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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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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*:

  1. Read the target audience, learning objectives, and author disclosures.
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  3. 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.

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Lessons Learned in the Abuse of Pain-Relief Medication: A Focus on Health Care Costs: How Did We Get Here?


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.