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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.

Accreditation Statements

    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: Consequences of Excessive Opioid Use


Consequences of Excessive Opioid Use

Figure 2.


Opioid-Related Deaths, 1999–2010 in all Categories. Data taken from [33].

Figure 3.


Deaths from Unintentional Drug Overdoses in the USA According to Major Type of Drug, 1999–2007. Adapted with permission from [211].

Figure 4.


Rates* of Opioid Pain Reliever Overdose Deaths, Opioid Pain Relief Treatment Admissions and Kilograms of Opioid Pain Relievers Sold – USA, 1999–2010.
*Age-adjusted rates per 100,000 population for OPR deaths, crude rates per 10,000 population for OPR abuse treatment admissions and crude rates per 10,000 population for kilograms of OPR sold. Adapted with permission from [33].

The number of deaths in the USA ascribed to prescription drugs is staggering, including those caused by opioids. In 2008, 36,450 deaths were credited to a drug overdose. Of these, a specific drug was attributed in 27,153 deaths, and of these, one or more prescription drugs were implicated in 20,044 deaths; 14,800 of these 20,044 deaths involved opioids.[33] In fact, published on 19 February 2013, the latest report from the CDC showed that continuing a trend that began more than a decade ago, in 2010, 16,651 people died of overdoses involving prescription opioids compared with 4030 such deaths in 1999, an increase of 313.2%. The CDC researchers once again wrote that this analysis confirms the predominant role opioid analgesics play in pharmaceutical overdose deaths, either alone or in combination with other drugs (Figure 2).[40] Opioid analgesics caused more overdose deaths in 2007 than heroin and cocaine combined (Figure 3).[41,210–212] Concurrently, suicide caused by drugs increased; by 2007, there were 8400 overdose deaths in the USA that were either suicide or the deceased’s intent could not be ascertained. Approximately 3000 of those deaths involved opioids.[34] In addition, for every unintentional opioid analgesic overdose death, nine were admitted for substance abuse treatment, 35 visited emergency departments, 161 reported drug abuse or dependence and 461 reported nonmedical use of opioid analgesics.[41] Furthermore, in 2007, non-suicidal drug poisoning deaths not related to suicide exceeded either motor vehicle accidents or suicide deaths in 20 states with data from Ohio illustrating the number of deaths from unintentional drug poisoning exceeding the numbers of deaths from both suicide and motor vehicle accidents combined.[34,212] A Government Accountability Office (GAO) report also concluded that key measures of prescription pain-reliever abuse and misuse increased from 2003 to 2009.[210] Consequently, a conclusion has been reached by many that opioid analgesic abuse contributed to increasing fatalities based on opioid abuse and increasing doses, doctor shopping and other aspects of drug abuse as illustrated in Figure 4.[33] Furthermore, the data from emergency department visits also illustrate that the use of opioids, sedatives and nonprescription sleep aids taken more than prescribed medication or solely for the feeling they cause continued to increase through 2009.[4–6,41]

Opioid abuse has been fueled by multiple factors including legitimate and easy availability in rural as well as urban areas, high street values and comorbid mental illnesses.[4–6,34]