Pain Management

81. 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...

82. 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...

83. 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...

84. 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...

85. 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...

86. 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...

87. 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.

88. 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.

89. Therapeutic Opioid Use and Risk of 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"

"Clinical Guideline for the 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://americanpainsociety.org...

90. 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.

91. 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...

92. 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...

93. 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.

94. 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...

95. 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...

96. 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...

97. 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.

98. 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.

99. 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.

100. 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...

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