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A Delicate Balance

Ever since the United States government passed laws governing the prescription of opioid drugs early in the 20th century, doctors and regulators have been engaged in a balancing act, trying to use the drugs to treat pain appropriately while preventing their abuse.

Anne Harding(aharding@the-scientist.com)
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Tim Simmons

Ever since the United States government passed laws governing the prescription of opioid drugs early in the 20th century, doctors and regulators have been engaged in a balancing act, trying to use the drugs to treat pain appropriately while preventing their abuse.

But growing use of opiate medications by patients with chronic, non-terminal pain – which carries a small, but real, risk of addiction – has made achieving balance even more difficult. A climb in prescription drug abuse has paralleled the rise in legitimate use, and law enforcement and regulatory crackdown efforts have made many physicians afraid to prescribe pain medication to patients who really need it.

"The person who suffers the worst is the patient," says Howard Heit, a physician and chronic pain specialist, certified in addiction medicine and practicing in Virginia.

A DEA FLIP-FLOP

Heit and others in the pain treatment field say the relationship between...

RAPID GROWTH

Regardless, wider application of opiates has led to "very rapid growth" in opioid consumption in the United States and in other parts of the world, Portenoy says. The Automation of Reports and Consolidated Orders System (ARCOS) has shown a steady climb in medical use of morphine, fentanyl, oxycodone, and hydromorphone in the US from 1990 to 2001. The amount of morphine, as measured in grams distributed, grew by 59% from 1990 to 1996, and by another 49% from 1997 to 2001.34

While European countries have seen a similar increase in legitimate opiate use, cultural forces, including a generally less punitive attitude toward drug addiction, have meant the medical community and drug regulators are not at odds to the extent seen in the United States.

Portenoy and others in the field say there is no evidence that a contemporaneous rise in prescription drug abuse – with 2 million people using prescription pain relievers for non-medical reasons in 2001 for the first time, compared to 600,000 in 1990, according to the National Survey on Drug Use and Health – has anything to do with growing medical use of opiates.

Research shows that between 3% and 19% of individuals receiving opiate treatment for pain will become addicted, according to Deborah Haller, director of research in the Department of Psychiatry at St. Luke's-Roosevelt Hospital in New York City. "Most experts in this field would agree that if a person doesn't have a personal history of an addiction problem, it's not a big risk," she says.

CRUCIAL DISTINCTIONS

Much of the confusion, then and now, lies in the distinction between dependence, which is associated with physical withdrawal symptoms, and addiction. The definitions of the two phenomena have been tangled, with physical dependence equated with addiction, rather than understood as an expected consequence of regular opiate use.

In 2001, the American Pain Society, the American Academy of Pain Medicine, and the American Society of Addiction Medicine published definitions of tolerance, dependence, and addiction intended to clear up the confusion. According to the document, addiction is characterized by one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

A problem remains, says Portenoy: There is no external validation of an addiction diagnosis. It remains a matter of clinical judgment. And abuse, or so-called aberrant drug-related behavior, is even more difficult to define and appears more common. "When you look at these kinds of issues from a diagnostic perspective, you can see it's something of a morass right now," he says.

Meanwhile, regulators have sought to crack down on the growing problem of prescription drug abuse by targeting individual physicians and pharmacists, making legitimate practitioners afraid even to deal with patients in pain, Joranson says.

Joranson argues for a more systematic, "public health" approach to drug abuse and diversion, involving a thorough investigation into the sources of diverted drugs – whether they are criminals stealing pain pills from drugstores and warehouses or fraudulent doctors. But the war on drugs doesn't lend itself to such an approach, Joranson says; headline-grabbing SWAT raids on physicians' offices and pharmacies tend to be more popular.

Michael Weaver, a physician certified in addiction medicine who runs pain clinics through Virginia Commonwealth University Medical Center and has published extensively on treating individuals with addiction problems, says the best way to cope with the issue of pain treatment and addiction is to carefully assess patients before prescribing opioids to determine if they may be at risk for abusing them.

"I think if you're going to treat chronic pain in a doctor's office, you need to be more structured than people have been," says Jane Ballantyne, chief of the Division of Pain Medicine at Massachusetts General Hospital.

"We're beginning to see that we physicians have to take on board the treatment of addiction as well as the treatment of pain," Ballantyne adds. "To ignore it is just to make matters worse."

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