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Table 1. Retail Sales of Opioid Medications (Grams of Medication) from 1997 to 2007.  


Lessons Learned in the Abuse of Pain-Relief Medication: A Focus on Health Care Costs

  • Authors: Laxmaiah Manchikanti, MD; Mark V. Boswell, MD, PhD; Joshua A. Hirsch, MD
  • CME Released: 4/29/2013
  • Valid for credit through: 4/29/2014
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Target Audience and Goal Statement

This activity is intended for primary care physicians, pain management specialists, and other physicians who might prescribe opioid analgesics.

The goal of this activity is to evaluate the problem of opioid medication abuse and how to improve it.

Upon completion of this activity, participants will be able to:

  1. Assess the epidemiology of prescription opioid abuse
  2. Distinguish the health impact of prescription opioid abuse
  3. Distinguish the economic impact of prescription opioid abuse
  4. Identify means to reduce the risk of prescription opioid abuse


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Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


  • Laxmaiah Manchikanti, MD

    Medical Director, Pain Management Center of Paducah, Paducah, Kentucky; Associate Clinical Professor, Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, Kentucky


    Disclosure: Laxmaiah Manchikanti, MD, has disclosed no relevant financial relationships.

  • Mark V. Boswell, MD, PhD

    Chairman, Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, Kentucky


    Disclosure: Mark V. Boswell, MD, PhD, has disclosed no relevant financial relationships.

  • Joshua A. Hirsch, MD

    Vice Chief of Interventional Care, Department of Radiology, Massachusetts General Hospital; Associate Professor of Radiology, Harvard Medical School, Boston, Massachusetts


    Disclosure: Joshua A. Hirsch, MD, has disclosed no relevant financial relationships.


  • Elisa Manzotti

    Publisher, Future Science Group, London, United Kingdom


    Disclosure: Elisa Manzotti has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Associate Professor and Residency Director, Department of Family Medicine, University of California-Irvine, Irvine


    Disclosure: Charles P. Vega, MD, has disclosed no relevant financial relationships.

CME Reviewer

  • Nafeez Zawahir, MD

    CME Clinical Director, Medscape, LLC


    Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.

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    For Physicians

  • This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Medscape, LLC and Expert Reviews, Ltd. Medscape is accredited by the ACCME to provide continuing medical education for physicians.

    Medscape, LLC designates this Journal-based CME activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Medscape, LLC staff have disclosed that they have no relevant financial relationships.

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Lessons Learned in the Abuse of Pain-Relief Medication: A Focus on Health Care Costs

Authors: Laxmaiah Manchikanti, MD; Mark V. Boswell, MD, PhD; Joshua A. Hirsch, MDFaculty and Disclosures

CME Released: 4/29/2013

Valid for credit through: 4/29/2014


Abstract and Introduction


The increasing prevalence of chronic pain with its major societal impact and the escalating use of opioids in managing it, along with their misuse, abuse, associated fatalities and costs, are epidemics in modern medicine. Over the past two decades, multiple lessons have been learned addressing various issues of abuse. Multiple measures have already been incorporated and more are expected to be incorporated in the future, which in turn may curtail the abuse of drugs and reduce healthcare costs, but these measures may also jeopardize access to appropriate pain treatment. This manuscript describes the lessons learned from the misuse, abuse and diversion of opioids, escalating healthcare costs and the means to control this epidemic.


Over the past two decades the world has not only learned about, but continues to attempt to control escalating chronic pain and associated disability, as well as opioid use, abuse and related fatalities.[1–14] In its 2006 report, the International Narcotics Control Board (INCB) noted that medications containing narcotic or psychotropic drugs were becoming the drugs of choice for many abusers.[15] They warned that the worldwide abuse of prescription drugs would soon exceed illicit drug use.[15] In fact, a 2011 report of the INCB reported that abuse of prescription drugs was growing rapidly around the world with more people abusing legal narcotics than heroin, cocaine and ecstasy combined.[201] It is commonly stated that there has and continues to be an escalation in the utilization of all types of interventions in managing chronic pain, but opioids and other prescription-controlled substances have taken a central role in the debate on increasing healthcare costs and related fatalities.[4–14,16–18] Consequently, the overuse and abuse of prescription drugs have been emphasized as a major and growing health problem globally by leading international monitoring entities.[15,201–203] Prescription drug abuse, while most prevalent in the USA, is also a problem in many areas around the world including Canada, Australia, Europe, Southern Africa and South Asia with tens of millions of people giving up control of their lives in favor of addiction.[11,12,15,19,201–204]

The past several years have seen soaring rates of prescription drug abuse across the USA, followed by rising numbers of deaths involving prescription drug overdoses.[204] Emergency department visits related to prescription drug abuse now exceed the number of visits related to illicit drug use.[204] However, it is not limited to the USA alone. Recently, it was reported that correlated to increasingly high overall prescription opioid consumption levels, nonmedical prescription opioid use and harms in Canada are high and now likely constitute the third highest level of substance-use disease burden after alcohol and tobacco.[11,20] Similarly, prescription opioid analgesics and related harms in Australia have been reported.[12]

Casati et al. performed a systematic review of the literature concerning the misuse of medicines in the EU, which showed an alarming increase;[19] multiple studies showed that opioids, sedatives and hypnotics have been extensively misused throughout Europe.[19] In Germany, the estimates show that between 1.3 and 1.4 million people are dependent on prescription drugs, representing approximately 1.6 or 1.7% of the German population.[19] One study showed that in Germany, approximately 25% of nursing home residents over the age of 70 are addicted to psychotropic drugs.[21] In addition, of Germans over 60 years old, between 1.7 and 2.8 million misuse psychotropic drugs or pain killers or are dependent on these substances. In a cross-sectional postal survey in the UK,[22] the past 2-week prevalence of nonprescription analgesic use was 37%. In Spain, it has been shown that 11.6% of the subjects in one study had a lifetime prevalence for substance-use disorder related to an opioid other than heroin.[23] In Denmark, a literature review showed that dependence prevalence rates for chronic nonmalignant pain patients were as high as 50%, depending on the patient population studied and the criteria used.[24] In France, multiple studies showed the misuse and abuse of multiple opioids, including such drugs as transdermal fentanyl and Actiq (fentanyl citrate).[19] There are no up-to-date data available for the nontherapeutic use of psychotherapeutic drugs in other countries. Based on the report by Casati et al., in Canada, an estimated 1.3% of the population abused prescription opioids, and in several European countries – such as France, Italy, Lithuania and Poland – between 10 and 18% of students use sedatives or tranquilizers without a prescription.[19]