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• An insight into opioid use and its deleterious effects in a setting where there are no limits to providing opioids.
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Author(s)

Laxmaiah Manchikanti, MD

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

Disclosures

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

Disclosures

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

Disclosures

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

Editor

Elisa Manzotti

Publisher, Future Science Group, London, United Kingdom

Disclosures

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

Disclosures

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

CME Reviewer

Nafeez Zawahir, MD

CME Clinical Director, Medscape, LLC

Disclosures

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

CME

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
THIS ACTIVITY HAS EXPIRED
Valid for credit through: 4/29/2014

Start Activity

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:

Assess the epidemiology of prescription opioid abuse
Distinguish the health impact of prescription opioid abuse
Distinguish the economic impact of prescription opioid abuse
Identify means to reduce the risk of prescription opioid abuse

Disclosures

Author(s)

Laxmaiah Manchikanti, MD

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

Disclosures

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

Disclosures

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

Disclosures

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

Editor

Elisa Manzotti

Publisher, Future Science Group, London, United Kingdom

Disclosures

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

Disclosures

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

CME Reviewer

Nafeez Zawahir, MD

CME Clinical Director, Medscape, LLC

Disclosures

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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For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]

Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 70% on the post-test.

Follow these steps to earn CME/CE credit*:

Read the target audience, learning objectives, and author disclosures.
Study the educational content online or printed out.
Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates from the CME/CE Tracker.

*The credit that you receive is based on your user profile.

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How Did We Get Here?

Opioid prescriptions for chronic noncancer pain skyrocketed in the late 1990s. The primary driver was the lifting of restrictions on opioid prescribing by state medical boards.^[213] Once these restrictions were lifted, other changes occurred, resulting in runaway opioid prescriptions. Among the changes were new standards for both inpatient and outpatient pain management, implemented in 2000 by the Joint Commission on Accreditation of Healthcare Organizations^[42] and the concept of a patient’s right to pain relief, resulting in the validation physicians needed to increase their opioid prescribing.^[4–6]

With the door open to acceptance, those with vested interests in opioid prescribing jumped into action. The pharmaceutical industry unleashed their marketing machine, many physicians promoted opioids and a number of organizations called for increasing opioid treatment for patients with chronic noncancer pain.^[4–6] However well meaning, these positions were based on misinformation and unsound science; the justification for increased opioid prescribing was that it was safe and effective so long as the opioids were prescribed by a physician.^{[4–6,38,39,214]}

One irony to come out of this groundswell of support for opioid prescribing is that many model guidelines, whose intent was to curtail controlled substance abuse, actually appeared to condone an increase in opioid prescribing.^[4–6,43] One guideline seems to absolve prescribers from the responsibility for their actions: ‘no disciplinary action will be taken against a practitioner based solely on the quantity and/or frequency of opioids prescribed’.^[213]

The result of all these factors is that opioid prescribing, including long-acting and potent forms, has increased exponentially. This increase has been driven by regulations based on weak evidence that opioids are highly effective and safe, especially when administered to those with chronic noncancer pain, as well as questionable selection criteria.^[4–6,214]

Today, there is still no unmistakable scientific evidence that opioids are effective for chronic noncancer pain.^{[4–6,43–53,214]} Opioids’ lack of effectiveness is not the only troubling concern regarding chronic opioid therapy. There is mounting evidence that opioids have multiple physiological and nonphysiological adverse effects including: opioid-induced hyperalgesia, misuse and abuse, providers not trained to identify or monitor their patients for misuse and overuse and fatalities related to opioids, which have steadily been climbing.^{[4–6,43–75,214–217]}

The steady increase in fatalities caused by opioids, coupled with the scant evidence for their effectiveness, begs the question of who will be held responsible for opioids being adopted prematurely as a treatment standard.^[4–6] Some have predicted that there will be a ‘postmortem’ on runaway opioid prescribing and the social ills that have accompanied it. Among those social ills are the damage done by opioid diversion, misuse and abuse. Prescribing opioids for chronic noncancer pain violates a sacred principle of medical intervention – there should be convincing evidence of a treatment’s benefit before its large-scale use.

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Impact on Healthcare Costs

CME Information

References

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

CME

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

Target Audience and Goal Statement

Disclosures

Author(s)

Laxmaiah Manchikanti, MD

Mark V. Boswell, MD, PhD

Joshua A. Hirsch, MD

Editor

Elisa Manzotti

CME Author

Charles P. Vega, MD

CME Reviewer

Nafeez Zawahir, MD