Opioid Crisis

1. 2016 Provisional US Drug Overdose Data via Centers for Disease Control

Total provisional count of drug overdose deaths in the US for the 12-month period ending in December 2016: 71,135.
  Attributed to synthetic opioids (excluding methadone): 19,547
  Attributed to heroin: 15,564
  Attributed to natural and semi-synthetic opioids: 14,550
  Attributed to cocaine: 10,479
  Attributed to psychostimulants with abuse potential: 7,602
  Attributed to methadone: 3,393

Provisional count of drug overdose deaths in the US for the 12-month period ending in December 2015: 51,335.
  Attributed to heroin: 13,051
  Attributed to natural and semi-synthetic opioids: 12,747
  Attributed to synthetic opioids (excluding methadone): 9,610
  Attributed to cocaine: 6,841
  Attributed to psychostimulants with abuse potential: 5,777
  Attributed to methadone: 3,309

Figures above based on data available for analysis on Oct. 1, 2017. The federal Centers for Disease Control compiles and publishes official data on annual causes of death in the United States. Demand for data on drug overdose deaths, and on drug overdoses generally, is so great that the CDC is now making raw data on these subjects available to the public. The data are provisional, not final, so there are several caveats that must be understood before examining the numbers. According to the CDC:
"Provisional counts are often incomplete and causes of death may be pending investigation (see table Notes). Data quality measures, such as percent completeness in overall death reporting and percentage of deaths pending investigation, are included to aid interpretation of provisional data, because both data completeness and the percentage of records pending investigation are related to the accuracy of provisional counts (see Technical Notes). Provisional data are based on available records that meet certain data quality criteria at the time of analysis and may not include all deaths that occurred during a given time period. Therefore, they should not be considered comparable with final data and are subject to change. Reporting of specific drugs and drug classes varies by jurisdiction, and comparisons across selected states should not be made (see Technical Notes)."

"Provisional Drug Overdose Death Counts," U.S. Centers for Disease Control, Atlanta, GA, based on data available for analysis on Oct. 1, 2017, last accessed Oct. 19, 2017 at https://www.cdc.gov/nchs/...

2. Estimated Prevalence of Current Heroin Use in the US

"About 475,000 people aged 12 or older were current heroin users in 2016, which rounds to the 0.5 million people shown in Figure 15. This number corresponds to about 0.2 percent of the population aged 12 or older (Figure 23).
"Despite the dangers associated with heroin use, its use has increased in recent years. The percentage of current heroin users aged 12 or older in 2016 was higher than the percentages in most years between 2002 and 2013, but it was similar to the percentages in 2014 and 2015 (Figure 23). However, even when there was a statistically significant difference between the 2016 estimate and estimates in prior years, the estimates ranged between 0.1 and 0.2 percent."

Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, p. 18. Retrieved from https://www.samhsa.gov/data/
https://www.samhsa.gov/data/si...
https://www.samhsa.gov/data/si...

3. Deaths from Overdose in the United States 2015

"During 2015, drug overdoses accounted for 52,404 U.S. deaths, including 33,091 (63.1%) that involved an opioid. There has been progress in preventing methadone deaths, and death rates declined by 9.1%. However, rates of deaths involving other opioids, specifically heroin and synthetic opioids other than methadone (likely driven primarily by illicitly manufactured fentanyl) (2,3), increased sharply overall and across many states."

Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015. MMWR Morb Mortal Wkly Rep 2016;65:1445–1452. DOI: http://dx.doi.org/10.15585/mmw...
https://www.cdc.gov/mmwr/volum...
https://www.cdc.gov/mmwr/volum...

4. Key Factors Underlying Increasing Rates of Heroin Use and Opioid Overdose in the US

"A key factor underlying the recent increases in rates of heroin use and overdose may be the low cost and high purity of heroin.45,46 The price in retail purchases has been lower than $600 per pure gram every year since 2001, with costs of $465 in 2012 and $552 in 2002, as compared with $1237 in 1992 and $2690 in 1982.45 A recent study showed that each $100 decrease in the price per pure gram of heroin resulted in a 2.9% increase in the number of hospitalizations for heroin overdose.46"

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...

5. 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...

6. Factors That May Skew Estimates of Overdose Deaths in the US 2015

"First, factors related to death investigation might affect rate estimates involving specific drugs. At autopsy, the substances tested for, and circumstances under which tests are performed to determine which drugs are present, might vary by jurisdiction and over time. Second, the percentage of deaths with specific drugs identified on the death certificate varies by jurisdiction and over time. Nationally, 19% (in 2014) and 17% (in 2015) of drug overdose death certificates did not include the specific types of drugs involved. Additionally, the percentage of drug overdose deaths with specific drugs identified on the death certificate varies widely by state, ranging from 47.4% to 99%. Variations in reporting across states prevent comparison of rates between states. Third, improvements in testing and reporting of specific drugs might have contributed to some observed increases in opioid-involved death rates. Fourth, because heroin and morphine are metabolized similarly (9), some heroin deaths might have been misclassified as morphine deaths, resulting in underreporting of heroin deaths. Finally the state-specific analyses of opioid deaths are restricted to 28 states, limiting generalizability."

Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015. MMWR Morb Mortal Wkly Rep 2016;65:1445–1452. DOI: http://dx.doi.org/10.15585/mmw...
https://www.cdc.gov/mmwr/volum...
https://www.cdc.gov/mmwr/volum...

7. 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...

8. 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...

9. Prevalence Of Illegal Use of Prescription Drugs In The US

"Use of prescription psychotherapeutic drugs in the past year was fairly common in the United States. In 2015, an estimated 119.0 million Americans aged 12 or older were past year users of prescription psychotherapeutic drugs, representing 44.5 percent of the population (Figure 1).
"Of the four categories of prescription psychotherapeutic drugs presented in this report (i.e., pain relievers, tranquilizers, stimulants, and sedatives), prescription pain relievers were the most commonly used (Figure 1). Approximately 97.5 million people aged 12 or older were past year users of prescription pain relievers in 2015, representing more than one third (36.4 percent) of the population aged 12 or older. In addition, approximately 39.3 million people were past year users of prescription tranquilizers in 2015, representing 14.7 percent of people aged 12 or older. Approximately 17.2 million people were past year users of prescription stimulants in 2015, representing 6.4 percent of the population aged 12 or older. Approximately 18.6 million people were past year users of prescription sedatives in 2015, representing 6.9 percent of the population aged 12 or older."

Substance Abuse and Mental Health Services Administration, Prescription Drug Use and Misuse in the United States: Results from the 2015 National Survey on Drug Use and Health, NSDUH Data Review, Rockville, MD: Substance Abuse and Mental Health Services Administration, September 2016, pp. 4-5.
https://www.samhsa.gov/data/si...
https://www.samhsa.gov/data/si...

10. 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...

11. 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...

12. Law Enforcement's "Chilling Effect" on Pain Treatment

"The under-treatment of pain is due in part to a kind of undesirable 'chilling effect.' The concept of a chilling effect, generally, is a useful law enforcement tool. When publicity surrounding a righteous prosecution 'chills' related criminal conduct, that chilling effect is intended, appropriate, and a public good. A chilling effect on the appropriate use of pain medicine, however, is not a public good. Recent research by members of the Law Enforcement Roundtable confirms that prosecutions of doctors for diversion of prescription drugs are rare.2 But, on occasion, overly-sensationalized stories of investigation of doctors have hit the nightly news. When that happens, the resulting chilling effect reaches far beyond a 'good' chilling effect on bad actors, and directly affects appropriate medical practice. The consequence is extreme, and not what law enforcement would ever seek – our parents and other loved ones who are in pain simply cannot get the medicines they need."

"Balance, Uniformity and Fairness: Effective Strategies for Law Enforcement for Investigating and Prosecuting the Diversion of Prescription Pain Medications While Protecting Appropriate Medical Practice," Center for Practical Bioethics (Kansas City, MO: February 2009), p. 3.
http://www.fsmb.org/Media/Defa...

13. Substance Use Disorders and Effective Pain Treatment

"Persons with substance use disorders are less likely than others to receive effective pain treatment (Rupp and Delaney, 2004). The primary reason is clinicians' concern that they may misuse opioids. Although mild to moderate pain can often be treated effectively with a combination of physical modalities (e.g., ice, rest, and splints) and nonopioid analgesics (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs], acetaminophen, or other adjuvant medications), management of severe pain, especially when cancer-related, often requires opioids. Moreover, physicians are increasingly using opioids to treat chronic non-cancer-related pain, and an emerging body of evidence suggests that, for some patients, this approach both reduces pain and may foster modest improvements in function and quality of life (Devulder, Richarz, and Nataraja, 2005; Haythornthwaite et al., 1998; Kalso et al., 2004; Martell et al., 2007; Noble et al., 2008; Passik et al., 2005; Portenoy et al., 2007; Portenoy and Foley, 1986)."

Savage, Seddon R., Kenneth L. Kirsh, and Steven D. Passik. "Challenges in Using Opioids to Treat Pain in Persons With Substance Use Disorders." Addiction Science & Clinical Practice 4.2 (2008): 4–25.
http://www.ncbi.nlm.nih.gov/pm...
http://www.ncbi.nlm.nih.gov/pm...

14. Balancing Control And Availability Of Opioid Painkillers In Pain Management

"Because opioid analgesics have both a medical indication and an abuse liability, their prescribing, dispensing, and administration, indeed their very availability in commerce, is governed by a combination of policies, including international treaties and U.S. federal and state laws and regulations. The main purpose of these policies is drug control: to prevent diversion and abuse of prescription medications. However, international and federal policies also express clearly a second purpose of drug control, that being availability: recognizing that many opioids (referred to in law as narcotic drugs or controlled substances) are necessary for pain relief and that governments must ensure their adequate availability for medical and scientific purposes. When both control and availability are appropriately recognized in public policy, and implemented in everyday practice, this is referred to as a balanced approach (American Medical Association?Department of Substance Abuse, 1990; Cooper, Czechowicz, Petersen, & Molinari, 1992; Drug Enforcement Administration et al., 2001; Fishman, 2012; Gilson, 2010a; Gilson, Joranson, Maurer, Ryan, & Garthwaite, 2005; Joranson & Dahl, 1989; Office of National Drug Control Policy, 2011; Woodcock, 2009; World Health Organization, 2011a)."

Pain & Policy Studies Group. Achieving Balance in Federal and State Pain Policy: A Guide to Evaluation (CY 2013). (University of Wisconsin Carbone Cancer Center: Madison, WI, July 2014), p. 17.
http://www.painpolicy.wisc.edu...
http://www.painpolicy.wisc.edu...

15. Using Opioids for Treatment of Acute Pain

"Mild to moderate acute pain is often relieved by physical interventions—such as the application of ice, transcutaneous electrical nerve stimulation (TENS), massage or stretching, and/or bracing—along with a mild analgesic such as an NSAID or acetaminophen. More severe pain often requires opioid therapy, which will be discussed in depth below. When appropriately skilled clinicians are available in a system that is comfortable supporting such treatments, nerve blocks or spinal infusions can sometimes control more severe acute pain. Examples of common acute pain procedures are rib blocks for rib fractures or thoracic incisions; epidural infusions for thoracic, abdominal, or lower body surgery or trauma; and brachial plexus infusions for upper extremity postsurgical or trauma-related pain.
"Clinicians should generally not let concerns about addiction deter them from using opioids that are needed for severe acute pain. Carefully supervised short-term use of opioids in the context of time-limited treatment of such pain has not been documented to affect the long-term course of addictive disorders. Rather, inadequate pain control and treatment that frustrates, stresses, or confuses patients may lead to relapse (Wasan et al., 2006)."

Savage, Seddon R., Kenneth L. Kirsh, and Steven D. Passik. "Challenges in Using Opioids to Treat Pain in Persons With Substance Use Disorders." Addiction Science & Clinical Practice 4.2 (2008): 4–25.
http://www.ncbi.nlm.nih.gov/pm...
http://www.ncbi.nlm.nih.gov/pm...

16. Barriers to Effective Pain Care

"A number of barriers to effective pain care involve the attitudes and training of the providers of care. First, health professionals may hold negative attitudes toward people reporting pain and may regard pain as not worth their serious attention. As discussed in detail in Chapter 2, patients can be at a particular disadvantage if they are members of racial or ethnic minorities, female, children, or infirm elderly. They also may have less access to care if they are perceived as drug seeking or if they have, or are perceived to have, mental health problems. A literature review showed that people with pain, especially women, often have attitudes and goals that are different from, and sometimes opposed to, the attitudes and goals of their practitioners; patients seek to have their pain legitimized, while practitioners focus on diagnosis and therapy (Frantsve and Kerns, 2007). Consumers testified before the committee that patients often believe practitioners trivialize pain, which makes them feel even worse. Researchers working with patient focus groups have noted the 'perceived failures of providers to fully respect, trust, and accept the patient, to offer positive feedback and support, and to believe the participants’ reports of the severity and adverse effects of their pain' (Upshur et al., 2010, p. 1793)."

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), pp. 153-154.
http://www.nap.edu/openbook.ph...

17. Undertreated Chronic Pain and Development of Substance Dependence

"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."

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.
http://jama.jamanetwork.com/ar...

18. Tolerance of Opiates and Escalation of Effective Dosage

"During long-term treatment, the effective opioid dose can remain constant for prolonged periods. Some patients need intermittent dose escalation, typically in the setting of physical changes that suggest an increase in the pain (eg, progressive neoplasm). Fear of tolerance should not inhibit appropriate early, aggressive use of an opioid. If a previously adequate dose becomes inadequate, that dose must usually be increased by 30 to 100% to control pain."

"Treatment of Pain." The Merck Manual for Health Professionals. Merck & Co. Inc. Last accessed April 6, 2013.
http://www.merckmanuals.com/pr...

19. Majority of Pain Patients Use Prescription Drugs Properly

"The research findings noted above need to be set against the testimony of people with pain, many of whom derive substantial relief from opioid drugs. This tension perhaps reflects the complex nature of pain as a lived experience, as well as the need for biopsychosocial assessments and treatment strategies that can maximize patients’ comfort and minimize risks to them and society. Regardless, the majority of people with pain use their prescription drugs properly, are not a source of misuse, and should not be stigmatized or denied access because of the misdeeds or carelessness of others."

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), p. 145.
http://www.nap.edu/openbook.ph...

20. Regulatory Barriers to Adequate Pain Care

"In the United States, many pain experts agree that physicians should prescribe opioids when necessary regardless of outside pressures as an exercise of their 'moral and ethical obligations to treat pain' (Payne et al., 2010, p. 11). For some time, observers have attributed U.S. patients’ difficulty in obtaining opioids to pressures on physicians from law enforcement and risk-averse state medical boards. Federal and state drug abuse prevention laws, regulations, and enforcement practices have been considered impediments to effective pain management since 1994, when the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality [AHRQ]) adopted clinical practice guidelines on cancer pain (Jacox et al., 1994a,b).
"Like AHRQ, the American Medical Directors Association (nursing home physicians) and American Geriatrics Society cite delays in access to prescribed opioids for nursing home patients, including those who are terminally ill, and the American Cancer Society has recognized the frequent inaccessibility of ­opioids necessary for treating some pain. The American Pain Society has developed evidence-based guidelines for controlling cancer pain, including the use of opioids when other treatments fail or when severe pain relief needs must be met immediately (Gordon et al., 2005). Fourteen years ago, the Institute of Medicine Committee on Care at the End of Life called for efforts to reduce regulatory barriers to pain relief at the end of life and termed some regulatory restrictions 'outdated and flawed' (IOM, 1997, p. 56)."

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), p. 145.
http://www.nap.edu/openbook.ph...

21. Risk of Opioid Medication Abuse by Pain Patients

"Opioid medications present some risk of abuse by patients as well. A structured review of 67 studies found that 3 percent of chronic noncancer pain patients regularly taking opioids developed opioid abuse or addiction, while 12 percent developed aberrant drug-related behavior (Fishbain et al., 2008). A recent analysis revealed that half of patients who received a prescription for opioids in 2009 had filled another opioid prescription within the previous 30 days, indicating that they were seeking and obtaining more opioids than prescribed by any single physician (NIH and NIDA, 2011)."

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), p. 146.
http://www.nap.edu/openbook.ph...

22. Definition of Diversion of Licit, Legally Prescribed Drugs

"'Drug diversion' is best defined as the diversion of licit drugs for illicit purposes. It involves the diversion of drugs from legal and medically necessary uses towards uses that are illegal and typically not medically authorized or necessary."

"Drug Diversion in the Medicaid Program: State Strategies for Reducing Prescription Drug Diversion in Medicaid," Centers for Medicare & Medicaid Services (Baltimore, MD: January 2012), p. 1.
https://www.cms.gov/Medicare-M...

23. Number Of Painkiller Prescriptions Written Annually In The US

"Prescribers wrote 82.5 OPR [Opioid Pain Reliever] prescriptions and 37.6 benzodiazepine prescriptions per 100 persons in the United States in 2012 (Table). LA/ER [Long-Acting or Extended Release] OPR accounted for 12.5%, and high-dose OPR accounted for 5.1% of the estimated 258.9 million OPR prescriptions written nationwide. Prescribing rates varied widely by state for all drug types. For all OPR combined, the prescribing rate in Alabama was 2.7 times the rate in Hawaii."

Leonard J. Paulozzi, MD1, Karin A. Mack, PhD2, Jason M. Hockenberry, PhD, "Vital Signs: Variation Among States in Prescribing of Opioid Pain Relievers and Benzodiazepines — United States, 2012," Morbidity and Mortality Weekly Report, July 4, 2014, US Centers for Disease Control, p. 564.
http://www.cdc.gov/mmwr/pdf/wk...

24. Influence of Drug Control Policy on Pain Medicine

"Opioid medications also have a potential for abuse (a discussion of this important issue is in the Executive Summary and Section III of the Evaluation Guide 2013). Consequently, opioid analgesics and the healthcare professionals who prescribe, administer, or dispense them are regulated pursuant to federal and state controlled substances laws, as well as under state laws and regulations that govern professional practice.70;71 Such policies are intended to prevent illicit trafficking, drug abuse, and substandard practice related to prescribing and patient care. However, in some states these policies go well beyond the usual framework of controlled substances and professional practice policy, and can negatively affect legitimate healthcare practices and create undue burdens for practitioners and patients,72-76 resulting in interference with appropriate pain management.
"Examples of such policy language include:
  "• Limiting medication amounts that can be prescribed and dispensed for every patient;
  "• Unduly restricting the period for which prescriptions are valid;
  "• Unconditionally denying treatment access to patients with pain who also have a history of substance abuse;
  "• Requiring special government-issued prescription forms only for a certain class of medications;
  "• Requiring opioids to be a treatment of last resort regardless of the clinical situation;
  "• Using outdated definitions that confuse physical dependence with addiction; and
  "• Defining 'unprofessional conduct' to include 'excessive' prescribing, without defining the standard or criteria under which such a determination is made."

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. 11.
http://www.painpolicy.wisc.edu...
http://www.painpolicy.wisc.edu...

25. Prosecutions and Administrative Reviews Of Physicians For Offenses Involving The Prescribing Of Opiates

"We identified a total of 986 cases over the 1998–2006 study time frame in which physicians had been criminally charged and/or administratively reviewed with offenses involving the prescribing of opioid analgesics. 335 were criminal cases (178 state, 157 federal) and 651 were administrative cases (525 state medical board cases, 126 DEA administrative actions regarding CS registrations).

"Numbers and Specialties of Study Physicians

"The 725 individual physicians involved in these cases over the study time period represent 0.1% of the total 691,873 patient-care physicians active in 2003, or one out of 954 physicians.

"As shown in Table 1, General Practice/Family Medicine physicians comprised the largest proportion of physicians involved in the criminal and administrative cases (39.3%). Pain Medicine specialists, both self-identified and board certified, comprised 3.5% of the physicians involved in these cases."

Goldenbaum, Donald M.; Christopher, Myra; Gallagher, Rollin M.; Fishman, Scott; Payne, Richard; Joranson, David; Edmondson, Drew; McKee, Judith; Thexton, Arthur, "Physicians Charged with Opioid Analgesic-Prescribing Offenses" Pain Medicine (Glenview, IL: American Academy of Pain Medicine, September 2008) Volume 9, Issue 6, pp. 741.
http://onlinelibrary.wiley.com...

26. Prevalence and Cost of Migraines

"Migraine headaches are a major public health problem affecting more than 28 million persons in this country.1 Nearly 25 percent of women and 9 percent of men experience disabling migraines.2,3 The impact of these headaches on patients and their families is tremendous, with many patients reporting frequent and significant disability.4 The economic burden of migraine headaches in the United States is also tremendous. Persons with migraines lose an average of four to six work days each year, with an annual total loss nationwide of 64 to 150 million work days. The estimated direct and indirect costs of migraine approach $17 billion.5,6 Despite the prevalence of migraines and the availability of multiple treatment options, this condition is often undiagnosed and untreated.7 About one half of patients stop seeking medical care for their migraines, in part because of dissatisfaction with the therapy they have received.4"

Aukerman, Glen; Knutson, Doug; and Miser, William F. M., "Management of the Acute Migraine Headache," American Family Physician (Shawnee Mission, KS: American Academy of Family Physicians, December 2002), Volume 66, Issue 11, p. 2123.
http://www.aafp.org/afp/2002/1...

27. Global Pain Growth Projection

"In the future, the global need for pain medicine will increase rapidly. In developed and developing countries, the world’s population is aging, resulting in an increase of the prevalence of chronic, painful conditions and cancer. By 2025, there will be 1.2 billion people over the age of 60, which is double the current estimate of 600 million.14 Future demand for such care is also expected to rise due to the dramatically expanding prevalence of HIV/AIDS in several parts of the world. Tragically, the greatest need for pain relief is increasingly concentrated in developing countries, where access to morphine and other opioid analgesics is inadequate or non-existent. For example, WHO estimates that the burden of cancer will increasingly shift from industrialized countries to developing states, so that by the year 2020, 70 percent of the estimated 20 million new cancer cases will occur in developing states.15"

Taylor, Allyn L. "Addressing the Global Tragedy of Needless Pain: Rethinking the United Nations Single Convention on Narcotic Drugs," Journal of Law, Medicine & Ethics (Washington, DC: Georgetown University Law Center, January 2008 ) Vol. 35, No. 556, p. 558.
http://papers.ssrn.com/sol3/De...

28. Prevalence Of Persistent Pain Among Adults In The US

"Approximately 19.0% of adults in the United States reported persistent pain in 2010, but prevalence rates vary significantly by subgroup (Table 1). Older adults are much more likely to report persistent pain than younger adults, with adults aged 60 to 69 at highest risk (AOR = 4.0, 95% CI = 2.7–5.8). Women are at slightly higher risk than men (AOR = 1.4, 95% CI = 1.2–1.7), as are adults who did not graduate from high school (AOR = 1.3, 95% CI = 1.1–1.7). Approximately half of adults who rated their health as fair or poor say they suffer from persistent pain (AOR = 4.7, 95% CI = 3.7–6.0). Recent hospitalization (AOR = 1.6, 95% CI = 1.3–2.1) and obesity (AOR = 1.6, 95% CI = 1.3–2.0) are also linked to higher rates of persistent pain. In contrast, Latino (AOR = .5, 95% CI = .4–.6) and African American (AOR = .6, 95% CI = .4–.7) adults are less likely to report persistent pain than their white counterparts."

Jae Kennedy, John M. Roll, Taylor Schraudner, Sean Murphy, and Sterling McPherson, "Prevalence of Persistent Pain in the U.S. Adult Population: New Data From the 2010 National Health Interview Survey," The Journal of Pain, Vol. 15, No. 10 (October), 2014, pp. 979-984. http://dx.doi.org/10.1016/j.jp...
http://www.jpain.org/article/S...

29. Barriers to Adequate Pain Care

"Adequate pain treatment and follow-up may be thwarted by a mix of uncertain diagnosis and the societal stigma that is applied, consciously or unconsciously, to people reporting pain, particularly if they do not respond readily to treatment. Questions and reservations may cloud perceptions of clinicians, family, employers, and others: Is he really in pain? Is she drug seeking? Is he just malingering? Is she just trying to get disability payments? Certainly, there is some number of patients who attempt to 'game the system' to obtain drugs or disability payments, but data and studies to back up these suspicions are few. The committee members are not naïve about this possibility, but believe it is far smaller than the likelihood that someone with pain will receive inadequate care. Religious or moral judgments may come into play: Mankind is destined to suffer; giving in to pain is a sign of weakness. Popular culture, too, is full of dismissive memes regarding pain: Suck it up; No pain, no gain."

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), pp. 46-47.
http://www.nap.edu/openbook.ph...

30. Insurance Barriers to Adequate Pain Treatment

"Costly team care, expensive medications, and procedural interventions—all common types of treatment for pain—are not readily obtained by the 19 percent of Americans under age 65 who lack health insurance coverage (Holahan, 2011) or by the additional 14 percent of under-65 adults who are underinsured (Schoen et al., 2008). Together, these groups make up one-third of the nation’s population. Lack of insurance coverage also may contribute to disparities in care. An inability to pay for pain care is especially prevalent among minorities and women (Green et al., 2011). As discussed above, even for people with insurance coverage, third-party reimbursement systems tend not to cover or to cover well psychosocial services and team approaches that represent the best care for people with the most difficult pain problems. Surmounting this barrier may require coordinated action by advocates for improvement."

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), p. 156.
http://www.nap.edu/openbook.ph...

31. Significance and Growing Prevalence of Lower Back Pain

"The potential impact of the growing prevalence of pain on the health care system is substantial. Although not all people with chronic low back pain are treated within the health care system, many are, and 'back problems' are one of the nation’s 15 most expensive medical conditions. In 1987, some 3,400 Americans with back problems were treated for every 100,000 people; by 2000, that number had grown to 5,092 per 100,000. At the same time, health care spending for these treatments had grown from $7.9 billion to $17.5 billion. Thorpe and colleagues (2004) estimate that low back pain alone contributed almost 3 percent to the total national increase in health care spending from 1987 to 2000. While about a quarter of the $9.5 billion increase could be attributable to increased population size, and close to a quarter was attributable to increased costs of treatment, more than half of the total (53 percent) was attributable to a rise in the prevalence of back problems."

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), p. 64.
http://www.nap.edu/openbook.ph...

32. Opioid Use And Risks In Treatment Of Pain

"Some opioids used for analgesia have both agonist and antagonist actions. Potential for abuse among those with a known history of abuse or addiction may be lower with agonist-antagonists than with pure agonists, but agonist-antagonist drugs have a ceiling effect for analgesia and induce a withdrawal syndrome in patients already physically dependent on opioids.
"In general, acute pain is best treated with short-acting pure agonist drugs, and chronic pain, when treated with opioids, should be treated with long-acting opioids (see Table 2: Opioid Analgesics Tables and Table 3: Equianalgesic Doses of Opioid Analgesics). Because of the higher doses in many long-acting formulations, these drugs have a higher risk of serious adverse effects (eg, death due to respiratory depression) in opioid-naive patients.
"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 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 September 24, 2014.
http://www.merckmanuals.com/pr...

33. Community Epidemiology Working Group Assessment of Non-Prescription Use of Prescription Analgestic in the US, 2012

"Mixed results were noted for prescription opioids, with increases in indicators for prescription opioids as a key finding reported by representatives in two areas—New York City and San Francisco—based on treatment admissions data (primary treatment admissions for opioids/opiates other than heroin increased in 2012 from 2011 in New York City), numbers of prescriptions (the Prescription Drug Monitoring Programs in both New York City and San Francisco showed increases in numbers of prescriptions in 2012), death data (unintentional opioid analgesic poisoning deaths increased in New York City by 65 percent from 2005 to 2011), and ED visit data (visits involving prescription opioids/other opiates increased in New York City from 2010 to 2011 and in San Francisco from 2004 to 2011). A decline in indicators for prescription opioids/opiates other than heroin was reported as a key finding in three other CEWG areas—Maine, Seattle, and South Florida/Miami-Dade and Broward Counties. Deaths related to prescription opioids/opiates other than heroin declined from 2011 to 2012 in Seattle and both Miami-Dade and Broward Counties in South Florida. Treatment admissions and drug reports among drug items seized and analyzed in NFLIS laboratories declined in 2012 from 2011 in the two South Florida counties. Arrests showed decreases in Maine from 2011 to 2012, and reported use of prescription-type opiates in the last month to 'get high' among high school students decreased significantly from 2010 to 2012 in the Seattle area."

"Epidemiologic Trends in Drug Abuse: Proceedings of the Community Epidemiology Work Group, Advance Report, June 2013" (Bethesda, MD: National Institute on Drug Abuse, December 2013), p. 4.
http://www.drugabuse.gov/sites...

34. Rise in Opiate Prescriptions in US

"Even though opioids have been controlled in the United States with regulations and restrictions, opioid utilization has been increasing at an unprecedented pace (1-10). Manchikanti et al (1), in an evaluation of opioid usage over a period of 10 years, showed an overall increase of 149% in retail sales of opioids from 1997 to 2007 in the United States, with an increase of 1,293% for methadone, 866% for oxycodone, and 525% for fentanyl. Similarly, the increase in therapeutic opioid use in the United States in milligrams per person from 1997 to 2007 increased 402% overall, with the highest increase in methadone of 1,124% mg/person and oxycodone of 899% mg/person."

Christo,Paul J.; Manchikanti, Laxmaiah; Ruan, Xiulu; Bottros, Michael; Hansen, Hans; Solanki, Daneshvari R.; Jordan, Arthur E.; and Colson, James , "Urine Drug Testing In Chronic Pain," Pain Physician (Paducah, KY: American Society of Interventional Pain Physicians, March/April 2011), Vol. 14, Issue 2, p. 124.
http://www.painphysicianjourna...

35. Undertreatment of Pain More Common Among African-American Patients Than Whites

"Undertreatment of pain among African Americans has been well documented. For example, children with sickle-cell anemia (a painful disease that occurs most often among African Americans) who presented to hospital emergency departments (EDs) with pain were far less likely to have their pain assessed than were children with long-bone fractures (Zempsky et al., 2011).
"In general, moreover, a number of studies have shown that physicians tend to prescribe less analgesic medication for African Americans than for whites (Bernabei et al., 1998; Edwards et al., 2001; Green and Hart-Johnson, 2010). A study that used a pain management index to evaluate pain control found that blacks were less likely than whites to obtain prescriptions for adequate pain relief, based on reported pain severity and the strength of analgesics provided. Because such an index is a way to quantify a person’s response to pain medication alone, it is likely that people in this study did not receive other types of treatment for pain either."

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), p. 68.
http://www.nap.edu/openbook.ph...

36. War on Pain Doctors

"The government is waging an aggressive, intemperate, unjustified war on pain doctors. This war bears a remarkable resemblance to the campaign against doctors under the Harrison Act of 1914, which made it a criminal felony for physicians to prescribe narcotics to addicts. In the early 20th century, the prosecutions of doctors were highly publicized by the media and turned public opinion against physicians, painting them not as healers of the sick but as suppliers of narcotics to degenerate addicts and threats to the health and security of the nation."

Libby, Ronald T., "Treating Doctors as Drug Dealers The DEA’s War on Prescription Painkillers," CATO Institute (Washington, DC: June 2005), p. 21.
http://www.csdp.org/research/c...

37. Growth of Federal Oxycontin Investigations and Arrests

"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."

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.
http://www.gao.gov/new.items/d...

38. Prevalence of Neuropathic Pain

"Neuropathic pain (NP) is defined as pain caused by a lesion or disease of the central or peripheral somatosensory nervous system.[1] NP affects between 5% and 10% of the US population [2] and examples include diabetic neuropathy, complex regional pain syndrome, radiculopathy, phantom limb pain, HIV sensory neuropathy, multiple sclerosis-related pain, and poststroke pain.[3]"

Collen, Mark, "Prescribing Cannabis for Harm Reduction," Harm Reduction Journal (London, United Kingdom: January 2012) Vol. 9, Issue 1, p. 1.
http://www.harmreductionjourna...

39. Pain-Related Lost Productivity

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."

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.
http://jama.jamanetwork.com/ar...

40. Limited Data Available on Pain Treatment

"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."

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.
http://jama.jamanetwork.com/ar...

41. Cost of Pain-Related Lost Productivity

"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."

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.
http://jama.jamanetwork.com/ar...

42. Populations At Increased Risk For Chronic Pain And For Inadequate Treatment

"An important message from epidemiologic studies cited by Blyth and colleagues (2010) is 'the universal presence across populations of characteristic subgroups of people with an underlying propensity or increased risk for chronic pain, in the context of a wide range of different precipitating or underlying diseases and injuries' (p. 282). These vulnerable subgroups are most often those of concern to public health.5 Increased vulnerability to pain is associated with the following:
"• having English as a second language,
"• race and ethnicity,
"• income and education,
"• sex and gender,
"• age group,
"• geographic location,
"• military veterans,
"• cognitive impairments,
"• surgical patients,
"• cancer patients, and
"• the end of life.
"Many of these same groups also are at risk of inadequate treatment."

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), pp. 64-65.
http://www.nap.edu/openbook.ph...

43. Overdose Risk Based on Prescription Type

"Dunn et al4 found that risk of drug-related adverse events among individuals treated for chronic noncancer pain with opioids was increased at opioid doses equivalent to 50 mg/d or more of morphine. Our analyses similarly found that the risk of opioid overdose increased when opioid dose was equivalent to 50 mg/d or more of morphine.
"The present study also extended prior research in several important ways. We used a large, national sample of individuals and focused exclusively on opioid overdose deaths. Because the circumstances that lead to overdose death may vary by the condition for which the opioid is prescribed and substance use disorder status, we conducted analyses for subgroups of patients, including those with cancer, acute pain, and substance use disorders.
"The present study also extended the prior research by exploring a novel risk factor, ie, concurrent prescriptions of regularly scheduled and as-needed opioids. We found that those patients who were simultaneously treated with as-needed and regularly scheduled opioids, a strategy for treating pain exacerbations,7,8 did not have a statistically significant increased risk of opioid overdose in adjusted models. Recent treatment guidelines have indicated that the long-term safety of this strategy for pain exacerbation has not been established,5,9 and in the present study we did not find evidence of greater overdose risk associated with this treatment practice after accounting for maximum daily dose and patient characteristics."

Bohnert, Amy S.B., et al., "Association Between Opioid Prescribing Patterns and Opioid Overdose-Related Deaths," Journal of the American Medical Association, April 6, 2011, Vol 305, No. 13, pp. 1319-1320.
http://jama.jamanetwork.com/ar...

44. Sources of Psychotherapeutic Drugs Used Nonmedically in the US, 2012

"• Past year nonmedical users of psychotherapeutic drugs are asked how they obtained the drugs they most recently used nonmedically. Rates averaged across 2011 and 2012 show that more than one half of the nonmedical users of pain relievers, tranquilizers, stimulants, and sedatives aged 12 or older got the prescription drugs they most recently used 'from a friend or relative for free.' About 4 in 5 of these nonmedical users who obtained prescription drugs from a friend or relative for free indicated that their friend or relative had obtained the drugs from one doctor."

Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013, p. 29.
http://www.samhsa.gov/data/NSD...
http://www.samhsa.gov/data/NSD...

45. Sources of Pain Relievers Used Nonmedically in the US, 2012

"• Among persons aged 12 or older in 2011-2012 who used pain relievers nonmedically in the past year, 54.0 percent got the pain relievers they most recently used from a friend or relative for free (Figure 2.16). Nearly 1 in 5 (19.7 percent) received them through a prescription from one doctor (which was higher than the 17.3 percent in 2009-2010). Another 10.9 percent bought them from a friend or relative. In addition, 4.0 percent of these nonmedical users in 2011-2012 took pain relievers from a friend or relative without asking. An annual average of 4.3 percent got pain relievers from a drug dealer or other stranger; 1.8 percent got pain relievers from more than one doctor; 0.8 percent stole pain relievers from a doctor's office, clinic, hospital, or pharmacy (which was higher than the 0.2 percent in 2009-2010); and 0.2 percent bought the pain relievers on the Internet.
"• Among persons aged 12 or older in 2011-2012 who used pain relievers nonmedically in the past year and indicated that they most recently obtained the drugs from a friend or relative for free, 82.2 percent of the friends or relatives obtained the drugs from just one doctor (Figure 2.16). About 1 in 20 of these past year nonmedical users of pain relievers (5.4 percent) reported that the friend or relative got the pain relievers from another friend or relative for free, 4.1 percent reported that the friend or relative bought the pain relievers from a friend or relative, 1.4 percent reported that the friend or relative bought the pain relievers from a drug dealer or other stranger (which was lower than the 2.3 percent in 2009-2010), 1.3 percent reported that the friend or relative took the pain relievers from another friend or relative without asking, and 0.2 percent reported that the friend or relative bought the pain relievers on the Internet."

Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013, pp. 29-30.
http://www.samhsa.gov/data/NSD...
http://www.samhsa.gov/data/NSD...

46. Undertreatment of Pain Among Those With Chemical Dependency

"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."

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.
http://jama.jamanetwork.com/ar...

47. Racial and Socioeconomic Disparities in Availability of Opioid Analgesic Availability

"Disparities in pain assessment and treatment on the basis of race and ethnicity are well documented.29 Diminished ability to obtain access to opioid analgesics in local pharmacies is a significant barrier to quality pain care. The present investigation provides evidence that Michigan pharmacies in predominantly minority areas were significantly less likely to have sufficient prescription opioid analgesic supplies when compared with predominantly white areas. Regardless of median income and median age, significant differences were found in opioid analgesic availability on the basis of ethnic composition. These results support the findings of Morrison et al38 that pharmacies in predominantly minority neighborhoods stock insufficient opioid analgesic supplies more so than those in predominantly white neighborhoods. However, these results also extend their findings by demonstrating the role of both social class and income on opioid analgesic availability. More specifically, the odds for not having sufficient opioid analgesic supplies are significantly higher among pharmacies in low income areas when compared with higher income areas, regardless of race. More importantly, we identified that the odds of having insufficient supplies in minority neighborhoods changed significantly on the basis of income (ie, high or low) (OR, 13.36 vs 54.42). Thus, social class and poverty seem to play a role for whites more so than minorities. Noncorporate pharmacies were also more likely to have sufficient opioid analgesic supplies than corporate pharmacies. These results suggest that if an opioid analgesic is prescribed for pain management, persons living in minority zip codes (even in higher income areas) or those living in low income zip codes (regardless of minority status) face additional barriers to quality pain care. Thus, vulnerable populations (eg, minorities and low income individuals) are at increased risk for inefficient and lesser quality pain care."

Carmen R. Green, S. Khady Ndao-Brumblay, Brady West, and Tamika Washington, "Differences in Prescription Opioid Analgesic Availability: Comparing Minority and White Pharmacies Across Michigan," The Journal of Pain - October 2005 (Vol. 6, Issue 10, Pages 689-699, DOI: 10.1016/j.jpain.2005.06.002), p. 695.
Abstract: http://www.ncbi.nlm.nih.gov/pu...
http://www.jpain.org/article/S...

48. Undertreatment of Pain Among the Elderly

"Factors affecting the severity of pain in the elderly include
"• complex manifestations of pain;
"• underreporting of pain;
"• concurrent problems and multiple diseases (comorbidities), which complicate diagnosis and treatment;
"• higher rates of medication side effects; and
"• higher rates of treatment complications (American Geriatrics Society, 2009).
"In general, these same factors also contribute to the documented undertreatment of pain in the elderly, along with the lack of an evidence base concerning the pharmacokinetic and pharmacodynamic changes that occur with aging (Barber and Gibson, 2009). Similar to the situation with children in the past, elderly people rarely are included in clinical trials of medications, so clinicians have inadequate information about appropriate dosages and potential interactions with medications being taken for other chronic diseases (Barber and Gibson, 2009).
"A study of more than 13,000 people with cancer aged 65 and older discharged from the hospital to nursing homes found that, among the 4,000 who were in daily pain, those aged 85 and older were more than 1.5 times as likely to receive no analgesia than those aged 65-74; only 13 percent of those aged 85 and older received opioid medications, compared with 38 percent of those aged 65-74 (Bernabei et al., 1998). (A similar excess risk of receiving no analgesia was found among African Americans, Hispanics, and Asians compared with whites.)"

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), pp. 79-80.
http://www.nap.edu/openbook.ph...

49. Estimated Prevalence of Opioid Diversion by "Doctor Shoppers" in the US

"We applied our composite probability distribution to each patient to calculate the probability that the patient was a member of the 'extreme' group. That is, we multiplied the size of each stratum of patients by its posterior probability of population 3 membership to estimate the total number of probable shoppers in the United States. Summing these probabilities, we estimated that of the 19 million patients in the US who purchased opioids in the first 60 days of 2008, 135,000 (0.7%) were members of this extreme population (Table 2).
"Although only a small fraction of active patients, members of this extreme population obtained an estimated 1.9% (4.3 million) of all 223 million opioid prescriptions dispensed during 2008, and 2.8% of all oxycodone prescriptions (Table 3). They purchased an average of 32 opioid prescriptions that year. When we accounted for the quantity of drugs prescribed, their share of the market was even larger: an estimated 4.0% of the total amounts of these drugs dispensed that year, or about 11.1 million grams. This was equivalent to approximately 5.4 million grams of morphine. This would have provided an average of 109 morphine equivalent milligrams per patient in this extreme group for every day in 2008."

Douglas C. McDonald and Kenneth E. Carlson, "Estimating the Prevalence of Opioid Diversion by 'Doctor Shoppers' in the United States," PLoS One, 2013; 8(7): e69241. Published online 2013 July 17. doi: 10.1371/journal.pone.0069241.
http://www.ncbi.nlm.nih.gov/pm...
http://www.ncbi.nlm.nih.gov/pm...

50. Barriers to Availability of Legal Opioid Analgesics in the US

"The most common reason cited as a barrier to opioid availability was low demand (93.1%). However, this did not vary by opioid analgesic sufficiency, pharmacy racial composition, pharmacy type, level of zip code urbanization, level of opioid analgesic supply, median age, household income, or proportion of residents ?65 years old. The fear that patients might use opioid analgesics for illicit purposes was the second most prevalent barrier identified (8.5%). Concern with illicit opioid analgesic use was more likely to be reported as a barrier by pharmacies with insufficient opioid analgesic supplies when compared with those with sufficient supplies (30.3% vs 4.3%; P ? .01). Again, this did not vary by pharmacy racial composition, pharmacy type, level of zip code urbanization, median age, household income, or proportion of residents ?65 years old. Too much paperwork (1%) and fear of robbery (1%) were rarely identified as potential reasons for opioid analgesic unavailability. Measures of association between covariates and barriers were not computed for the least common barriers (ie, too much paperwork, fear of robbery, and drug disposal regulations) because of empty cells. Other responses cited for failing to supply opioid analgesics (eg, pharmacy was located in a small community, pharmacy was near a major medical center, and community residents do not have adequate health insurance coverage) were of low frequency and were not analyzed further."

Carmen R. Green, S. Khady Ndao-Brumblay, Brady West, and Tamika Washington, "Differences in Prescription Opioid Analgesic Availability: Comparing Minority and White Pharmacies Across Michigan," The Journal of Pain - October 2005 (Vol. 6, Issue 10, Pages 689-699, DOI: 10.1016/j.jpain.2005.06.002), p. 694.
Abstract: http://www.ncbi.nlm.nih.gov/pu...

51. Global Lack of Pain Relief

"Current estimates suggest that upward of 80% of the world’s population lacks access to basic pain relief [6]. Paradoxically, those 80% are mostly in poorer countries, and their need for pain relief is heightened by a relative absence of curative care such as surgery, or treatment for both communicable and non-communicable diseases causing pain (e.g., HIV/AIDS, cancer)[7]."

Nickerson, Jason W., and Attaran, Amir, "The Inadequate Treatment of Pain: Collateral Damage from the War on Drugs," PLoS Medicine (Cambridge, United Kingdom: Public Library of Science, Jan. 2012) Vol. 9, Issue 1, p. 1.
http://www.plosmedicine.org/ar...

52. Global Medical Opiate Shortage

"We determined per capita need of strong opioids for pain related to three important pain causes for 188 countries. These needs were extrapolated to the needs for all the various types of pain by using an adequacy level derived from the top 20 countries in the Human Development Index. By comparing with the actual consumption levels for relevant strong opioid analgesics, we were able to estimate the level of adequacy of opioid consumption for each country. Good access to pain management is rather the exception than the rule: 5.5 billion people (83% of the world’s population) live in countries with low to nonexistent access, 250 million (4%) have moderate access, and only 460 million people (7%) have adequate access. Insufficient data are available for 430 million (7%). The consumption of opioid analgesics is inadequate to provide sufficient pain relief around the world. Only the populations of some industrialized countries have good access."

Marie-Josephine Seya, Susanne F. A. M. Gelders, Obianuju Uzoma Achara, Barbara Milani, and Willem Karel Scholten, "A First Comparison Between the Consumption of and the Need for Opioid Analgesics at Country, Regional, and Global Levels," Journal of Pain & Palliative Care Pharmacotherapy. 2011;25:6–18. ISSN: 1536-0288 print / 1536-0539 online. DOI: 10.3109/15360288.2010.536307
http://apps.who.int/medicinedo...

53. Global Lack of Access to Pain Medication

"Opioid medications are essential not only for drug dependence treatment but also for pain management. WHO estimates that 5 billion people live in countries with little or no access to controlled medicines that are used to treat moderate to severe pain.90 Up to 80% of the estimated 1 million patients in the end stages of AIDS are in great pain, but very few have access to pain relieving drugs91 because of insufficient knowledge among physicians, inadequate health systems, fears of addiction, antiquated laws, and unduly strict regulations.92"

Jürgens, Ralf; Csete, Joanne; Amon, Joseph J.; Baral, Stefan; and Beyrer, Chris, "People who use drugs, HIV, and human rights," The Lancet (London, United Kingdom: August 7, 2010) Vol. 376, Issue 9739, pp. 478-479.
http://www.canadianharmreducti...

54. Societal Impact of Diversion

"The societal impact of CPD [controlled prescription drugs] diversion and abuse is considerable. Violent and property crime associated with CPD diversion and abuse has increased in all regions of the United States over the past 5 years, according to the National Drug Intelligence Center (NDIC) National Drug Threat Survey (NDTS). However, the association between crime and CPD diversion is reported much less frequently than the association between crime and illicit drugs. Increases in crime rates often result in higher budgetary expenditures for additional law enforcement resources. Moreover, the estimated cost of CPD diversion and abuse to public and private medical insurers is $72.5 billion a year,3 much of which is passed to consumers through higher health insurance premiums. Additionally, the abuse of prescription opioids is burdening the budgets of substance abuse treatment providers, particularly as prescription opioid abuse might be fueling heroin abuse rates in some areas of the United States."

National Drug Intelligence Center, Drug Enforcement Administration, "National Prescription Drug Threat Assessment," (Washington DC, April 2009), p. IV.
http://www.justice.gov/archive...

55. Unrelieved Pain Continues To Burden Americans

"Pain remains one of the most common physical complaints upon a person’s admission into the healthcare system (Burton, Fanciullo, Beasley, & Fisch, 2007; Foley et al., 2005; Freburger et al., 2009; McCarberg, 2010; Peterlin, Rosso, Rapoport, & Scher, 2009; Schug & Chong, 2009; Weiss, Emanuel, Fairclough, & Emanuel, 2001). Pain is prevalent in cancer, especially near the end of life (Paice, 2010; Smith et al., 2010), and in other diseases and conditions such as HIV/AIDS (Breitbart & Cortes?Ladino, 2010; Tsao, Stein, & Dobalian, 2010) and sickle?cell anemia (American Pain Society, 1999; Ballas, 2010); indeed, persistent pain itself is increasingly being recognized as a disease (Institute of Medicine Committee on Advancing Pain Research, 2011). However, insufficient treatment attention often is given to appropriate pain relief, especially when pain is severe or prolonged. In extreme circumstances, pain can impair all aspects of life and sometimes contribute to a person’s wish for death (Fishman & Rathmell, 2010; Ilgen et al., 2013; Institute of Medicine Committee on Advancing Pain Research, 2011; Institute of Medicine National Cancer Policy Board, 2001; Wasan, Sullivan, & Clark, 2010). When pain relief is achieved, it can result in improved quality of living for people with prolonged pain and can decrease suffering for people at the end of life (Higginson & Evans, 2010)."

Pain & Policy Studies Group. Achieving Balance in Federal and State Pain Policy: A Guide to Evaluation (CY 2013). (University of Wisconsin Carbone Cancer Center: Madison, WI, July 2014), p. 13.
http://www.painpolicy.wisc.edu...
http://www.painpolicy.wisc.edu...

56. Reasons for Non-Prescription Use of Prescription Opioids by US High School Seniors

"Approximately 12.3% of the respondents -- high school seniors in the United States -- reported lifetime nonmedical use of prescription opioids and 8.0% reported past-year nonmedical use. Table 1 shows the prevalence of motives for nonmedical use of prescription opioids among high school seniors in the United States. The leading motives included 'to relax or relieve tension' (56.4%), 'to feel good or get high' (53.5%), 'to experiment-see what it's like' (52.4%), 'to relieve physical pain' (44.8%), and 'to have a good time with friends' (29.5%).

Sean Esteban McCabe, Phd, et al., "Motives for Nonmedical Use of Prescription Opioids among High School Seniors in the United States: Self-Treatment and Beyond," Archives of Pediatric and Adolescent Medicine, 2009 August; 163(8): 739-744. doi:10.1001/archpediatrics.2009.120.
http://www.ncbi.nlm.nih.gov/pu...
http://www.ncbi.nlm.nih.gov/pm...

57. Prevalence of Chronic Pain

According to a survey conducted by Roper Starch Worldwide for the American Pain Society in 1999, "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."

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.

58. Pain Management - Data - 1999 - 2-20-10

According to a public opinion poll released in 1999, "It is estimated that 9% of the U.S. adult population suffer from moderate to severe non-cancer related chronic pain."

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.

59. Pain Relief and Non-Prescription Use of Prescription Opioids by US High School Seniors

"The lifetime medical use of prescription opioids was reported by approximately 14.0% of those who did not engage in past-year nonmedical use of prescription opioids, 76.1% of nonmedical users of prescription opioids motivated only by pain relief, 71.4% of those motivated by pain relief and other motives, and 46.7% of those who reported non-pain relief motives only (p < 0.001). Among past-year nonmedical users of prescription opioids, approximately 56.5% of those motivated only by pain relief as compared to 23.1% of those who reported pain relief and other motives, and 14.2% of those who reported only non-pain relief motives had initiated medical use of prescription opioids before nonmedical use of prescription opioids. In contrast, approximately 19.6% of those motivated only by pain relief as compared to 48.3% of those who reported pain relief and other motives, and 32.5% of those who reported only non-pain relief motives initiated nonmedical use of prescription opioids before medical use of prescription opioids."

Sean Esteban McCabe, Phd, et al., "Motives for Nonmedical Use of Prescription Opioids among High School Seniors in the United States: Self-Treatment and Beyond," Archives of Pediatric and Adolescent Medicine, 2009 August; 163(8): 739-744. doi:10.1001/archpediatrics.2009.120.
http://www.ncbi.nlm.nih.gov/pu...
http://www.ncbi.nlm.nih.gov/pm...

60. Prescribing Patterns and Opioid Overdose-Related Deaths

"There is some evidence that higher prescribed doses increase the risk of drug overdose among individuals treated with opioids for chronic non-cancer pain.4 Specifically, the risk of drug-related adverse events is higher among individuals prescribed opioids at doses equal to 50 mg/d or more of morphine. The association of opioid prescribing patterns with risk of over-dose may vary across groups of patients; opioid treatment recommendations for pain are typically specific to particular subgroups such as those with chronic noncancer pain,5 cancer-related pain, and substance use disorders.6 However, potential subgroup differences in opioid prescribing have not been examined."

Bohnert, Amy S.B., et al., "Association Between Opioid Prescribing Patterns and Opioid Overdose-Related Deaths," Journal of the American Medical Association, April 6, 2011, Vol 305, No. 13, p. 1315.
http://jama.jamanetwork.com/ar...

61. Estimated Prevalence of Current Nonmedical Use of Psychotherapeutics in the US, 2014

Nonmedical Use of Prescription Drugs

"In 2014, the estimate of 6.5 million Americans aged 12 or older who were current nonmedical users of psychotherapeutic drugs represents 2.5 percent of the population aged 12 or older (Figures 1 and 4). The 2014 estimate for current nonmedical use of psychotherapeutic drugs among people aged 12 or older was slightly lower than the estimates in 2006, 2007, 2009, and 2010 (ranging from 2.7 to 2.9 percent), and it was similar to the estimates in the other years between 2002 and 2013.19"

Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50), p. 6.
http://www.samhsa.gov/data/sit...
http://www.samhsa.gov/data/sit...

62. Initiation of Nonmedical Use of Prescription Psychotherapeutics in the US, 2013

"• Nonmedical use of psychotherapeutics includes nonmedical use of any prescription-type pain relievers, tranquilizers, stimulants, or sedatives. Over-the-counter substances are not included. In 2013, there were approximately 2.0 million persons aged 12 or older who used psychotherapeutics nonmedically for the first time within the past year, which averages to about 5,500 initiates per day. The number of new nonmedical users of psychotherapeutics in 2013 was lower than the estimates for prior years from 2002 through 2012 (ranging from 2.3 million to 2.8 million).
"• In 2013, the numbers of initiates were 1.5 million for pain relievers, 1.2 million for tranquilizers, 603,000 for stimulants, and 128,000 for sedatives (Figure 5.6).
"• The number of new nonmedical users of pain relievers in 2013 (1.5 million) was lower than the numbers in 2002 through 2012 (ranging from 1.9 million to 2.5 million) (Figure 5.6). The number of past year initiates for nonmedical use of tranquilizers has been fairly stable from 2002 to 2013 (ranging from 1.1 million to 1.4 million). The number of initiates for nonmedical use of stimulants in 2013 was similar to the numbers in 2003, 2005, and in 2007 to 2012 (ranging from 602,000 to 715,000), but was lower than the numbers in 2002, 2004, and 2006 (ranging from 783,000 to 846,000). The number of initiates for nonmedical use of sedatives in 2013 was similar to the numbers in 2002, 2003, 2007 to 2009, 2011, and 2012 (ranging from 159,000 to 209,000), but was lower than the numbers in 2004 to 2006 and in 2010 (ranging from 240,000 to 267,000).
"• In 2013, the average age at first nonmedical use of any psychotherapeutics among recent initiates aged 12 to 49 was 22.4 years. Average ages at first nonmedical use were 21.6 years for stimulants, 21.7 years for pain relievers, 25.0 years for sedatives, and 25.4 years for tranquilizers. All of these 2013 estimates were similar to the corresponding estimates in 2012.
"• In 2013, the number of new nonmedical users of OxyContin® aged 12 or older was 436,000, which was similar to the estimates for prior years from 2004 through 2012. The average age at first use of OxyContin® among past year initiates aged 12 to 49 was similar in 2012 and 2013 (22.0 and 23.6 years, respectively)."

Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014, pp. 64-66.
http://www.samhsa.gov/data/NSD...
http://www.samhsa.gov/data/NSD...

63. Nonmedical Prescription Drug Use by Young Adults Aged 18-25 in the US, 2013

"• Among young adults aged 18 to 25, the rate of current nonmedical use of psychotherapeutic drugs in 2013 (4.8 percent) was similar to the rates in 2011 (5.0 percent) and 2012 (5.3 percent), but it was lower than the rates in 2002 to 2010 (ranging from 5.5 to 6.5 percent) (Figure 2.9). The rate of current nonmedical use of pain relievers among young adults in 2013 (3.3 percent) was lower than the rates in 2012 (3.8 percent) and in 2002 to 2010 (ranging from 4.1 to 5.0 percent), but it was similar to the rate in 2011 (3.6 percent)."

Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014, p. 23.
http://www.samhsa.gov/data/NSD...
http://www.samhsa.gov/data/NSD...

64. Nonmedical Use of Psychotherapeutic Drugs by Type, 2004

"In 2004, 6.0 million persons were current users of psychotherapeutic drugs taken nonmedically (2.5 percent). These include 4.4 million who used pain relievers, 1.6 million who used tranquilizers, 1.2 million who used stimulants, and 0.3 million who used sedatives. These estimates are all similar to the corresponding estimates for 2003.
"There were significant increases in the lifetime prevalence of use from 2003 to 2004 in several categories of pain relievers among those aged 18 to 25. Specific pain relievers with statistically significant increases in lifetime use were Vicodin®, Lortab®, or Lorcet® (from 15.0 to 16.5 percent); Percocet®, Percodan®, or Tylox® (from 7.8 to 8.7 percent); hydrocodone products (from 16.3 to 17.4 percent); OxyContin® (from 3.6 to 4.3 percent); and oxycodone products (from 8.9 to 10.1 percent)."

Substance Abuse and Mental Health Services Administration, Results from the 2004 National Survey on Drug Use and Health: National Findings (Rockville, MD: US Dept. of Health and Human Services, Office of Applied Studies, 2005), p. 1.
http://www.oas.samhsa.gov/nsdu...

65. OxyContin Availability

"The large amount of OxyContin available in the marketplace may have increased opportunities for abuse and diversion. Both DEA and Purdue have stated that an increase in a drug's availability in the marketplace may be a factor that attracts interest by those who abuse and divert drugs."

General Accounting Office, "Prescription Drugs: Oxycontin Abuse and Diversion and Efforts to Address the Problem," GAO-04-110 (Washington, DC: Government Printing Office, December 2003), p. 30.
http://www.gao.gov/new.items/d...

66. Oxycontin

"There are several factors that may have contributed to the abuse and diversion of OxyContin. OxyContin's formulation as a controlled- release opioid that is twice as potent as morphine may have made it an attractive target for abuse and diversion. In addition, the original label’s safety warning advising patients not to crush the tablets because of the possible rapid release of a potentially toxic amount of oxycodone may have inadvertently alerted abusers to possible methods for misuse. Further, the rapid growth in OxyContin sales increased the drug's availability in the marketplace and may have contributed to opportunities to obtain the drug illicitly. The history of abuse and diversion of prescription drugs in some geographic areas, such as those within the Appalachian region, may have predisposed some states to problems with OxyContin. However, we could not assess the relationship between the growth in OxyContin prescriptions or increased availability with the drug's abuse and diversion because the data on abuse and diversion are not reliable, comprehensive, or timely."

General Accounting Office, "Prescription Drugs: Oxycontin Abuse and Diversion and Efforts to Address the Problem," GAO-04-110 (Washington, DC: Government Printing Office, December 2003), p. 29.
http://www.gao.gov/new.items/d...

67. Estimated Prevalence of Non-Medical Use of Pain Relievers in the US, 2014

"Overall estimates of current nonmedical use of prescription psychotherapeutic drugs among the population aged 12 or older that were described previously have largely been driven by the nonmedical use of prescription pain relievers. In 2014, about two thirds of the current nonmedical users of psychotherapeutic drugs who were aged 12 or older reported current nonmedical use of pain relievers (Figure 5).
"The estimated 4.3 million people aged 12 or older in 2014 who were current nonmedical users of pain relievers represent 1.6 percent of the population aged 12 or older (Figures 5 and 6). The percentage of people aged 12 or older who were current nonmedical users of pain relievers in 2014 was lower than the percentages in most years from 2002 to 2012, but it was similar to the percentage in 2013."

Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50), p. 7.
http://www.samhsa.gov/data/sit...
http://www.samhsa.gov/data/sit...

68. Source of Pain Relievers Used Non-Medically

"Among persons aged 12 or older in 2010-2011 who used pain relievers nonmedically in the past year, 54.2 percent got the pain relievers they most recently used from a friend or relative for free (Figure 2.14). Another 12.2 percent bought them from a friend of relative (which was higher than the 9.9 percent in 2008-2009). In addition, 4.4 percent of these nonmedical users in 2010-2011 took pain relievers from a friend or relative without asking. More than one in six (18.1 percent) indicated that they got the drugs they most recently used through a prescription from one doctor. Less than 1 in 20 users (3.9 percent) got pain relievers from a drug dealer or other stranger, 1.9 percent got pain relievers from more than one doctor, and 0.3 percent bought them on the Internet. These other percentages were similar to those reported in 2008-2009."

Substance Abuse and Mental Health Services Administration, Results from the 2011 National
Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012, p. 28.
http://www.samhsa.gov/data/NSD...

69. Source For Pain Relievers Used Non-Medically Which Were Obtained From A Friend Or Relative For Free

"Among persons aged 12 or older in 2010-2011 who used pain relievers nonmedically in the past year and indicated that they most recently obtained the drugs from a friend or relative for free in the past year, 81.6 percent of the friends or relatives obtained the drugs from just one doctor (Figure 2.14). About 1 in 20 of these past year nonmedical users of pain relievers (5.5 percent) reported that the friend or relative got the pain relievers from another friend or relative for free, 3.9 percent reported that the friend or relative bought the drugs from a friend or relative, 1.9 percent reported that the friend or relative bought the drugs from a drug dealer or other stranger, and 1.8 percent reported that the friend or relative took the drugs from another friend or relative without asking."

Substance Abuse and Mental Health Services Administration, Results from the 2011 National
Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012, p. 28.
http://www.samhsa.gov/data/NSD...

70. Pain Treatment and Opioid Abuse

"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."

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.
http://jama.jamanetwork.com/ar...

71. Prescription Opioid Overdose

"Among patients who are prescribed opioids, an estimated 80% are prescribed low doses (<100 mg morphine equivalent dose per day) by a single practitioner (7,8), and these patients account for an estimated 20% of all prescription drug overdoses (Figure 3). Another 10% of patients are prescribed high doses (?100 mg morphine equivalent dose per day) of opioids by single prescribers and account for an estimated 40% of prescription opioid overdoses (9,10). The remaining 10% of patients are of greatest concern. These are patients who seek care from multiple doctors and are prescribed high daily doses, and account for another 40% of opioid overdoses (11). Persons in this third group not only are at high risk for overdose themselves but are likely diverting or providing drugs to others who are using them without prescriptions. In fact, 76% of nonmedical users report getting drugs that had been prescribed to someone else, and only 20% report that they acquired the drug from their own doctor (4). Furthermore, among persons who died of opioid overdoses, a significant proportion did not have a prescription in their records for the opioid that killed them; in West Virginia, Utah, and Ohio, 25%–66% of those who died of pharmaceutical overdoses used opioids originally prescribed to someone else (11–13). These data suggest that prevention of opioid overdose deaths should focus on strategies that target 1) high-dosage medical users and 2) persons who seek care from multiple doctors, receive high doses, and likely are involved in drug diversion."

"CDC Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic" Morbidity and Mortality Weekly Report (Atlanta, GA: Centers for Disease Control and Prevention, January 13, 2012) Vol. 61, No. 1, p. 10.
http://www.cdc.gov/mmwr/pdf/wk...

72. Prescribing Patterns and Opioid Overdose-Related Deaths

"There is some evidence that higher prescribed doses increase the risk of drug overdose among individuals treated with opioids for chronic non-cancer pain.4 Specifically, the risk of drug-related adverse events is higher among individuals prescribed opioids at doses equal to 50 mg/d or more of morphine. The association of opioid prescribing patterns with risk of over-dose may vary across groups of patients; opioid treatment recommendations for pain are typically specific to particular subgroups such as those with chronic noncancer pain,5 cancer-related pain, and substance use disorders.6 However, potential subgroup differences in opioid prescribing have not been examined."

Bohnert, Amy S.B., et al., "Association Between Opioid Prescribing Patterns and Opioid Overdose-Related Deaths," Journal of the American Medical Association, April 6, 2011, Vol 305, No. 13, p. 1315.
http://jama.jamanetwork.com/ar...

73. Factors Influencing Methadone-Related Mortality

"Still, methadone is a potent drug; fatal overdoses have been reported over the years (Baden, 1970; Gardner, 1970; Clark, et al., 1995; Drummer, et al., 1992). As with most other opioids, the primary toxic effect of excessive methadone is respiratory depression and hypoxia, sometimes accompanied by pulmonary edema and/or aspiration pneumonia (White and Irvine, 1999; Harding-Pink, 1993). Among patients in addiction treatment, the largest proportion of methadone-associated deaths have occurred during the drug's induction phase, usually when (1) treatment personnel overestimate a patient's degree of tolerance to opioids, or (2) a patient uses opioids or other central nervous system (CNS) depressant drugs in addition to the prescribed methadone (Karch and Stephens, 2000; Caplehorn, 1998; Harding-Pink, 1991; Davoli, et al., 1993). In fact, when deaths occur during later stages of treatment, other drugs usually are detected at postmortem examination (Appel, et al., 2000). In particular, researchers have called attention to the 'poison cocktail' resulting from the intake of multiple psychotropic drugs (Borron, et al., 2001; Haberman, et al., 1995) such as alcohol, benzodiazepines, and other opioids. When used alone, many of these substances are relatively moderate respiratory depressants; however, when combined with methadone, their additive or synergistic effects can be lethal (Kramer, 2003; Payte and Zweben, 1998).
"It is important to note that postmortem blood concentrations of methadone do not appear to reliably distinguish between individuals who have died from methadone toxicity and those in whom the presence of methadone is purely coincidental (Drummer, 1997; Caplan, et al., 1983)."

Center for Substance Abuse Treatment, "Methadone-Associated Mortality: Report of a National Assessment, May 8-9, 2003," CSAT Publication No. 28-03 (Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 2004), p. 11.
http://atforum.com/documents/C...

74. Insurance Fraud and Diversion

"Insurance fraud is the main financier and enabler of drug diversion. Even so, few health insurers understand the pivotal role insurance fraud plays in a diversion epidemic that costs insurers up to $72.5 billion a year.
"More specifically:
"• Swindlers and drug abusers obtain the bulk of their illicit prescription narcotics through fraudulent insurance claims for bogus prescriptions, treating phantom injuries and other illegal deceptions;
"• Drug diversion drains health insurers of up to $72.5 billion a year, including up to $24.9 billion annually for private insurers. The losses include insurance schemes, plus the larger hidden costs of treating patients who develop serious medical problems from abusing the addictive narcotics they obtained through the swindles;
"• Insurers are potentially vulnerable to enormous liability lawsuits for failing to reasonably prevent fraud schemes that kill and injure people addicted by diversion schemes. Drug manufacturers and pharmacists already face such lawsuits."

The Mahon Consulting Group LLC for the Coalition Against Insurance Fraud, "Prescription for Peril: How Insurance Fraud Finances Theft and Abuse of Addictive Prescription Drugs," (Washington, DC: December, 2007), p. 4.
http://www.insurancefraud.org/...

75. Cost of Controlled Prescription Drug (CPD) Diversion

"Moreover, the estimated cost of CPD diversion and abuse to public and private medical insurers is $72.5 billion a year,3 much of which is passed to consumers through higher health insurance premiums. Additionally, the abuse of prescription opioids is burdening the budgets of substance abuse treatment providers, particularly as prescription opioid abuse might be fueling heroin abuse rates in some areas of the United States."

National Drug Intelligence Center, Drug Enforcement Administration, "National Prescription Drug Threat Assessment," (Washington DC, April 2009), p. V.
http://www.justice.gov/archive...

76. Theft of Pharmaceuticals

The Journal of Pain and Symptom Management published a research letter by scientists from the Pain & Policy Studies Group at the University of Wisconsin-Madison on drug crime as a source of diverted pharmaceuticals. The researchers examined data maintained by the US Drug Enforcement Administration on thefts and other incidents of loss of controlled substances by DEA registrants including pharmacists, manufacturers, and distributors. The data was complete for the years 2000-2003 for 22 Eastern states representing 53% of the US population. According to the researchers:
"A total of 12,894 theft/loss incidents were reported in these states between 2000 and 2003. Theft/losses were primarily from pharmacies (89.3%), with smaller portions from medical practitioners, manufacturers, distributors, and some addiction treatment programs that reported theft/losses of methadone.
"Over the 4-year period, almost 28 million dosage units of all controlled substances were diverted. The total number of dosage units for the six opioids is as follows: 4,434,731 for oxycodone; 1,026,184 for morphine; 454,503 for methadone; 325,921 for hydromorphone; 132,950 for meperidine; 81,371 for fentanyl."

Joranson, David E. MSSW & Aaron M. Gilson, PhD, Pain & Policy Studies Group, University of Wisconsin-Madison, "Drug Crime is a Source of Abuse Pain Medication in the United States," Letters, Journal of Pain & Symptom Management, Vol. 30, No. 4, Oct. 2005, p. 299.
http://www.painpolicy.wisc.edu...

77. Prescriptions for OxyContin and Other Opioids

"According to IMS Health data, the annual number of OxyContin prescriptions for noncancer pain increased nearly tenfold, from about 670,000 in 1997 to about 6.2 million in 2002. In contrast, during the same 6 years, the annual number of OxyContin prescriptions for cancer pain increased about fourfold, from about 250,000 in 1997 to just over 1 million in 2002. The noncancer prescriptions therefore increased from about 73 percent of total OxyContin prescriptions to about 85 percent during that period, while the cancer prescriptions decreased from about 27 percent of the total to about 15 percent. IMS Health data indicated that prescriptions for other schedule II opioid drugs, such as Duragesic and morphine products, for noncancer pain also increased during this period. Duragesic prescriptions for noncancer pain were about 46 percent of its total prescriptions in 1997, and increased to about 72 percent of its total in 2002. Morphine products, including, for example, Purdue's MSContin, also experienced an increase in their noncancer prescriptions during the same period. Their noncancer prescriptions were about 42 percent of total prescriptions in 1997, and increased to about 65 percent in 2002."

General Accounting Office, "Prescription Drugs: Oxycontin Abuse and Diversion and Efforts to Address the Problem," GAO-04-110 (Washington, DC: Government Printing Office, December 2003), p. 18.
http://www.gao.gov/new.items/d...

78. Deaths Related to Opioid Analgesic Use

"By 2002, opioid analgesics were involved in more deaths than either of the illicit drugs responsible for most urban drug abuse in the 1990s: heroin and cocaine. These trends are generally consistent with trends in drug-related emergency department visits reported by DAWN from 1997 to 2002: a 101.4% increase in opioid analgesics, a 23.7% increase in cocaine, and a 32.2% increase in heroin.
"The increased involvement of these analgesics is related to exponential growth in their domestic sales over the past decade as physicians began to treat chronic pain with stronger analgesics.10 Oxycodone sales in grams increased 402.9% from 1997 to 2002; methadone (excluding that used in narcotics treatment programs) increased 410.8%; and fentanyl increased 226.7%.11 OxyContin, introduced in 1996, accounted for 68% of oxycodone sales by 2002."

Paulozzi, Leonard J., "Opioid Analgesic Involvement in Drug Abuse Deaths in American Metropolitan Areas," American Journal of Public Health (Vol 96, No. 10), October 2006, p. 1756.
http://www.ncbi.nlm.nih.gov/pm...

79. OxyContin Investigations, Arrests, and Seizures, 1996-2002

"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."

General Accounting Office, "Prescription Drugs: Oxycontin Abuse and Diversion and Efforts to Address the Problem," GAO-04-110 (Washington, DC: Government Printing Office, December 2003), p. 37.
http://www.gao.gov/new.items/d...

80. Illicit Sales of OxyContin, 2001

"According to a 2001 HIDTA [High Intensity Drug Trafficking Area] report, the Appalachian region, which encompasses parts of Kentucky, Tennessee, Virginia, and West Virginia, has been severely affected by prescription drug abuse, particularly pain relievers, including oxycodone, for many years. Three of the four states -- Kentucky, Virginia, and West Virginia -- were among the initial states to report OxyContin abuse and diversion. Historically, oxycodone, manufactured under brand names such as Percocet, Percodan, and Tylox, was among the most diverted prescription drugs in Appalachia. According to the report, OxyContin has become the drug of choice of abusers in several areas within the region. The report indicates that many areas of the Appalachian region are rural and poverty-stricken, and the profit potential resulting from the illicit sale of OxyContin may have contributed to its diversion and abuse. In some parts of Kentucky, a 20-milligram OxyContin tablet, which can be purchased by legitimate patients for about $2, can be sold illicitly for as much as $25. The potential to supplement their incomes can lure legitimate patients into selling some of their OxyContin to street dealers, according to the HIDTA report."

General Accounting Office, "Prescription Drugs: Oxycontin Abuse and Diversion and Efforts to Address the Problem," GAO-04-110 (Washington, DC: Government Printing Office, December 2003), pp. 31-32.
http://www.gao.gov/new.items/d...

81. Growth in Overdose Deaths and Treatment Admissions, 2001-2006

"According to the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics, unintentional overdose deaths involving prescription opioids increased 114 percent from 2001 (3,994) to 2005 (8,541), the most recent nationwide data available. Further, the number of treatment admissions for prescription opioids as the primary drug of abuse increased 74 percent from 46,115 in 2002 to 80,131 in 2006, the most recent data available, according to the SAMHSA Treatment Episode Data Set (TEDS)."

National Drug Intelligence Center, Drug Enforcement Administration, "National Prescription Drug Threat Assessment," (Washington DC, April 2009), p. III.
http://www.justice.gov/archive...

82. Oxycodone Production Quotas

"Until 2011, the DEA had increased the quota for oxycodone every year since 2002101 with the exception of 2008, when the quota remained unchanged from 2007.102 In 2010, the quota for oxycodone available for sale was 105,500,000 grams.103 In 2002, the quota for oxycodone available for sale was 34,482,000 grams, which means that over that eight-year period, the DEA permitted a 206% increase in the oxycodone quota.104 The DEA decreased the quota to 98,000,000 grams in 2011.105 OxyContin is available in seven dosage strengths, ranging from ten milligram to eighty milligram tablets.106 Although oxycodone is used in other medications, if one assumes, for illustrative purposes, that OxyContin was the only medication manufactured from oxycodone, the 2010 quota would permit the production of between 15,050,000,000 (for ten milligram tablets) and 1,881,250,000 (for eighty milligram tablets) tablets of OxyContin. Although the DEA has the power to limit OxyContin production through its quota authority, the DEA has dramatically increased the availability of oxycodone over the last eight years. While this may be warranted for legitimate users, the increase remains in stark contrast to the limited availability of addiction-assistance medications.107 Additionally, while the rate of marijuana dependence or abuse has remained steady over the last eight years, the number of people suffering from pain reliever dependence or abuse has increased from 1.5 million to 1.9 million over the same period of time.108"

Ferrara, Melissa M., "The Disparate Treatment of Medications and Opiate Pain Medications Under the Law: Permitting the Proliferation of Opiates and Limiting Access to Treatment," Seton Hall Law Review (South Orange, NJ: Seton Hall University, May 24, 2012) Volume 42, Issue 2, pp. 751-752.
http://scholarship.shu.edu/cgi...

83. Diversion and Fraud

"According to law enforcement reporting, some individuals and criminal groups divert CPDs [controlled prescription drugs] through doctor-shopping and use insurance fraud to fund their schemes. In fact, Aetna, Inc. reports that nearly half of its 1,065 member fraud cases in 2006 (the latest year for which data are available) involved prescription benefits, and most were related to doctor-shopping, according to the Coalition Against Insurance Fraud (CAIF). CAIF further reports that diversion of CPDs collectively costs insurance companies up to $72.5 billion annually, nearly two-thirds of which is paid by public insurers. Individual insurance plans lose an estimated $9 million to $850 million annually, depending on each plan’s size; much of that cost is passed on to consumers through higher annual premiums."

National Drug Intelligence Center, Drug Enforcement Administration, "National Prescription Drug Threat Assessment," (Washington DC, April 2009), p. 20.
http://www.justice.gov/archive...

84. Pharmaceutical Drug Distribution in the US

"Drugs in the United States generally do not travel straight from the line of production to the dispensing pharmacy. Rather, a serpentine maze provides a ripe environment for the infiltration of counterfeit, adulterated, and diverted drugs.15

"The distribution system is primarily tiered among manufacturers, the “Big 3” distributors/drug wholesalers, secondary wholesalers,16 and repackagers. The FDA has identified three primary routes for drug sales in the United States, and each involves drugs passing through multiple hands, demonstrating the vulnerability of the distribution system to counterfeit, adulterated, and diverted products.17 The “Big 3” wholesalers—Cardinal Health,18 McKesson19 and Amerisource Bergen,20 which collectively account for nearly 90% of the primary wholesale arket21—sell drugs into a distribution web containing large governmental agencies, secondary wholesalers, and criminal actors.22 “Repackagers” of drugs further obscure the origin of a particular drug when they break wholesale drugs in bulk containers into smaller units for sale to pharmacies or, conversely, re-aggregate smaller units purchased as overstock from pharmacies into larger bundles for resale to wholesalers.23 Because of the multiple distributors and the repackaging, the true origin of drugs in this net remains obscure.24"

Aleong, Stephanie Feldman, "Green Medicine: Using Lessons From Tort Law and Environmental Law to Hold Pharmaceutical Manufacturers and Authorized Distributors Liable for Injuries Caused by Counterfeit Drugs," University of Pittsburgh Law Review (Pittsburgh, PA: Winter 2007) Volume 69, Issue 2, p. 248-250.
http://lawreview.law.pitt.edu/...
http://lawreview.law.pitt.edu/...

85. Health Care Reform and Development of Pain Management Policies

Laws & Policies

"With the passage of the Patient Protection and Affordable Care Act in March 2010, the U.S. health care system may undergo profound changes, although how these changes will evolve over the next decade is highly uncertain. Health care reform or other broad legislative actions may offer new opportunities to prevent and treat pain more effectively. Both clinical leaders and patient advocates must pursue these opportunities and be alert to any evidence that barriers to adequate pain prevention and treatment are increasing.
"To remediate the mismatch between knowledge of pain care and its application will require a cultural transformation in the way clinicians and the public view pain and its treatment. Currently, the attitude is often denial and avoidance. Instead, clinicians, family members, employers, and friends inevitably must rely on a person’s ability to express his or her subjective experience of pain and learn to trust that expression, and the medical system must give these expressions credence and endeavor to respond to them honestly and effectively."

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), p. 47.
http://www.nap.edu/openbook.ph...

86. Progress In Achieving Balance In Pain Management Policy In The US

"Alabama and Idaho now join Georgia, Iowa, Kansas, Maine, Massachusetts, Michigan, Montana, Oregon, Rhode Island, Vermont, Virginia, Washington, and Wisconsin as having the most balanced policies in the country related to pain management, including with the appropriate use of pain medications for legitimate medical purposes. Over time, these 15 states took advantage of available policy templates and resources, and repealed all excessively restrictive and ambiguous policy. This achievement does not mean that their work is finished, because policy needs to be properly implemented (see next section). Importantly, there is no ceiling on policy quality, so states with high grades should continue to explore how additional policy can help to improve access to pain management while avoiding the adoption of restrictive requirements or limitations. In fact, 25 states that achieved an A for positive language in the past have continued to adopt policy language promoting appropriate pain management during this evaluation timeframe.h"

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. 23.
http://www.painpolicy.wisc.edu...
http://www.painpolicy.wisc.edu...

87. Pain Contracts

"Another control strategy that has gained traction is opioid 'contracts' or 'treatment agreements' between health care providers and patients, under which medication use by highrisk patients is closely monitored. In a study of a primary are clinic’s use of such contracts, three-fifths of patients adhered to the agreement (with a median follow-up of 23 months) (Hariharan et al., 2006). However, many pain experts have concluded that pain agreements/contracts do not necessarily improve the treatment of pain or minimize diversion and abuse of prescription drugs, particularly when used indiscriminately. A systematic review of the literature found only weak evidence to support either pain contracts or urine tests as a strategy for reducing opioid abuse (Starrels et al., 2010)."

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), p. 147.
http://www.nap.edu/openbook.ph...

88. Strategies to Reduce Risk of Abuse

"Current voluntary strategies to reduce opioid abuse include
"• the clinician’s assessment in a history and physical exam that includes psychosocial factors, family history, and risk of abuse;
"• the clinician’s regular monitoring of the progress of patients on opioids and assessment for aberrant behavior that may indicate abuse;
"• random urine drug screening and pill counts for patients at risk;
"• state prescription drug monitoring programs (the U.S. Justice Department and other agencies have cooperated in forming an interstate information exchange for such programs);
"• new drug formulations intended to prevent abuse by (1) hindering the extraction of active ingredients through physical barrier mechanisms, (2) releasing agents that neutralize the opioid effects when products are tampered with, and (3) introducing substances that cause unpleasant side effects when drugs are consumed to excess (Fishbain et al., 2010); and
"• removing unused drugs from home medicine cabinets and disposing of them at 'drug take-back' events (see Box 2-4 in Chapter 2) (Office of National Drug Control Policy, 2010)."

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), p. 146.
http://www.nap.edu/openbook.ph...

89. Development of Pain Management Model Policy

"In the wake of criticism of state medical boards’ actions against physicians who prescribed large amounts of opioids, the Federation of State Medical Boards developed a model policy in 1998—since adopted by many individual state boards—that supports use of opioids for pain management if appropriately documented by the treating physician (Federation of State Medical Boards of the United States, 2004). State medical boards generally are believed to be the best locus for sanctioning physicians for their opioid prescribing patterns, as opposed to criminal prosecution (Reidenberg and Willis, 2007). However, sanctions and prosecutions are rare: between 1998 and 2006, only 0.1 percent of practicing physicians were charged by prosecutors, medical licensing boards, or other administrative agencies with opioid-related prescribing offenses, providing 'little objective basis for concern that pain specialists have been ‘singled out’ for prosecution or administrative sanctioning' (Goldenbaum et al., 2008, p. 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. 144.
http://www.nap.edu/openbook.ph...
The Federation of State Medical Board's Model Policy on the Use of Controlled Substances for the Treatment of Pain (2004) is available at http://www.painpolicy.wisc.edu...

90. AMA on Controlled Substances and Pain

"The AMA [American Medical Association] 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."

American Medical Association, "About the AMA Position on Pain Management Using Opioid Analgesics," 2010.
http://www.ama-assn.org/go/pai...

91. American Medical Association on the Undertreatment of Pain, 2004

"Unbalanced and misleading media coverage on the abuse of opioid analgesics not only perpetuates misconceptions about pain management; it also compromises the access to adequate pain relief sought by over 75 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."

American Medical Association, "About the AMA Position on Pain Management Using Opioid Analgesics," 2004.
Note: This report no longer available on the AMA's website, however its content is discussed in "California law eases threat to pain medication prescribers," American Medical News, Sept. 13, 2004.
http://www.amednews.com/articl...

92. Legal Opium Producers

"Almost half14 of global opium is legally produced for processing into various opiate based medicines. Any country can formally apply to the UN’s Commission on Narcotic Drugs to cultivate, produce and trade in licit opium, under the auspices of the UN Single Convention on Narcotics Drugs 1961 and under the supervision and guidance of the International Narcotic Control Board (INCB). As of 2001 there were eighteen countries that do, including Australia, Turkey, India, China and the UK."

Transform Drug Policy Foundation, "After the War on Drugs: Blueprint for Regulation," (Bristol, United Kingdom: September 2009), p. 32.
http://www.tdpf.org.uk/resourc...

93. International Law and the "Central Principle of Balance"

"In 1998, WHO [World Health Organization], in cooperation with its collaborating center at the University of Wisconsin, elaborated the concept of the 'Central Principle of Balance' in order to guide the development of national drug regulatory policies pursuant to the Single Convention.64 According to WHO, 'The Central Principle of Balance' represents the dual imperative of preventing the abuse, trafficking, and diversion of narcotic drugs while, at the same time, ensuring medical availability. As stated by WHO, 'When misused, opioids pose a threat to society; a system of control is necessary to prevent abuse, trafficking, and diversion, but the system of control is not intended to diminish the medical usefulness of opioids, nor interfere in their legitimate medical uses and patient care.'65
"The concept of the Central Principle of Balance should not be limited to national regulatory policies, but should also guide the development and implementation of international drug control policies."

Taylor, Allyn L. "Addressing the Global Tragedy of Needless Pain: Rethinking the United Nations Single Convention on Narcotic Drugs," Journal of Law, Medicine & Ethics (Washington, DC: Georgetown University Law Center, January 2008) Vol. 35, No. 556, p. 564.
http://papers.ssrn.com/sol3/De...

94. PDMP Definition

"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."

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.
http://www.gao.gov/new.items/d...

95. State Prescription Drug Monitoring Programs

"There have been significant advances in implementing PDMPs, 49 states and Washington, D.C. now have operational PDMPs. PDMPs help providers understand their patients’ medication histories, as well as problematic behaviors that signal a need for more in-depth conversations about pain and substance use. The Bureau of Justice Assistance (BJA) supported PDMP expansion grants in 11 states in 2015. ONC, SAMHSA, and CDC all have funded research and standards development for PDMP improvements. The IHS, DoD, and VA have piloted the integration of PDMP systems within their electronic health records systems. In July 2016, both VA and IHS announced new policies that require prescribers to check the PDMP prior to making a decision to prescribe controlled medications.
"Historically, the ability of states to share data has been limited, but agencies are currently involved in efforts to enhance the interoperability of state PDMPs. At the time of this writing, two electronic data sharing hubs are operational, enabling 43 states to work through one or both to share PDMP data with at least one other state. Funding from BJA and DoD has been used to enhance this interstate data sharing.
"PDMPs are only one approach to monitoring. The DoD, VA, and CMS all have initiated drug utilization review programs for some of their patient populations to better coordinate care for individuals who are prescribed opioid medications. Many hospitals administer patient surveys to determine whether their pain was managed adequately. CMS has proposed new questions for these surveys that avoid the perception that performance is linked to prescribing opioid medications for pain control.14"

Office of National Drug Control Policy, "National Drug Control Strategy 2016," (Washington, DC: Executive Office of the President, January 2017), p. 67.
https://obamawhitehouse.archiv...
https://obamawhitehouse.archiv...

96. PDMPs and Limits on Access to Pain Medication

"In this survey of a random sample of Kentucky Medicaid beneficiaries, nearly 90% of respondents report they are unaffected by the KASPER [Kentucky All Schedule Prescription Electronic Reporting] program. Of the small group affected, Hispanic respondents are more likely to report discussing KASPER with a health care provider. Respondents with non-cancer chronic pain conditions are also more apt to report discussing KASPER with a health care provider as well as difficulty obtaining controlled substance prescriptions due to KASPER when confounding factors are controlled for in multivariate analyses. Respondents living in rural counties report less difficulty obtaining and filling controlled substance prescriptions due to KASPER. This result is not surprising, given that data reported by the KASPER program consistently shows higher usage of controlled substances (per 1,000 patients) in Kentucky’s rural counties compared with urban counties (16)."

Amie Goodin, MPP, Karen Blumenschein, PharmD, Patricia Rippetoe Freeman, PhD, and Jeffrey Talbert, PhD, "Consumer/Patient Encounters with Prescription Drug Monitoring Programs: Evidence from a Medicaid Population," Pain Physician 2012; 15:ES169-ES175.
http://www.painphysicianjourna...

97. Effect of Implementation of PDMP

"Our analysis showed that the implementation of a province-wide centralized prescription network was associated with large, immediate and sustained reductions in filled prescriptions for opioid analgesics and benzodiazepines deemed inappropriate by our definition. These findings provide empirical evidence that centralized prescription networks can reduce inappropriate prescribing and dispensing of prescriptions by offering health care professionals real-time access to prescription data. Physicians did not have access to PharmaNet when it was first introduced; consequently, the reductions observed in our study likely reflect the availability of real-time prescription information to front-line pharmacists."

Dormuth, Colin R., et al., "Effect of a centralized prescription network on inappropriate prescriptions for opioid analgesics and benzodiazepines," Canadian Medical Association Journal, November 6, 2012, vol. 184, no. 16, DOI:10.1503/cmaj.120465, p. 854.
http://www.cmaj.ca/content/184...

98. PDMPs and Reduction of Diversion

"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."

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.
http://www.gao.gov/new.items/d...

99. Effectiveness of PDMPs

"States with PDMPs [prescription drug monitoring programs] 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."

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.
http://www.gao.gov/new.items/d...

100. Impact of PDMPs on Drugs Being Prescribed

"The presence of a PDMP [prescription drug monitoring program] 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."

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.
http://www.gao.gov/new.items/d...

101. Physician Concerns Over PDMPs

"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."

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.
http://www.gao.gov/new.items/d...

102. Effects of PDMPs

"Although several studies found implementation of prescription monitoring programs for Schedule II opioids associated with a decrease in prescription rates for Schedule II opioids and a shift towards increased rates of Schedule III, non-monitored opioid prescribing, the studies were not designed to determine whether the changes were due to a decrease in inappropriate or unnecessary Schedule II opioid use, or if these changes resulted in subsequent undertreatment of pain.317, 318 No study has evaluated patient outcomes such as pain relief, functional status, ability to work, and abuse/addiction associated with implementation of a prescription monitoring program, formulary restriction, or other policies related to opioids prescribing. Claims of positive effects of prescription monitoring programs on reducing diversion are primarily based on anecdotal reports of impressions of efficacy from policymakers and law enforcement officials.316"

"Use of Chronic Opioid Therapy in Chronic Noncancer Pain: Evidence Review," The American Pain Society in Conjunction with The American Academy of Pain Medicine (Glenview, IL: American Pain Society, February 2009), pp. 98-99.
http://www.americanpainsociety...

103. PDMP start-ups

"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."

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.
http://www.gao.gov/new.items/d...

104. PDMP Growth

"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."

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.
http://www.gao.gov/new.items/d...

105. PDMPs and Neighboring States

"The existence of a PDMP [prescription drug monitoring program] 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."

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.
http://www.gao.gov/new.items/d...

106. Definition Of Complementary And Alternative Medicine (CAM) In Pain Management

Complementary and Alternative Medicine (CAM) Approaches to Pain Management

"Definitions of CAM differ. For example, a study of CAM in hospices identified practices as diverse as massage therapy, supportive group therapy, music therapy, pet therapy, and guided imagery or relaxation, not all of which are usually associated with CAM (Bercovitz et al., 2011). Acupuncture, chiropractic ­spinal manipulation, magnets, massage therapy, and yoga often are considered CAM pain treatments. According to the National Institutes of Health’s (NIH) National Center for Complementary and Alternative Medicine, additional CAM therapies used for pain include dietary supplements, such as glucosamine and chondroitin intended to improve joint health; various herbs; acupuncture; and mind–body approaches, such as meditation and yoga (NIH and NCCAM, 2010)."

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), p. 134.
http://www.nap.edu/openbook.ph...

107. Reasons People Use Complementary And Alternative Medicines (CAM) For Pain Management

"CAM holds special appeal for many people with pain for several reasons:
"• deficits in the way that many physicians treat pain, using only single modalities without attempting to track their effectiveness for a particular person over time or to coordinate diverse approaches;
"• the higher preponderance of pain in women (see Chapter 2), given that 'women are more likely than men to seek CAM treatments; (IOM, 2005, p. 10); and
"• a welcoming, less reserved attitude toward people with pain on the part of CAM practitioners and an apparent willingness to listen to the story of a patient’s pain journey.
"Whatever the reasons, pain is a common complaint presented to CAM practitioners (NIH and NCCAM, 2010). In 2007, 44 percent of people with pain or neurologic conditions sought help from CAM practitioners (Wells et al., 2010).
"In 2002, three-fifths of people who turned to CAM for relief of back pain found a 'great deal' of benefit as a result (Kanodia et al., 2010). The National Center for Complementary and Alternative Medicine’s strategic plan, released in February 2011, supports the development of better strategies for managing back pain, in particular."

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), pp. 134-135.
http://www.nap.edu/openbook.ph...

108. Extent Of Use And Types Of Pain Conditions For Which Complementary And Alternative Medicine (CAM) Are Used In The US

"For which pain conditions are CAM treatments most often used? In the 2007 National Health Interview Survey (NHIS), adults reported using CAM in the previous year most often to treat various musculoskeletal problems. Just over 17 percent of adults — more than 14 million Americans—used CAM for back pain/problems, almost 6 percent (5 million) for neck pain/problems, 5 percent for joint pain/stiffness (5 million), and 44 percent specifically for arthritis (3 million). An additional 1.5 million used CAM for other musculoskeletal problems, 1 million for severe headache or migraine, 11 million for 'regular headaches,' and 0.8 million for fibromyalgia (Barnes et al., 2008). Rates of reported use of CAM for these conditions had remained relatively unchanged since 2002. Even among children, NHIS data show that CAM therapies are used most often for back or neck pain (7 percent of all children).7"

Institute of Medicine, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research" (Washington, DC: National Academy of Sciences, 2011), p. 135.
http://www.nap.edu/openbook.ph...

109. Alternative Therapies

"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."

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.

110. Pain Management - Research - 2-20-10

Sociopolitical and Clinical Research

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

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.

111. Opioids and Impairment

"Opioids are associated with adverse events such as sedation and dizziness that could potentially impact driving or work safety83. However, some studies suggest that opioids do not necessarily impair or may improve psychomotor and cognitive functioning in patients on opioids for chronic noncancer pain.224-227"

"Use of Chronic Opioid Therapy in Chronic Noncancer Pain: Evidence Review, " The American Pain Society in Conjunction with The American Academy of Pain Medicine (Glenview, IL: American Pain Society, February 2009), p. 65.
http://www.americanpainsociety...

112. Likelihood of Seeing a Physician for Pain

"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."

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.

113. Medical Cannabis Laws and Opioid Overdose Mortality Rates

"In an analysis of death certificate data from 1999 to 2010, we found that states with medical cannabis laws had lower mean opioid analgesic overdose mortality rates compared with states without such laws. This finding persisted when excluding intentional overdose deaths (ie, suicide), suggesting that medical cannabis laws are associated with lower opioid analgesic overdose mortality among individuals using opioid analgesics for medical indications. Similarly, the association between medical cannabis laws and lower opioid analgesic overdose mortality rates persisted when including all deaths related to heroin, even if no opioid analgesic was present, indicating that lower rates of opioid analgesic overdose mortality were not offset by higher rates of heroin overdose mortality. Although the exact mechanism is unclear, our results suggest a link between medical cannabis laws and lower opioid analgesic overdose mortality."

Bacchuber, Marcus A., MD; Saloner, Brendan, PhD; Cunningham, Chinazo O., MD, MS; and Barry, Colleen L., PhD, MPP. "Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010." JAMA Intern Med. doi:10.1001/jamainternmed.2014.4005. Published online August 25, 2014.
http://archinte.jamanetwork.co...

114. Pain-Related Lost Productive Time

"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%)."

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.
http://jama.jamanetwork.com/da...

115. Self-Medication with Alcohol

"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."

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.

116. Pain-Related Lost Productive Time

"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)."

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.
http://jama.jamanetwork.com/ar...

117. Pain Patients in Methadone Treatment

"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."

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.
http://jama.jamanetwork.com/ar...

118. Pain Patients in Methadone Treatment

"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."

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.
http://jama.jamanetwork.com/ar...

119. Reasons for Changing Doctors

"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."

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.

120. Getting Pain Under Control

"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."

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.

121. Chronic Pain Severity and Control

"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."

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.

122. Medical Marijuana - Supporters - 5-15-11

(US Department of Veterans Affairs, Medical Marijuana, and Pain Management) "If a Veteran obtains and uses medical marijuana in manner consistent with state law, testing positive for marijuana would not preclude the Veteran from receiving opioids for pain management in the Department of Veteran Affairs (VA) facility. The Veteran would need to inform his provider of the use of medical marijuana, and of any other non-VA prescribed medications he or she is taking to ensure that all medications, including opioids, are prescribed in a safe manner. Standard pain management agreements should draw a clear distinction between use of illegal drugs, and legal medical marijuana. However, the discretion to prescribe, or not prescribe, opioids in conjunction with medical marijuana, should be determined on clinical grounds, and thus will remain the decision of the individual health care provider. The provider will take the use of medical marijuana into account in all prescribing decisions, just as the provider would for any other medication. This is a case-by-case decision, based on the provider's judgment, and the needs of the patient."

Petzel, Robert A., Letter to Michael Krawitz from the Dept. of Veterans Affairs concerning its postion on medical marijuana, (Washington, DC: Department of Veterans Affairs, Under Secretary for Health, July 6, 2010).
http://www.veteransformedicalm...