Pain meds: A balancing act
■ A government effort to crack down on prescription drug abuse must not exacerbate the undertreatment of chronic pain.
Posted April 12, 2004.
The Bush administration last month unveiled a strategy to fight a frightening escalation in the illegal diversion and misuse of prescription drugs. This is, of course, an essential goal. But policy-makers engaged in this effort must address a fundamental paradox.
While the government estimates that 6.2 million Americans abuse prescription drugs (often opioid painkillers), an untold number of the many millions of Americans who experience chronic pain are undertreated for that pain. Some of the methods used to control drug abuse make physicians fearful of prescribing opioid painkillers for patients who truly need these medications.
That is why any attempt to clamp down on prescription drug abuse must not discourage patients and physicians from appropriately treating chronic pain. The federal initiative can achieve this balance if carried out properly.
President Bush's strategy includes a crackdown on rogue Internet pharmacies selling controlled substances illegally, an increase in the number of state prescription monitoring programs, and wider dissemination of educational and training materials to physicians authorized to prescribe controlled substances.
The American Medical Association has called for tough enforcement against illegal pharmacies. These "pill mills" undermine the safeguards of the prescription system and expose patients to increased risk of harm from counterfeit, altered or contaminated drugs. The lack of a patient-physician relationship makes drug abuse and diversion even more likely.
An expansion of state drug monitoring programs would also be welcomed. Twenty states now have these programs, which track the use of prescription medicines and identify people who go "doctor shopping," visiting many doctors to get multiple prescriptions for the same drug.
The AMA does not support every aspect of each of these initiatives -- the funding of a program by physicians, for example. However, it does view them as an important part of states' efforts to address their unique prescription drug abuse problems. But expansion of these drug-monitoring programs must be handled with care.
For instance, the programs must maintain physician-patient confidentiality, lest patients shy away from seeking treatment for prescription drug abuse. They must involve collaboration between the physician community and the enforcement community to succeed in balancing enforcement with proper pain management and addiction treatment.
And they must not increase physicians' liability by holding doctors at fault for not requesting patients' prescribing histories. Doctors might opt to check into the prescription history of patients they suspect of abusing or diverting drugs. But the patient-physician relationship is built on trust, and a monitoring program that effectively requires physicians to "check up" on their patients with chronic pain could strain that relationship.
In the new strategy, the government emphasizes the need to widely distribute pain management education and training tools as a way to prevent prescription drug abuse. The AMA shares this goal and has been a leader in this area. About 95,000 physicians have ordered the Association's four-part, self-study continuing medical education program on pain management, and another 3,000 doctors have reviewed it online since January.
But again, caution is necessary. The CME program's effectiveness "could be compromised significantly if the program were viewed by physicians as an enforcement tool instead of an educational tool," the AMA wrote in a letter last month to Drug Enforcement Administration Administrator Karen Tandy.
In implementing its strategy, the federal government would do well to embrace the principles laid out in a joint statement signed in 2001 by the DEA and 21 health organizations, including the AMA. The document recognizes the need for both prevention of opioid abuse and adequate access to medication for appropriate pain management.
The goals need not be mutually exclusive. Only by working together will the federal government and the medical community ensure that these shared objectives are met.