Pain Management

Related Chapters:
Addictive Properties
Diversion
Heroin
Heroin Assisted Treatment
Methadone Treatment
Opioid Crisis

Page last updated June 9, 2020 by Doug McVay, Editor.

1. Factors in the Transition from Prescription Opiate Use to Heroin Use

"Multiple studies that have examined why some persons who abuse prescription opioids initiate heroin use indicate that the cost and availability of heroin were primary factors in this process. These reasons were generally consistent across time periods from the late 1990s through 2013.34-41 Some interviewees made reference to doctors generally being less willing to prescribe opioids as well as to increased attention to the issue by law enforcement, which may have affected the available supply of opioids locally.38,40"

Wilson M. Compton, M.D., M.P.E., Christopher M. Jones, Pharm.D., M.P.H., and Grant T. Baldwin, Ph.D., M.P.H. Relationship between Nonmedical Prescription-Opioid Use and Heroin Use. N Engl J Med 2016; 374:154-163. January 14, 2016. DOI: 10.1056/NEJMra1508490
http://www.nejm.org/doi/full/1...
http://www.nejm.org/doi/pdf/10...

2. Pain as a Public Health Problem

"Pain is a significant public health problem. Chronic pain alone affects approximately 100 million U.S. adults. Pain reduces quality of life, affects specific population groups disparately, costs society at least $560-635 billion annually (an amount equal to about $2,000 for everyone living in the United States), and can be appropriately addressed through population health-level interventions."

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), p. 5.
http://www.nap.edu/openbook.ph...

3. Prevalence of Chronic Pain in the US

"To estimate the prevalence of chronic pain and high-impact chronic pain in the United States, CDC analyzed 2016 National Health Interview Survey (NHIS) data. An estimated 20.4% (50.0 million) of U.S. adults had chronic pain and 8.0% of U.S. adults (19.6 million) had high-impact chronic pain, with higher prevalences of both chronic pain and high-impact chronic pain reported among women, older adults, previously but not currently employed adults, adults living in poverty, adults with public health insurance, and rural residents."

Dahlhamer J, Lucas J, Zelaya, C, et al. Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults — United States, 2016. MMWR Morb Mortal Wkly Rep 2018;67:1001–1006. DOI: http://dx.doi.org/10.15585/mmw...
https://www.cdc.gov/mmwr/volum...

4. CDC Opioid Prescribing Guidelines Are Making It Difficult For Cancer Patients To Obtain Pain Medication

"There has been a significant increase in cancer patients and survivors being unable to access their opioid prescriptions since 2016, when the Centers for Disease Control and Prevention (CDC) finalized opioid prescribing guidelines."

Percent of cancer patients and survivors who report being unable to get opioid prescription pain medication because the pharmacy did not have the particular drug in stock:
December 2016: 16%
May 2018: 41%

Percent of cancer patients and survivors who report being questioned by a pharmacist about why they needed their opioid pain medication:
December 2016: 16%
May 2018: 35%

Percent of cancer patients and survivors who report being unable to get their prescription pain medication because the pharmacist would not fill it for whatever reason even though the pharmacist had it in stock?
December 2016: 12%
May 2018: 27%

Percent of cancer patients and survivors who report being unable to get their opioid prescription pain medication because their insurance would not cover it:
December 2016: 11%
May 2018: 30%

Percent of cancer patients and survivors who report that their insurance company has limited them to just one pharmacy to go to for filling their opioid prescription pain medication.
December 2016: 14%
May 2018: 32%

Percent of cancer patients and survivors who report that their insurance company has reduced the number of times their opioid prescription can be refilled:
December 2016: 21%
May 2018: 36%

Percent of cancer patients and survivors who report that their insurance company has reduced the number of pills in their opioid prescription pain medication:
December 2016: 19%
May 2018: 25%

American Cancer Society Cancer Action Network, Patient Quality of Life Coalition, and Public Opinion Strategies. Key Findings Summary: Opioid Access Research Project. June 2018.
https://www.acscan.org/release...
https://www.acscan.org/sites/d...

5. Reductions in Opioid Prescribing for People with Severe Pain

"According to the Medical Expenditure Panel Survey, the annual share of US adults who were prescribed opioids decreased from 12.9 percent in 2014 to 10.3 percent in 2016, and the decrease was concentrated among adults with shorter-term rather than longer-term prescriptions. The decrease was also larger for adults who reported moderate or more severe pain (from 32.8 percent to 25.5 percent) than for those who reported lessthan-moderate pain (from 8.0 percent to 6.6 percent). In the same period opioids were prescribed to 3.75 million fewer adults reporting moderate or more severe pain and 2.20 million fewer adults reporting less-thanmoderate pain. Because the decline in prescribing primarily involved adults who reported moderate or more severe pain, these trends raise questions about whether efforts to decrease opioid prescribing have successfully focused on adults who report less severe pain."

Mark Olfson, Shuai Wang, Melanie M. Wall, and Carlos Blanco. Trends In Opioid Prescribing And Self-Reported Pain Among US Adults. Health Affairs 2020 39:1, 146-154.
https://www.healthaffairs.org/...

6. Reasons Why Many in the US Receive Inadequate Treatment for Pain

"Currently, large numbers of Americans receive inadequate pain prevention, assessment, and treatment, in part because of financial incentives that work against the provision of the best, most individualized care; unrealistic patient expectations; and a lack of valid and objective pain assessment measures. Clinicians’ role in chronic pain care is often a matter of guiding, coaching, and assist­ing patients with day-to-day self-management, but many health professionals lack training in how to perform this support role, and there is little reimbursement for their doing so. Primary care is often the first stop for patients with pain, but primary care is organized in ways that rarely allow clinicians time to perform comprehensive patient assessments. Sometimes patients turn to, or are referred to, pain specialists or pain clinics, although both of these are few in number. Unfortunately, patients often are not told, or do not understand, that their journey to find the best combination of treatments for them may be long and full of uncertainty."

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), p. 8.
http://www.nap.edu/openbook.ph...

7. Restrictions On Opioid Prescribing Are Negatively Impacting People With Cancer And Other Serious Illnesses

"A growing number of restrictions on opioid prescribing are already impacting these patient populations."

According to a survey conducted for the American Cancer Society Cancer Action Network and the Patient Quality of Life Coalition:

Patients answering yes to "Has your doctor indicated his or her treatment options for your pain were limited by laws, guidelines, or your insurance coverage?"
Patients Being Treated For Cancer: 48%
Patients Being Treated For Chronic Pain: 40%
Patients Being Treated For Other Serious Illnesses: 56%

Patients answering yes to "Has your insurance company or pharmacy required you to only have opioid prescriptions from one doctor?"
Patients Being Treated For Cancer: 36%
Patients Being Treated For Chronic Pain: 25%
Patients Being Treated For Other Serious Illnesses: 26%

Patients answering yes to "Has your doctor refused to give you a prescription for an opioid plan medication?"
Patients Being Treated For Cancer: 35%
Patients Being Treated For Chronic Pain: 25%
Patients Being Treated For Other Serious Illnesses: 36%

Patients answering yes to "Has the pharmacist give you only part of your opioid prescription (for example: for 7 days instead of 30 days the prescription was written), and told you to call your doctor for a new prescription if you need more?"
Patients Being Treated For Cancer: 31%
Patients Being Treated For Chronic Pain: 18%
Patients Being Treated For Other Serious Illnesses: 21%

Patients answering yes to "Have you been unable to get your opioid prescription pain medication because the pharmacist or pharmacy sent you home without your prescription because they had to contact your doctor before filling the prescription?"
Patients Being Treated For Cancer: 26%
Patients Being Treated For Chronic Pain: 30%
Patients Being Treated For Other Serious Illnesses: 22%

Patients answering yes to "Has the pharmacist given you only part of your opioid prescription (for example: for 7 days instead of 30 days the prescription had been written), and told you to come back if you need more?"
Patients Being Treated For Cancer: 25%
Patients Being Treated For Chronic Pain: 26%
Patients Being Treated For Other Serious Illnesses: 26%

Patients answering yes to "Has your doctor or pharmacist told you that you have been flagged in their system as a potential opioid abuser?"
Patients Being Treated For Cancer: 21%
Patients Being Treated For Chronic Pain: 14%
Patients Being Treated For Other Serious Illnesses: 11%

American Cancer Society Cancer Action Network, Patient Quality of Life Coalition, and Public Opinion Strategies. Key Findings Summary: Opioid Access Research Project. June 2018.
https://www.acscan.org/release...
https://www.acscan.org/sites/d...

8. Prevalence of Undertreatment of Pain

"Approximately 100 million American adults experience pain from common chronic conditions, and additional millions experience short-term acute pain (Chapter 2). Many people could have better outcomes if they received incrementally better care as part of the treatment of the chronic diseases that are causing their pain. A nationwide health system straining to contain costs will be hard pressed to address the problem, however, unless early savings can be clearly demonstrated through reduced health care utilization and disability and fewer dollars wasted on ineffective treatments. The high prevalence of pain suggests that it is not being adequately treated, and undertreatment generates enormous costs to the system and to the nation’s economy (see Chapter 2)."

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), p. 153.
http://www.nap.edu/openbook.ph...

9. Unrelieved Pain A Serious Health Problem In The US

"It is well-documented that unrelieved pain continues to be a serious public health problem for the general population in the United States.1-8 This issue is particularly salient for children,9-14 the elderly,15-19 people of racial and ethnic subgroups,20-24 people with developmental disabilities,25;26 people in the military or military veterans27-30 as well as for those with diseases such as cancer,31-36 HIV/AIDS,37-40 or sickle-cell disease.41-43 Clinical experience has demonstrated that adequate pain management leads to enhanced functioning and quality of life, while uncontrolled severe pain contributes to disability and despair.4;44"

Pain & Policy Studies Group, "Achieving Balance in State Pain Policy: A Progress Report Card (CY 2013)" (Madison, WI: University of Wisconsin Carbone Cancer Center, July 2014), p. 10.
http://www.painpolicy.wisc.edu...
http://www.painpolicy.wisc.edu...

10. Opioids and Pain Management

"Opioid analgesics are useful in managing acute and chronic pain. They are sometimes underused in patients with severe acute pain or with pain and a terminal disorder such as cancer, resulting in needless pain and suffering. Reasons for undertreatment include
"• Underestimation of the effective dose
"• Overestimation of the risk of adverse effects
"Generally, opioids should not be withheld when treating acute, severe pain; however, simultaneous treatment of the condition causing the pain usually limits the duration of severe pain and the need for opioids to a few days or less. Also, opioids should generally not be withheld when treating cancer pain; in such cases, adverse effects can be prevented or managed, and addiction is less of a concern.
"In patients with chronic noncancer pain, nonopioid therapy should be tried first (see Chronic Pain : Treatment). Opioids should be used when the benefit of pain reduction outweighs the risk of adverse effects and of drug misuse. If nonopioid therapy has been unsuccessful, opioid therapy should be considered. In such cases, obtaining informed consent may help clarify the goals, expectations, and risks of treatment and facilitate education and counseling about misuse. Patients receiving chronic (> 3 mo) opioid therapy should be regularly assessed for pain control, adverse effects, and signs of misuse. If patients have persistent severe pain despite increasing opioid doses, do not adhere to the terms of treatment, or have deteriorating physical or mental function, opioid therapy should be tapered and stopped.
"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. Thus, opioids should be used as briefly as possible, and in dependent patients, the dose should be tapered to control withdrawal symptoms when opioids are no longer necessary. Patients with pain due to an acute, transient disorder (eg, fracture, burn, surgical procedure) should be switched to a nonopioid drug as soon as possible. Dependence is distinct from addiction, which, although it does not have a universally accepted definition, typically involves compulsive use and overwhelming involvement with the drug including craving, loss of control over use, and use despite harm."

"Treatment of Pain." The Merck Manual for Health Professionals. Merck & Co. Inc. Last accessed November 1, 2017.
http://www.merckmanuals.com/pr...

Pages