The health crises of chronic pain and prescription drug misuse

Chronic pain is one of the most significant health problems of our time — and, arguably, one that has harmful consequences, both on the individual and society, and is largely under recognized. An estimated 116 million American adults suffer from chronic pain — more than the total number of people affected by diabetes, heart disease, and cancer combined.¹

Chronic pain takes a financial toll as well. The yearly cost of healthcare and reduced productivity for people with chronic pain is estimated at $635 billion.¹ Considering that advancing age heightens the risk for some pain-related disorders like arthritis, the incidence of chronic pain is likely to increase as our nation’s population grays.

Opiate (also called opioid) pain medications, most notably oxycodone, hydrocodone, codeine, morphine, and fentanyl, can help relieve chronic pain. These drugs, which block the perception of pain by binding to opioid receptors in the brain, spinal cord, and gastrointestinal tract, have been beneficial for millions of patients. They are among the most frequently dispensed medications in the United States, and their use is climbing. Opiate-positive test results in the general U.S. workforce climbed 40% from 2005 to 2009, according to a recent Quest Diagnostics Drug Testing Report of more than 5.5 million urine drug tests.

Prescribing opioids for pain can be an essential facet of effective pain management. Yet, the substance abuse of prescription pain medications — which includes illegal and unintentional drug misuse, abuse, and diversion — is a growing health epidemic. The National Institute on Drug Abuse estimates that 48 million people over the age of 12 have abused prescription drugs for non-medical reasons, such as to get high or as a sleep aid.² According to the U.S. Centers for Disease Control and Prevention, more than 14,500 people a year die from opioid overdoses nationally.³

Chronic pain is a major health problem — but so is prescription drug abuse. Healthcare providers are caught in the middle of these health crises, often unsure how to balance the benefits and risks of opioid medications. While primary-care practitioners, internists, and pain specialists have a responsibility to offer pain-relieving treatments, they also have certain responsibilities for their appropriate use. Adding to the confusion are federal and state regulations that recommend monitoring of patients on pain medications but provide scant specifics on the form monitoring should take.

Despite these realities, as a society and as healthcare professionals, we can deal with the twin epidemics of chronic pain and prescription pain drug abuse to improve the quality of patients’ lives.

We in the laboratory can help promote better pain management by educating physicians about the potential value of urine drug testing for monitoring patients. A recent study of chronic pain patients treated with long-term opioids found that fewer than one quarter of high-risk patients underwent any urine testing to monitor their drug use.⁴

In addition, we need to help physicians understand that the “a test is a test” mentality overlooks vital differences between the two chief monitoring tests in use today: point-of-care immunoassays (POC tests) and reference laboratory testing by tandem mass spectrometry. While the former provides fast results, it has certain limitations. It only indicates which class of drug is present, and has limited ability to detect low concentrations of drugs. POC tests for detecting opioids may have cutoffs of 2,000 ng/mL, causing some patients to test inappropriately negative. Reference laboratory testing using tandem mass spectrometry can identify the specific drug and/or drug metabolites present, typically at concentrations as low as 50 ng/mL, to help provide the confirmatory data from which to identify important discrepancies in drug use.

Finally, we need to invest in research in pain management and prescription substance abuse. While we know that certain patients are prone to addiction — such as those with a family history of alcohol abuse — we are only beginning to understand which therapeutic algorithms increase the likelihood for addiction. Until more peer-reviewed literature is published, physicians will use largely arbitrary criteria to decide which patients are at risk.

With increased education about drug safety, further research into the risk factors for opioid misuse, and continued advances in laboratory testing, healthcare practitioners will be able to do a better job of balancing the risks and benefits of pain medication. Doing this will help protect society from the tragedy of prescription drug abuse while giving people treatment that relieves pain and improves their quality of life.

References

1. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Institute of Medicine. June 29, 2011.
2. U.S. Department of Health and Human Services. National Institute on Drug Abuse. Research Report. 05-4881. http://drugabuse.gov/PDF/RRPrescription.pdf. Accessed August 5, 2010.
3. Centers for Disease Control and Prevention. QuickStats: Number of Poisoning Deaths Involving Opioid Analgesics and Other Drugs or Substances – United States, 1999-2007. MMWR. 2010;59(32);1026.
4. Starrels JL, et al. Low Use of Opioid Risk Reduction Strategies in Primary Care Even for High Risk Patients with Chronic Pain. J Gen Intern Med. February 24, 2011. [Epub ahead of print].

Jon R. Cohen, MD, is senior vice president and chief medical officer at Quest Diagnostics, which offers prescription drug monitoring testing services and access to the company’s Care360 ePrescribing technology. For more information, visit www.QuestDiagnostics.com.