Prescription Opioid Policy Christina Baumann, PAH 575 Winter 2011 The demand for chronic pain management is huge—one estimate is that at least 116 million U.S. adults experience chronic pain at a cost of $560-635 billion annually in direct medical treatment costs and lost productivity. However, chronic pain management is a difficult field, due to its multifaceted etiology and limited evidence-based therapies. Over the past decade, there has been a successful push by pain advocates (and the pharmaceutical industry) to address chronic pain, making pain the “fifth vital sign” (in addition to heart rate, blood pressure, respiratory rate, and temperature). Unfortunately, this advocacy has led to a surge in the amount of opiates prescribed, despite the controversy over the efficacy of long-term opiate therapy for chronic non-cancer pain. *For optional reading, see the 2011 AIM article by von Korff, Long-term Opiate Therapy Reconsidered). Now we are faced with a huge public health problem of fatal and nonfatal overdoses from prescription opiates. The CDC estimates that in 2010 enough opiates were prescribed to medicate every American adult around the clock for one month. The misuse of opiates has spread: 12 million people (1 in 20 persons age ≥12 years) tried prescription opiates for nonmedical reasons in the past year. Nearly 15,000 people die every year from overdoses of these medications. *For optional reading, see CDC’s Vital Signs: Prescription Painkiller Overdoses in the US). **Please read the 2010 NEJM article by Okie, Flood of Opiates. Though there are other avenues for prescription opiates to be introduced into the community, the primary way is through the prescriber. Licensed practitioners are the gatekeepers for these addictive and abuse-prone pharmaceuticals, but there are significant barriers to safe prescribing practices. These include in adequate education in multimodal pain management, inability to implement appropriate surveillance, and lack of education in addiction medicine. In Oregon, all newly licensed practitioners must complete 6 hours of CME (continuing medical education) on pain management, with 1 hour from the Oregon Pain Management Commission’s module. **Please look over the DEA’s website “Good Medicine Bad Behavior”. Explore any aspect of the issue you are interested in, but the ExplorePain ManagementPrescribing Today page is especially interesting. http://www.goodmedicinebadbehavior.org/explore/pain_management.html **Please look over the Module, with an eye on the general attitude toward prescriber management of pain, and what is missing from the discussion. http://www.oregon.gov/OHA/OHPR/PMC/index.shtml Clearly prescription opioids are a risk in the general population. Preventing diversion and misuse is a large task that requires multiple players. Unfortunately, these players (law enforcement, DEA, prescribers, pain patients and advocates, the pharmaceutical industry, the larger public...) have objectives that are often at odds with each other, creating a problem for policymakers. An additional limitation is that no policy has definitely been shown to decrease overall mortality from opioids. Discussion Questions: 1) Does the current public health risk necessitate increased regulation and oversight versus more education? Who and what should be targeted? 2) If we are to hone in on prescribing practices, some states such as Washington have implemented voluntary guidelines on maximum doses, pain clinic referrals, and patient monitoring. For more info on Washington’s guidelines: http://www.agencymeddirectors.wa.gov/opioiddosing.asp Should Oregon implement something similar or take a stronger approach? 3) PDMPs (prescription drug monitoring programs) are databases of prescriptions that are filled within a state. Oregon just implemented its PDMP, which allows a provider or pharmacist to look up the prescription history of his/her patient. Law enforcement and the medical board are only granted access in special situations, such as a court order for an investigation. Prescribers are not required to register or use the PDMP, and the PDMP does not actively monitor for red flags. There is no national PDMP and only a few states have interstate sharing agreements, despite there being 37 active state PDMPs. For more info on PDMPs: http://www.deadiversion.usdoj.gov/faq/rx_monitor.htm Do you agree with this structure of the PDMP? If not, what would you change?