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 The leading web portal for pharmacy resources, news, education and careers July 22, 2017
Pharmacy Choice - Dietary Supplements Disease State Management - July 22, 2017

Dietary Supplements Disease State Management

Pain Treatment - Opioids and Pain
by Ken Baker, BS Pharm, JD

Pain as a Disease
Pain is one of the most common diseases worldwide.1 The National Institutes of Health estimates 50 million American adults have "significant chronic pain or severe pain."2 According to the American Academy of Pain Management:3
Millions suffer from acute or chronic pain every year and the effects of pain exact a tremendous cost on our country in health care costs, rehabilitation and lost worker productivity, as well as the emotional and financial burden it places on patients and their families.
The Institute of Health estimates pain costs society "at least $560 to $635 Billion dollars annually."3 More people suffer from chronic pain in the United States than from diabetes, coronary heart disease, stroke and cancer–more than all of those put together.3 Back pain is the most common and the leading cause of disability in Americans under 45 years of age.3

Every American pharmacist knows opioids are a mainstay in the treatment of chronic pain. It is estimated that 20% of patients with noncancer pain symptoms or pain-related diagnoses (including acute and chronic pain) are prescribed an opioid.4 In a 2012 study over 11% of the total population of the United States suffer daily pain.4 It is generally recognized by health care professions that pain should be treated.4

Abuse and Overuse
In a recent report it was estimated that 165,000 people died from opioid medication in the United States.4 The Drug Abuse Warning Network (DAWN) opined that over 400,000 emergency department visits were related to misuse or abuse of narcotic pain relievers in 2011.4 Many of these figures and estimates have been disputed. The Cato Institute, a conservative think tank in Washington, D.C. argues in a Policy Analysis the numbers are greatly distorted. Regarding the DAWN report, a CATO article says:5
…[T]he DAWN report only cites "mentions" of oxycodone-related drugs in emergency room reports, which can include cases in which oxycodone medication had nothing to do with why the patient came to the emergency room.
Looking at reported deaths due to OxyContin overdoses, the CATO Analysis notes, "…there's simply no test to determine whether or not OxyContin caused or contributed to those overdose deaths."5 Arguing the "War on Drugs" has had a negative effect on the treatment of pain, CATO quotes a 2005 Minneapolis VA Medical Center study: "Doubts or concerns about opioid efficacy, toxicity, tolerance, and abuse or addiction should not be used to justify the withholding of opioids from patients who have pain."5

CATO concluded: "The DEA's renewed war on pain doctors has frightened many physicians out of pain management altogether, exacerbating an already serious health crisis—the widespread undertreatment of intractable pain."5

Pharmacists' Dual Roles
Overstated or not, pharmacists know there is a problem of overuse of opioids. There are so-called "pill mill" doctors; and those posing as patients with either forged prescriptions or medications prescribed for other than legitimate medical purposes; and there are real patients, many of whom feel their pain is undertreated.

Pharmacists have dual roles–to treat the real pain patients and to turn away non-legitimate prescriptions.

What is the answer for the pharmacist who is fearful and yet doesn't want to not fail to treat a real patient?
First, pharmacists should be aware of the legal test for a legitimate prescription. Federal regulations state:6

A prescription for a controlled substance to be effective must be
  1. issued for a legitimate medical purpose
  2. by an individual practitioner acting in the usual course of his professional practice.
A pharmacist may not knowingly7 fill a prescription that does not meet this test.6 Second, the pharmacist should be familiar with the RED FLAGS8 that indicate there may be a problem with the legitimacy of the prescription. Third, if a red flag appears to be a problem, the prescription may not be filled until the red flag has been resolved. Fourth, talk to the patient and/or the prescriber to see if the red flag(s) can be resolved. Fifth, if the red flag is resolved, document the answer and note why the prescription was filled and why the pharmacist believed the two tests above were answered affirmatively.
  1. Siebenhuener, K; Eschmann, E, et al; Chronic Pain: How Challenging are DDIs in the Analgesic Treatment of Inpatient in Multiple Chronic Conditions?; PLOS-One, Jan. 3, 2017, Last Accessed, 3/4/2017.
  2. NIH Study Shows Prevalence of Chronic or Severe Pain in U.S. Adults, American Pain Society, Aug 18, 2015. last assessed 3/4/2017.
  3. AAPM Facts and Figures on Pain; Last Assessed 3/3/2017.
  4. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1-49. DOI: Last Accessed 3/1/2017.

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