Pain Management

21. 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.

22. 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.

23. 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.

24. 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.

25. 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.

26. 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.

27. 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.

28. 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.

29. 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.

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.

31. 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.

32. 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.

33. 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.

34. 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.

35. 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.

36. 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.

37. 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.

38. 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.

39. 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.

40. 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.