit the patient populations we care for.’’5
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NOTES FROM THE EDITOR References
1. Institute of Medicine: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Institute of Medicine, 2011. 2. Portenoy RK, Foley KM: Chronic use of opioid analgesics in non-malignant pain: Report of 38 cases. Pain 1986;25: 171–186. 3. Chou R, Deyo R, Devine B, et al.: The effectiveness and risks of long-term opioid treatment of chronic pain. (Evidence report/technology assessment no. 218.) Rockville, MD: Agency for Healthcare Research and Quality, 2014. 4. Substance Abuse and Mental Health Services Administration: Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. (NSDUH series H-48, HHS
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publication no. (SMA) 14-4863.) Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. 5. Tan PD, Barclay J, Blackhall L: Do palliative care clinics screen for substance abuse and diversion? Results of a national survey. J Pallit Med 2015;18:752–757.
Address correspondence to: Daniel David Matlock, MD, MPH Department of Medicine University of Colorado School of Medicine 12631 E 17th Avenue, Box B-180 Aurora, CO 80045 E-mail: [email protected]
Notes from the Editor
The Pain Pendulum Swinging Again Daniel David Matlock, MD, MPH, Associate Editor
W
hen I began my medical training 20 years ago, there were major concerns about the undertreatment of pain. In response, I was taught to treat nonmalignant pain similarly to malignant pain. I even remember reading articles arguing that patients with true nonmalignant pain will not become addicted.2 These concerns about undertreatment were reiterated in the 2011 Institute of Medicine report Relieving Pain in America.1 Perspectives on pain have changed drastically since then. Important studies have questioned the long-term benefit of chronic opiates for nonmalignant pain.3 More importantly, the rapidly increasing rates of nonmedical opiate use are extremely alarming. The 2013 National Survey on Drug Use and Health demonstrates that 4.5 million persons aged 12 or older report current nonmedical use of prescription pain medications. In 2013 alone, two million people—or about 5500 per day—used psychotherapeutics nonmedically for the first time.4 These data have grabbed the attention of regulators, who are starting to impose restrictions such as daily dose and monthly pill limits. In my primary care practice I have recently made a conscious decision to monitor my patients more closely. As a palliative trained primary care physician, my practice has been enriched over the years with a host of patients on chronic opiates, often from internal referrals within my clinic. While I would have long discussions with patients about the safety of these medications and the importance of a multidisciplinary plan of care regarding pain, I still sometimes used opiates. Admittedly, I haven’t been as diligent as I could or should have been in using opiate agreements or urine toxicology screens for drugs of abuse, largely because these interventions, too, suffer from a paucity of evidence. Recently I discovered that one of my patients likely wasn’t taking the medications as prescribed. For years, even before I became his physician, he had been taking benzodiazepines for anxiety and opiates for pain. I randomly checked his urine and there were no benzodiazepines or opiates (there was marijuana, but this is Colorado). I learned in a quick literature search that the benzodiazepine should have been detectable in his urine for two to three weeks. I spoke to several primary care colleagues about how I should handle this. I received responses ranging from ‘‘continue to prescribe and repeat the testing’’ to ‘‘never fill them again’’ to ‘‘fire him from our clinic.’’ It turns out that the oxycodone he was taking was not detected in the traditional urine toxicology screen that I or-
dered. Instead, I was supposed to order a separate urine toxicology screen designated for ‘‘pain management’’ if I wanted evidence he was taking the oxycodone. However, the benzodiazepine should have been there. After a long and agonizing clinic visit, he left without further medication. I would characterize my personal attempt to improve the safety of these medications as clumsy. What does this mean for palliative care? This issue of the Journal of Palliative Medicine includes a small but provocative survey of academic palliative care programs across the country.5 The results demonstrate that perhaps some of us in palliative medicine are being naı¨ve. Half of the respondents recognized that substance abuse and diversion were potential problems, but the other half did not. More surprising, only about a quarter had any written policies related to screening for substance abuse or diversion. Given the abuse statistics cited above, this lack of concern among some programs is problematic. Another patient story illustrates the challenge of opiate prescription. One of my patients with end-stage metastatic prostate cancer experienced a significant increase in pain and took more of the short-acting opiate—at my encouraging. When I saw him in clinic, we increased his long-acting opiate and I gave him a prescription for another #120 short-acting opiate. I found out the next Monday that the pharmacy did not refill the medication because the insurance would not pay for the ‘‘early’’ refill. He suffered all weekend from severe pain. Once the insurance company realized that this was for cancer, they reluctantly agreed to the ‘‘early’’ refill. Which is the greater evil? Is it worse to give a patient opiates who intends to abuse or divert them, or is it worse to create a system where the undertreatment of pain is exacerbated? The sensitivity and specificity of our evaluation to distinguish between these two groups will never be 100%. There will always be false positives and false negatives— regardless of where you draw your line. The landscape of prescription pain medication is changing, and the trends of increasing abuse have to be stopped. Concerns about these trends will diffuse to malignant pain, if they haven’t already. We in palliative medicine must take the lead in these discussions. As the authors of the survey state in their articulate discussion, ‘‘Given the increasing regulatory concern about opioid prescribing, failure of palliative care and oncology programs to develop best practice guidelines and follow them voluntarily is likely to result in regulations being developed by outside agencies such as the DEA, which do not fit the patient populations we care for.’’5
734
NOTES FROM THE EDITOR References
1. Institute of Medicine: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Institute of Medicine, 2011. 2. Portenoy RK, Foley KM: Chronic use of opioid analgesics in non-malignant pain: Report of 38 cases. Pain 1986;25: 171–186. 3. Chou R, Deyo R, Devine B, et al.: The effectiveness and risks of long-term opioid treatment of chronic pain. (Evidence report/technology assessment no. 218.) Rockville, MD: Agency for Healthcare Research and Quality, 2014. 4. Substance Abuse and Mental Health Services Administration: Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. (NSDUH series H-48, HHS
735
publication no. (SMA) 14-4863.) Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. 5. Tan PD, Barclay J, Blackhall L: Do palliative care clinics screen for substance abuse and diversion? Results of a national survey. J Pallit Med 2015;18:752–757.
Address correspondence to: Daniel David Matlock, MD, MPH Department of Medicine University of Colorado School of Medicine 12631 E 17th Avenue, Box B-180 Aurora, CO 80045 E-mail: [email protected]
