The Opioid Overdose Crisis

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36. 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 November 1, 2017.
http://www.merckmanuals.com/pr...

37. 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...

38. 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...

39. 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...

40. 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...

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