Pain Control Advances Leave Troublesome Legacy

The beginning of the new millennium brought unprecedented focus to the issue of pain control.

In 1997, the American Academy of Pain Medicine and the American Pain Society teamed up to promulgate guidelines on the use of opioids for the treatment of chronic pain; the American Society of Anesthesiologists introduced their guidelines for chronic pain management that year as well. In late 2000, Congress passed and President Clinton signed into law a measure that declared the period that began January 1, 2001, as the Decade of Pain Control and Research. Also in January 2001, the Joint Commission presented pain-management standards for ambulatory care facilities, behavioral health care organizations, hospitals, and other medical care settings. In 2004, the Federation of State Medical Boards published its model policy for the use of controlled substances for pain treatment.

Advocates of pain control hailed the results of these events, saying they've led to heightened awareness, improved treatment, and more funding for pain-control efforts and research. But as the "Decade" ended, it left behind a less desirable legacy of unintended consequences: that of a spectacular rise in the diversion and abuse of opioid pain-control medications.

Nowhere has that been more evident than in West Virginia, where the nation's most substantial increase in drug overdose mortality rates—a 550 percent jump—occurred from 1999 to 2004. In 2006, 295 West Virginia residents suffered unintentional overdose with prescription pharmaceuticals, the majority of which were due to nonmedical use and diversion of opioid analgesics, according to a report in the December 10, 2008, Journal of the American Medical Association (JAMA).

And West Virginia is by no means alone. Statistics from the Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Administration are equally alarming:

In the April 6 JAMA, Amy Bohnert, Ph.D., of the Department of Veterans Affairs Health Services Research and Development Center of Excellence, and the Serious Mental Illness Treatment Resource and Evaluation Center in Ann Arbor, Mich., and colleagues described their efforts to see if there is an association between the maximum prescribed daily opioid dose and dosing schedule ("as needed," regularly scheduled, or both) and the risk of opioid overdose death. "Among patients receiving opioid prescriptions for pain, higher opioid doses—those equivalent to 50 mg/day or more of morphine—were associated with increased risk of opioid overdose death," the researchers found.