Drug War Facts : Pain Management

"Unbalanced and misleading media coverage on the abuse of opioid analgesics not only perpetuates misconceptions about pain management; it compromises the access to adequate pain relief sought by over 50 million Americans living with pain.
"In the past several years, there has been growing recognition on the part of health care providers, government regulators, and the public that the undertreatment of pain is a major societal problem.
"Pain of all types is undertreated in our society. The pediatric and geriatric populations are especially at risk for undertreatment. Physicians’ fears of using opioid therapy, and the fears of other health professionals, contribute to the barriers to effective pain management."

Source: American Medical Association, "About the AMA Position on Pain Management Using Opioid Analgesics," 2004, from the web at http://www.ama-assn.org/ama/pub/category/11541.html, last accessed March 1, 2004.

"The AMA supports the position that (1) physicians who appropriately prescribe and/or administer controlled substances to relieve intractable pain should not be subject to the burdens of excessive regulatory scrutiny, inappropriate disciplinary action, or criminal prosecution. It is the policy of the AMA that state medical societies and boards of medicine develop or adopt mutually acceptable guidelines protecting physicians who appropriately prescribe and/or administer controlled substances to relieve intractable pain before seeking the implementation of legislation to provide that protection; (2) education of medical students and physicians to recognize addictive disorders in patients, minimize diversion of opioid preparations, and appropriately treat or refer patients with such disorders; and (3) the prevention and treatment of pain disorders through aggressive and appropriate means, including the continued education of physicians in the use of opioid preparations."

Source: American Medical Association, "About the AMA Position on Pain Management Using Opioid Analgesics," 2004, from the web at http://www.ama-assn.org/ama/pub/category/11541.html, last accessed March 1, 2004.

The Gallup polling organization performed a survey on pain for the Arthritis Foundation. They found that:
"* Nine in 10 Americans aged 18 and older (89%) suffer from pain at least once a month.
"* Forty-three percent of adults - a projected 83 million - report that pain frequently affects their participation in some activities.
"* Fewer than half (43%) of respondents report they have a "great deal of control" over their pain.
"* More than half (54%) of adults report that they prefer to be alone when in pain and 50 percent say they are in a bad mood when in pain.
"* One in four Americans (23%) experience joint pain daily or every few days and 18% report suffering pain from arthritis, a disease that affects areas in or around the joints.
"* More than 26 million Americans (15%) who suffer pain monthly have severe pain.
"* More than half (55%) of Americans aged 65 and older have pain daily.
"* Older pain sufferers are considerably less likely than younger pain sufferers to talk to family and friends about pain (38% of those aged 65 and older and 46% of those aged 50 to 64 are likely to discuss their pain vs. 58% of those aged 18 to 34).
"* Older Americans (age 65 and older) are most likely to cite getting older (88%) and arthritis (69%) as causes of their pain. Younger Americans (aged 18 to 34), on the other hand, are more likely to say tension or stress (73%), overwork or overexertion (64%) or their lifestyle (51%) cause their pain.
"* Eighty percent of Americans believe their aches and pains are "just part of getting older" and 28 percent believe there is no solution to their pain.
"* Pain experienced by older Americans tends to be more frequent (55% of those aged 65 and older compared to 32% of those aged 18 to 34 suffer daily pain) and lasts longer (110 weeks for those aged 65 and older vs. 49 weeks for those aged 18 to 34 with severe or moderate pain).
"* Forty-six percent of women report experiencing daily pain compared to only 37 percent of men.
"* Women feel they have significantly less control over their pain than men - only 39 percent of women with severe or moderate pain claim to have a "great deal of control over their pain" compared to 48 percent of men.
"* While tension and stress are significant causes of pain for both men and women, they are the leading causes of pain among women (72% of women vs. 56% of men).
"* Women more often become upset when their pain prevents them from doing things they enjoy (60% of women vs. 50% of men)
"* Women are more likely to want to be alone when in pain (61% of women vs. 46% of men)
"* Men are more likely than women to see a doctor only when they are urged by others to do so. Thirty-eight percent of men say they will wait to see a doctor until someone encourages them to go compared with 27% of women.
"* One in three women (35%) cite the trials of balancing work and family life as the most significant cause of their pain compared to only 24 percent of men.
"* Women are more likely than men to experience frequent pain, particularly headache (17% vs. 8%), backache (24% vs. 19%), arthritis (20% vs. 15%) and sore feet (25% vs. 17%).
"* Sixty-four percent of pain sufferers will see a doctor only when they cannot stand the pain any longer.
"* Less than half (42%) of people who visit their doctor for pain believe that their doctor completely understands how their pain makes them feel."

Source: The Arthritis Foundation, "Pain In America: Highlights from a Gallup Survey," 2000, from the web at http://www.arthritis.org/conditions/speakingofpain/factsheet.asp, last accessed March 1, 2004.

"It is estimated that 9% of the U.S. adult population suffer from moderate to severe non-cancer related chronic pain."

Source: Roper Starch Worldwide, Inc., "Chronic Pain In America: Roadblocks To Relief," research conducted for the American Pain Society, the American Academy of Pain Medicine and Janssen Pharmaceutica, Jan. 1999, from the web at http://www.ampainsoc.org/whatsnew/conclude_road.htm, last accessed March 2, 2004.

"Conventional wisdom suggests that the abuse potential of opioid analgesics is such that increases in medical use of these drugs will lead inevitably to increases in their abuse. The data from this study with respect to the opioids in the class of morphine provide no support for this hypothesis. The present trend of increasing medical use of opioid analgesics to treat pain does not appear to be contributing to increases in the health consequences of opioid analgesic abuse."

Source: Joranson, David E., MSSW, Karen M. Ryan, MA, Aaron M. Gilson, PhD, June L. Dahl, PhD, "Trends in Medical Use and Abuse of Opioid Analgesics," Journal of the American Medical Association, Vol. 283, No. 13, April 5, 2000, p. 1713.

"Opioid analgesics are useful in managing severe acute or chronic pain. They are often underused, resulting in needless pain and suffering because clinicians often underestimate the required dosage, overestimate the duration of action and risk of adverse effects, and have unreasonable concerns about addiction (see Drug Use and Dependence: Opioids). Physical dependence (development of withdrawal symptoms when a drug is stopped) should be assumed to exist in all patients treated with opioids for more than a few days. However, addiction (loss of control, compulsive use, craving and use despite harm) is very rare in patients with no history of substance abuse. Before opioid therapy is initiated, clinicians should ask about risk factors for abuse and addiction. These risk factors include prior alcohol or drug abuse, a family history of alcohol or drug abuse, and a prior major psychiatric disorder. If risk factors are present, treatment may still be appropriate; however, the clinician should use more controls to prevent abuse (eg, small prescriptions, frequent visits, no refills for 'lost' prescriptions) or should refer the patient to a pain specialist or an addiction medicine specialist experienced in pain management."

Source: "Pain," The Merck Manual, Section 16. Neurologic Disorders, Chapter 209. Pain, Merck & Co. Inc., from the web at http://www.merck.com/mmpe/sec16/ch209/ch209a.html last accessed May 31, 2007.

"Therapeutic doses taken regularly over 2 to 3 days can lead to some tolerance and dependence, and when the drug is stopped, the user may have mild withdrawal symptoms which are scarcely noticed or are flu-like.
"Patients with chronic pain requiring long-term use should not be labeled addicts, although they may have some problems with tolerance and physical dependence. Opioids induce cross-tolerance so that abusers can substitute one for another. People who have developed tolerance may show few signs of drug use and may function normally in their usual activities, but obtaining the drug is an ever-present problem. Tolerance to the various effects of these drugs frequently develops unevenly. Heroin users, for example, may become largely tolerant to the drug's euphoric and lethal effects but continue to have constricted pupils and constipation."

Source: "Opioids," The Merck Manual, Section 15: Psychiatric Disorders, Chapter 198: Drug Use and Dependence, Merck & Co. Inc., from the web at http://www.merck.com/mmpe/sec15/ch198/ch198l.html last accessed May 24, 2007.

"The undertreatment of pain is a significant concern in populations with chemical dependency. In painful disorders for which there is a broad consensus about the role of opioid therapy, specifically cancer and AIDS-related pain, studies have documented that this treatment commonly diverges from accepted guidelines. Undertreatment is far more challenging to assess when a broad consensus concerning optimal treatment approaches does not exist. It would be difficult, therefore, to determine the extent to which the pain and functional impairments experienced by patients in this study relate to inadequate pain management. However, given the number of barriers identified as potential reasons for inadequate pain management, it is appropriate to raise concerns about undertreatment and to investigate it further."

Source: Rosenblum, Andrew, PhD, Herman Joseph, PhD, Chunki Fong, MS, Steven Kipnis, MD, Charles Cleland, PhD, Russell K. Portenoy, MD, "Prevalence and Characteristics of Chronic Pain Among Chemically Dependent Patients in Methadone Maintenance and Residential Treatment Facilities," Journal of the American Medical Association (Chicago, IL: American Medical Association, May 14, 2003), Vol. 289, No. 18, p. 2377.

"In our study, there was greater evidence for an association between substance use and chronic pain among inpatients than among MMTP [Methadone Maintenance Treatment Program] patients. Among inpatients, there were significant bivariate relationships between chronic pain and pain as a reason for first using drugs, multiple drug use, and drug craving. In the multivariate analysis, only drug craving remained significantly associated with chronic pain. Not surprisingly, inpatients with pain were significantly more likely than those without pain to attribute the use of alcohol and other illicit drugs, such as cocaine and marijuana, to a need for pain control. These results suggest that chronic pain contributes to illicit drug use behavior among persons who were recently using alcohol and/or cocaine. Inpatients with chronic pain visited physicians and received legitimate pain medications no more frequently than those without pain, raising the possibility that undertreatment or inability to access appropriate medical care may be a factor in the decision to use illicit drugs for pain."

Source: Rosenblum, Andrew, PhD, Herman Joseph, PhD, Chunki Fong, MS, Steven Kipnis, MD, Charles Cleland, PhD, Russell K. Portenoy, MD, "Prevalence and Characteristics of Chronic Pain Among Chemically Dependent Patients in Methadone Maintenance and Residential Treatment Facilities," Journal of the American Medical Association (Chicago, IL: American Medical Association, May 14, 2003), Vol. 289, No. 18, pp. 2376-2377.

"There were 6.4 million (2.6 percent) persons aged 12 or older who used prescription-type psychotherapeutic drugs nonmedically in the past month. Of these, 4.7 million used pain relievers, 1.8 million used tranquilizers, 1.1 million used stimulants (including 512,000 using methamphetamine), and 272,000 used sedatives. Each of these estimates is similar to the corresponding estimate for 2004."

Source: Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services, Results from the 2005 National Survey on Drug Use and Health: National Findings (Rockville, MD: Office of Applied Studies, Sept. 2006), p. 1.

"Among persons aged 12 or older who used pain relievers nonmedically in the past 12 months, 59.8 percent reported that the source of the drug the most recent time they used was from a friend or relative for free. Another 16.8 percent reported they got the drug from one doctor. Only 4.3 percent got the pain relievers from a drug dealer or other stranger, and only 0.8 percent reported buying the drug on the Internet."

Source: Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services, Results from the 2005 National Survey on Drug Use and Health: National Findings (Rockville, MD: Office of Applied Studies, Sept. 2006), p. 26.

According to a review by the General Accounting Office (GAO) of medical cannabis programs in four states, "Most medical marijuana recommendations in states where data are collected have been made for applicants with severe pain or muscle spasticity as their medical condition. Conditions allowed by the states' medical marijuana laws ranged from illnesses such as cancer and AIDS, to symptoms, such as severe pain. Information is not collected on the conditions for which marijuana has been recommended in Alaska or California. However, data from Hawaii's registry showed that the majority of recommendations have been made for the condition of severe pain or the condition of muscle spasticity. Likewise, data from Oregon’s registry showed that, 84 percent of recommendations were for the condition of severe pain or for muscle spasticity."

Source: General Accounting Office, "Marijuana: Early Experiences with Four States' Laws That Allow Use for Medical Purposes" (Washington, DC: Government Printing Office, Nov. 2002), GAO-03-189, p. 24.

According to a survey conducted by Roper Starch Worldwide for the American Pain Society, "Chronic pain as defined by this study is a severe and ever present problem. It can be as much of a problem to middle age adults as seniors and is one women are more likely to face than men. The majority of chronic pain sufferers have been living with their pain for over 5 years. Although the more common type is pain that flares up frequently versus being constant, it is still present on average almost 6 days in a typical week.
"About one third of all chronic sufferers describe their pain as being almost the worst pain one can possibly imagine. Their pain is more likely to be constant than flaring up frequently and two-thirds of them have been living with it for over 5 years."

Source: Roper Starch Worldwide, Inc., "Chronic Pain In America: Roadblocks To Relief," research conducted for the American Pain Society, the American Academy of Pain Medicine and Janssen Pharmaceutica, Jan. 1999, from the web at http://www.ampainsoc.org/whatsnew/conclude_road.htm, last accessed March 2, 2004.

"Just over one-half of chronic pain sufferers say their pain is pretty much under control. But, this can be attributed primarily to those with moderate pain. The majority of those with the most severe pain do not have it under control and among those who do, it took almost half of them over a year to reach that point. In contrast, 7 of every 10 with moderate pain say they have it under control and it took the majority less than a year to reach that point. Pain can become more severe even when it is under control. Among those with very severe pain, 4 of every 10 said their pain was moderate or severe before getting their pain under control."

Source: Roper Starch Worldwide, Inc., "Chronic Pain In America: Roadblocks To Relief," research conducted for the American Pain Society, the American Academy of Pain Medicine and Janssen Pharmaceutica, Jan. 1999, from the web at http://www.ampainsoc.org/whatsnew/conclude_road.htm, last accessed March 2, 2004.

"Almost all chronic pain sufferers have gone to a doctor for relief of their pain at one time or another. Almost 4 of every 10 are not currently doing so, since they think either there is nothing more a doctor can do or in one way or another their pain is under control or they can deal with it themselves.
"This is not the case with those having very severe pain; over 7 of every 10 are currently going to a doctor for pain relief. In addition, significant numbers of those with very severe pain are significantly more likely to require emergency room visits, hospitalization and even psychological counseling or therapy to treat their pain.
"A significant proportion (over one-fourth) of all chronic pain sufferers wait for at least 6 months before going to a doctor for relief of their pain because they underestimate the seriousness of it and think they can tough it out."

Source: Roper Starch Worldwide, Inc., "Chronic Pain In America: Roadblocks To Relief," research conducted for the American Pain Society, the American Academy of Pain Medicine and Janssen Pharmaceutica, Jan. 1999, from the web at http://www.ampainsoc.org/whatsnew/conclude_road.htm, last accessed March 2, 2004.

"Chronic pain sufferers are having difficulty in finding doctors who can effectively treat their pain, since almost one half have changed doctors since their pain began; almost a fourth have made at least 3 changes. The primary reasons for a change are the doctor not taking their pain seriously enough, the doctor's unwillingness to treat it aggressively, the doctor's lack of knowledge about pain and the fact they still had too much pain. This level of frustration is significantly higher among those with very severe pain where the majority have changed doctors at least once and almost of every 3 have done it 3 or more times. Their primary reason for changing was still having too much pain after treatment."

Source: Roper Starch Worldwide, Inc., "Chronic Pain In America: Roadblocks To Relief," research conducted for the American Pain Society, the American Academy of Pain Medicine and Janssen Pharmaceutica, Jan. 1999, from the web at http://www.ampainsoc.org/whatsnew/conclude_road.htm, last accessed March 2, 2004.

"Almost all chronic pain sufferers have used OTC [Over The Counter medications] to relieve their pain and over one half have used Rx NSAIDs [Prescription Non-Steroidal Anti-Inflammatory Drugs]. Narcotic pain relievers have been tried by just over 4 of every 10 sufferers; their use, along with Rx NSAIDs, anti-depressants and anti-seizure drugs, varies directly with the severity of pain."

Source: Roper Starch Worldwide, Inc., "Chronic Pain In America: Roadblocks To Relief," research conducted for the American Pain Society, the American Academy of Pain Medicine and Janssen Pharmaceutica, Jan. 1999, from the web at http://www.ampainsoc.org/whatsnew/summary3_road.htm, last accessed March 2, 2004.

"Medical therapies are not providing sufficient relief, since the majority of chronic pain sufferers, especially those with severe pain, have also turned to non-medicinal therapies. The primary one is a hot/cold pack. Surprisingly, almost all of the major non-medicinal therapies currently used are perceived as providing more relief by their users than OTCs, the most widely used medicines; the one exception are herbs/dietary supplements/vitamins which are perceived as offering the least amount of relief than any medicines or other major non-medicinal therapies.
"The overall favorable perceptions of non-medicinal therapies are driven by those with moderate pain. Although those with very severe pain are more likely to use them, they have a significantly lower opinion of their efficacy versus medicinal therapies."

Source: Roper Starch Worldwide, Inc., "Chronic Pain In America: Roadblocks To Relief," research conducted for the American Pain Society, the American Academy of Pain Medicine and Janssen Pharmaceutica, Jan. 1999, from the web at http://www.ampainsoc.org/whatsnew/conclude_road.htm, last accessed March 2, 2004.

"A small, but significant, percent of chronic pain sufferers have at one time or another turned to alcohol for relief; this occurred more often among middle age adults and men."

Source: Roper Starch Worldwide, Inc., "Chronic Pain In America: Roadblocks To Relief," research conducted for the American Pain Society, the American Academy of Pain Medicine and Janssen Pharmaceutica, Jan. 1999, from the web at http://www.ampainsoc.org/whatsnew/conclude_road.htm, last accessed March 2, 2004.

"Chronic pain sufferers currently taking narcotic pain relievers differ from other chronic pain sufferers as to the severity of their pain, being less likely to have it under control, changing doctors more often, requiring more intensive treatment at hospitals, taking more pills per day, more likely following their doctors prescribed regimen and lastly, to being referred to a specialized program/clinic for their pain."

Source: Roper Starch Worldwide, Inc., "Chronic Pain In America: Roadblocks To Relief," research conducted for the American Pain Society, the American Academy of Pain Medicine and Janssen Pharmaceutica, Jan. 1999, from the web at http://www.ampainsoc.org/whatsnew/summary4_road.htm, last accessed March 2, 2004.

"The quality of life has improved significantly among those who have their pain under control."

Source: Roper Starch Worldwide, Inc., "Chronic Pain In America: Roadblocks To Relief," research conducted for the American Pain Society, the American Academy of Pain Medicine and Janssen Pharmaceutica, Jan. 1999, from the web at http://www.ampainsoc.org/whatsnew/summary4_road.htm, last accessed March 2, 2004.

Researchers used data from the American Productivity Audit to measure lost productivity in the US due to common pain conditions. In an article published in the Journal of the American Medical Association in 2003, they reported that "Overall, the estimated $61.2 billion per year in pain-related lost productive time in our study accounts for 27% of the total estimated work-related cost of pain conditions in the US workforce."

Source: Stewart, Walter F., PhD, MPH, Judith A. Ricci, ScD, MS, Elsbeth Chee, ScD, David Morganstein, MS, Richard Lipton, MD, "Lost Productive Time and Cost Due to Common Pain Conditions in the US Workforce," Journal of the American Medical Association (Chicago, IL: American Medical Association, Nov. 12, 2003), Vol. 290, No. 18, p. 2449.

"Our estimate of $61.2 billion per year in pain-related lost productive time does not include costs from4 other causes. First, we did not include lost productive time costs associated with dental pain, cancer pain, gastrointestinal pain, neuropathy, or pain associated with menstruation. Second, we do not account for pain-induced disability that leads to continuous absence of 1 week or more. Third, we did not consider secondary costs from other factors such as the hiring and training of replacement workers or the institutional effect among coworkers. Taking these other factors into consideration could increase, decrease, or have no net effect on health-related lost productive time cost estimates. Fourth, we may be prone to underestimating current lost productive time among those with persistent pain problems (eg, chronic daily headache). To the extent that these workers remain employed,they may adjust both their performance and perception of their performance over time. The latter, a form of perceptual accommodation, makes it difficult to accurately ascertain the impact of a chronic pain condition on work in the recent past through self-report."

Source: Stewart, Walter F., PhD, MPH, Judith A. Ricci, ScD, MS, Elsbeth Chee, ScD, David Morganstein, MS, Richard Lipton, MD, "Lost Productive Time and Cost Due to Common Pain Conditions in the US Workforce," Journal of the American Medical Association (Chicago, IL: American Medical Association, Nov. 12, 2003), Vol. 290, No. 18, p. 2452.

"Lost productive time varied to some degree in the workforce. First, little or no variation was observed by age. In large part, the lack of differences by age was due to the counterbalancing effects of different pain conditions. Headache, common at younger ages (ie, 18-34 years), rapidly declines in prevalence thereafter. In contrast, the other 3 pain conditions are either more common with increasing age (eg, arthritis) or peak at a later age than headache (eg, back pain)."

Source: Stewart, Walter F., PhD, MPH, Judith A. Ricci, ScD, MS, Elsbeth Chee, ScD, David Morganstein, MS, Richard Lipton, MD, "Lost Productive Time and Cost Due to Common Pain Conditions in the US Workforce," Journal of the American Medical Association (Chicago, IL: American Medical Association, Nov. 12, 2003), Vol. 290, No. 18, p. 2449.

"A total of 52.7% of the workforce reported having headache, back pain, arthritis, or other musculoskeletal pain in the past 2 weeks. Overall, 12.7% of the workforce lost productive time in a 2-week period due to a common pain condition; 7.2% lost 2 h/wk or more of work. Headache was the most common pain condition resulting in lost productive time, affecting 5.4% (2.7% with >= 2/wk) of the workforce (Table 1), which was followed by back pain (3.2%), arthritis (2.0%), and other musculoskeletal pain (2.0%)."

Source: Stewart, Walter F., PhD, MPH, Judith A. Ricci, ScD, MS, Elsbeth Chee, ScD, David Morganstein, MS, Richard Lipton, MD, "Lost Productive Time and Cost Due to Common Pain Conditions in the US Workforce," Journal of the American Medical Association (Chicago, IL: American Medical Association, Nov. 12, 2003), Vol. 290, No. 18, p. 2446.

"Among those who lost productive time due to a pain condition, an average of 4.6 h/wk was lost (Table 1). The mean lost productive time was for headache (3.5 h/wk) and highest for other musculoskeletal pain (5.5 h/wk). Absence days were uncommon. A total of 1.1% of the workforce was absent from work 1 or more days per week from 1 of the 4 pain conditions; 0.12% were absent 2 d/wk or more. Headache and back pain were dominant causes of missed days of work. Overall, lost productive time due to health-related reduced performance on days at work accounted for 4 times more lost time than absenteeism. The ratio of lost productive time due to health-related performance on days at work compared with absenteeism varied among categories of pain disorders: headache, 4.5 h/wk; arthritis, 6.5 h/wk; back pain, 2.9 h/wk; and other musculoskeletal pain, 3.6 h/wk."

Source: Stewart, Walter F., PhD, MPH, Judith A. Ricci, ScD, MS, Elsbeth Chee, ScD, David Morganstein, MS, Richard Lipton, MD, "Lost Productive Time and Cost Due to Common Pain Conditions in the US Workforce," Journal of the American Medical Association (Chicago, IL: American Medical Association, Nov. 12, 2003), Vol. 290, No. 18, p. 2446.

"National survey data that provide detailed data on use of treatments are limited. Of the common pain conditions, sufficient details have only been reported on migraine headaches. Recent data indicate that only 41% of individuals who have migraine headaches in the US population ever receive any prescription drug for migraine. Only 29% report that satisfaction with treatment is moderate, especially among those who are often disabled by their episodes. Randomized trials demonstrate that optimal therapy for migraine dramatically reduces headache-related disability time in comparison with usual care."

Source: Stewart, Walter F., PhD, MPH, Judith A. Ricci, ScD, MS, Elsbeth Chee, ScD, David Morganstein, MS, Richard Lipton, MD, "Lost Productive Time and Cost Due to Common Pain Conditions in the US Workforce," Journal of the American Medical Association (Chicago, IL: American Medical Association, Nov. 12, 2003), Vol. 290, No. 18, p. 2453.

"Pain was very prevalent in representative samples of 2 distinct populations with chemical dependency, and chronic severe pain was experienced by a substantial minority of both groups. Methadone patients differed from patients recently admitted to a residential treatment center in numerous ways and had a significantly higher prevalence of chronic pain (37% vs. 24%). Although comparisons with other studies of pain epidemiology are difficult to make because of methodological differences, the prevalence of chronic pain in these samples is in the upper range reported in surveys of the general population. The prevalence of chronic pain in these chemically dependent patients also compares with that in surveys of cancer patients undergoing active therapy, approximately a third of whom have pain severe enough to warrant opioid therapy."

Source: Rosenblum, Andrew, PhD, Herman Joseph, PhD, Chunki Fong, MS, Steven Kipnis, MD, Charles Cleland, PhD, Russell K. Portenoy, MD, "Prevalence and Characteristics of Chronic Pain Among Chemically Dependent Patients in Methadone Maintenance and Residential Treatment Facilities," Journal of the American Medical Association (Chicago, IL: American Medical Association, May 14, 2003), Vol. 289, No. 18, p. 2376.

"Although MMTP [Methadone Maintenance Treatment Program] patients were significantly more likely than inpatients to report chronic pain, and almost a quarter reported that pain was one of the reasons for first using drugs, there was relatively little evidence that pain was associated with current levels of substance abuse. In the multivariate analysis, the associations between chronic pain and the substance abuse behaviors observed in the bivariate analysis (pain as a reason for first using drugs and drug craving) were not sustained. Moreover, the bivariate associations that were found in the inpatient group between chronic pain and multiple drug use, and between pain and the use of illicit drugs to treat pain complaints, were not identified among MMTP patients."

Source: Rosenblum, Andrew, PhD, Herman Joseph, PhD, Chunki Fong, MS, Steven Kipnis, MD, Charles Cleland, PhD, Russell K. Portenoy, MD, "Prevalence and Characteristics of Chronic Pain Among Chemically Dependent Patients in Methadone Maintenance and Residential Treatment Facilities," Journal of the American Medical Association (Chicago, IL: American Medical Association, May 14, 2003), Vol. 289, No. 18, p. 2377.

"Physicians are concerned that their prescribing decisions and patterns may be questioned and that they could be investigated without sufficient cause. Some physicians contend that patients may suffer because physicians will be reluctant to prescribe appropriate controlled substances to manage a patient’s pain or treat their condition. Patients are concerned that their personal information may be used inappropriately by those with authorized access or shared with unauthorized entities. Pharmacists have also expressed concerns."

Source: General Accounting Office, "Prescription Drugs: State Monitoring Programs Provide Useful Tool to Reduce Diversion" (Washington, DC: Government Printing Office, May 2002), GAO-PO-634, p. 18.

"DEA has increased enforcement efforts to prevent abuse and diversion of OxyContin. From fiscal year 1996 through fiscal year 2002, DEA initiated 313 investigations involving OxyContin, resulting in 401 arrests. Most of the investigations and arrests occurred after the initiation of the action plan. Since the plan was enacted, DEA initiated 257 investigations and made 302 arrests in fiscal years 2001 and 2002. Among those arrested were several physicians and pharmacists. Fifteen health care professionals either voluntarily surrendered their controlled substance registrations or were immediately suspended from registration by DEA. In addition, DEA reported that $1,077,500 in fines was assessed and $742,678 in cash was seized by law enforcement agencies in OxyContin-related cases in 2001 and 2002."

Source: General Accounting Office, "Prescription Drugs: OxyContin Abuse and Diversion and Efforts to Address the Problem," GAO-04-110 (Washington, DC: Government Printing Office, Dec. 2003), p. 37.

"In addition to these [state pharmacy] regulatory boards, 15 states operate prescription drug monitoring programs as a means to control the illegal diversion of prescription drugs that are controlled substances. Prescription drug monitoring programs are designed to facilitate the collection, analysis, and reporting of information on the prescribing, dispensing, and use of controlled substances within a state. They provide data and analysis to state law enforcement and regulatory agencies to assist in identifying and investigating activities potentially related to the illegal prescribing, dispensing, and procuring of controlled substances."

Source: General Accounting Office, "Prescription Drugs: OxyContin Abuse and Diversion and Efforts to Address the Problem," GAO-04-110 (Washington, DC: Government Printing Office, Dec. 2003), p. 15.

Regarding prescription drug monitoring programs (PDMPs), the Office of National Drug Control Policy reported in 2004 that "Currently, 21 states have some form of reporting mechanism, with additional states in the development stage."

Source: Office of National Drug Control Policy, "National Drug Control Strategy," (Washington, DC: Executive Office of the President, March 2004), p. 28.

"States with PDMPs have realized benefits in their efforts to reduce drug diversion. These include improving the timeliness of law enforcement and regulatory investigations. For example, Kentucky’s state drug control investigators took an average of 156 days to complete the investigation of an alleged doctor shopper prior to the implementation of the state’s PDMP. The average investigation time dropped to 16 days after the program was established. In addition, law enforcement officials in Kentucky and other states view the programs as a deterrent to doctor shopping, because potential diverters are aware that any physician from whom they seek a prescription may first examine their prescription drug utilization history based on PDMP data."

Source: General Accounting Office, "Prescription Drugs: State Monitoring Programs Provide Useful Tool to Reduce Diversion" (Washington, DC: Government Printing Office, May 2002), GAO-PO-634, p. 3.

"States with PDMPs have experienced considerable reductions in the time and effort required by law enforcement and regulatory investigators to explore leads and the merits of possible drug diversion cases. The presence of a PDMP helps a state reduce its illegal drug diversion, but diversion activities may increase in contiguous states without PDMPs."

Source: General Accounting Office, "Prescription Drugs: State Monitoring Programs Provide Useful Tool to Reduce Diversion" (Washington, DC: Government Printing Office, May 2002), GAO-PO-634, p. 15.

"The presence of a PDMP may also have an impact on the use of drugs more likely to be diverted. For example, DEA rank-ordered all states for 2000 by the number of OxyContin prescriptions per 100,000 people. Eight of the 10 states with the highest number of prescriptions-West Virginia, Alaska, Delaware, New Hampshire, Florida, Pennsylvania, Maine, and Connecticut-had no PDMPs, and only 2 did-Kentucky and Rhode Island. Six of the 10 states with the lowest number of prescriptions-Michigan, New Mexico,14 Texas, New York, Illinois, and California-had PDMPs, and 4-Kansas, Minnesota, Iowa, and South Dakota-did not."

Source: General Accounting Office, "Prescription Drugs: State Monitoring Programs Provide Useful Tool to Reduce Diversion" (Washington, DC: Government Printing Office, May 2002), GAO-PO-634, p. 16.

"The existence of a PDMP within a state, however, appears to increase drug diversion activities in contiguous non-PDMP states. When states begin to monitor drugs, drug diversion activities tend to spill across boundaries to non-PDMP states. One example is provided by Kentucky, which shares a boundary with seven states, only two of which have PDMPs-Indiana and Illinois. As drug diverters became aware of the Kentucky PDMP’s ability to trace their drug histories, they tended to move their diversion activities to nearby nonmonitored states. OxyContin diversion problems have worsened in Tennessee, West Virginia, and Virginia-all contiguous non-PDMP states-because of the presence of Kentucky’s PDMP, according to a joint federal, state, and local drug diversion report."

Source: General Accounting Office, "Prescription Drugs: State Monitoring Programs Provide Useful Tool to Reduce Diversion" (Washington, DC: Government Printing Office, May 2002), GAO-PO-634, pp. 16-17.

"Officials from DEA, the Alliance [National Alliance for Model State Drug Laws], and state PDMPs told us that states considering establishing a PDMP, or expanding an existing one, face several challenges. These include educating the public and policymakers about the extent of prescription drug diversion and abuse in their state and the benefits of a PDMP, responding to the concerns of physicians, patients, and pharmacists regarding the confidentiality of prescription information, and funding the cost of program development and operations. Given a state’s particular funding availability and budget priorities, program costs can be a major hurdle. The start-up costs for the three most recent PDMPs were $415,000 for Kentucky, $134,000 for Nevada, and $50,000 for Utah. Estimated annual operating costs for these PDMPs varied from a high of about $500,000 in Kentucky, to $150,000 in Utah and $112,000 in Nevada. Costs in these three states vary because of differences in the PDMP systems implemented, the number of pharmacies reporting drug dispensing data, and the number of practitioners and law enforcement agencies seeking information from the systems."

Source: General Accounting Office, "Prescription Drugs: State Monitoring Programs Provide Useful Tool to Reduce Diversion" (Washington, DC: Government Printing Office, May 2002), GAO-PO-634, pp. 3-4.

"If the PDMP seeks to provide same-day responses to report requests, the costs involved in returning the response to the requester may increase. For example, Kentucky has spent up to $12,000 in 1 month for faxing reports. PDMP officials from Kentucky, Nevada, and Utah estimated 3- to 4-hour turnaround times for PDMP data requests, and all mainly use faxing, rather than more costly mailing, to return the report to the requester. Same-day PDMP responses may be preferable for physicians who want the prescription drug history for a patient being seen that day, and for law enforcement users who need immediate data for investigations of suspected illegal activity."

Source: General Accounting Office, "Prescription Drugs: State Monitoring Programs Provide Useful Tool to Reduce Diversion" (Washington, DC: Government Printing Office, May 2002), GAO-PO-634, p. 14.

"As users become more familiar with the benefits of PDMP report data, requests and the attendant costs to provide them may increase. In Kentucky, Nevada, and Utah, usage has increased substantially, mostly because of the increased number of requests by physicians to check patients’ prescription drug histories. In Kentucky, these physician requests increased from 28,307 in 2000, the first full year of operation, to 56,367 in 2001, an increase of nearly 100 percent. Law enforcement requests increased from 4,567 in 2000 to 5,797 in 2001, an increase of 27 percent. Similarly, Nevada’s requests from all authorized users have also increased-from 480 in 1997, its first full year, to 6,896 in 2001, an increase of about 1,400 percent. Additionally, as a PDMP matures, the needs it addresses may change, and operating costs may increase as a result."

Source: General Accounting Office, "Prescription Drugs: State Monitoring Programs Provide Useful Tool to Reduce Diversion" (Washington, DC: Government Printing Office, May 2002), GAO-PO-634, p. 14.