Understanding Delaware Prescribing and Distribution of Controlled Substances

Chronic pain and opioid use and abuse are significant problems in the United States. Over one-quarter of United States citizens suffer from chronic pain. It is among the most common complaints seen in an outpatient clinic and in the emergency department. Failure to manage chronic pain, as well as the possible complication of opioid dependence related to treatment, can result in significant morbidity and mortality. One in five patient complaints in an outpatient clinic is related to pain, with over half of all patients seeing their primary care provider for one pain complaint or another. It is paramount that providers have a firm grasp on the management of patients with chronic pain. As a country, the United States spends well over 100 billion dollars a year on healthcare costs related to pain management and opioid dependence. Pain-related expenses exceed those for the costs of cancer, diabetes, and heart disease combined. How a patient's chronic pain is managed can have profound and long-lasting effects on a patient's quality of life. The International Association for the Study of Pain defines chronic pain as any pain lasting longer than three months. There are multiple sources of chronic pain. Combination therapy for pain includes both pharmacological therapies and nonpharmacological treatment options. There is a more significant reduction in pain with combination therapy compared to a single treatment alone. Escalation of pharmacological therapy should be in a stepwise approach. Comorbid depression and anxiety are widespread in patients with chronic pain. Patients with chronic pain are also at increased risk for suicide. Chronic pain can impact every facet of a patient's life. Thus learning to diagnose and appropriately manage patients experiencing chronic pain is critical. Unfortunately, studies have revealed an inherent lack of education regarding pain management in most medical schools and training programs. The Association of American Medical Colleges recognized the problem and has encouraged schools to commit to opioid-related education and training by incorporating the Centers for Disease Control and Prevention guidelines for prescribing opioids for chronic pain into the medical school curriculum. Appropriate opioid prescribing includes prescribing sufficient opioid medication through regular assessment, treatment planning, and monitoring to provide effective pain control while avoiding addiction, abuse, overdose, diversion, and misuse. To be successful, clinicians must understand appropriate opioid prescribing, assessment, the potential for abuse and addiction, and potential psychological problems. Inappropriate opioid prescribing typically involves not prescribing, underprescribing, overprescribing, or continuing to prescribe opioids when they are no longer effective. The American Society of Addiction Medicine defines addiction as "a primary, chronic disease of brain reward, motivation, memory, and related circuitry."Individuals that become addicted to opioids or other medications often engage in behaviors that become compulsive and result in dangerous consequences. The American Society of Addiction Medicines notes that while the following should not be used as diagnostic criteria due to variability among addicted individuals, there are five characteristics of addiction: 1. Craving for drug or positive reward. 2. Dysfunctional emotional response. 3. Failure to recognize significant problems affecting behavior and relationships. 4. Inability to consistently abstain. 5. Impairment in control of behavior. Unfortunately, many health providers' understanding regarding addiction is confused, inaccurate, and inconsistent due to the broad range of perspectives of those dealing with patients suffering from addiction. While a knowledge gap is present among healthcare providers, it is equally prevalent in politicians writing laws and law enforcement attempting to enforce the laws they write. Payers are responsible for the expenses associated with the evaluation and treatment of addiction. Persistent lack of education and the use of obsolete terminology continue to contribute to a societal lack of understanding for how to effectively deal with the challenges of addiction. In the past, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders defined "addiction," "substance abuse," and "substance dependence" separately. The result was provider confusion that contributed to the undertreatment of pain. Over time, the manual has eliminated these terms and now defines an inclusive "substance use disorder" ranging from mild to severe. Pain management presents numerous challenges, including avoidance of both under and overprescribing opioids. This is particularly relevant when treating patients with chronic pain. Many patients suffer from inadequately treated pain while at the same time there are issues of opioid abuse, addiction, diversion, and overdose. As a result of concerns related to overprescribing, providers often fail to deliver appropriate, effective, and safe opioids to patients with chronic pain. Providers have, in the past, been poorly trained and ill-informed in their opioid prescribing. Determining appropriate opioid therapy for chronic pain patients is even more difficult because these patients often develop opioid tolerance as well as significant psychological, behavioral, and emotional problems. These can include anxiety and depression related to under or overprescribing opioids.  Clinicians that prescribe opioids are at risk for allegations of medical negligence for failure to provide adequate pain control, while also risking loss of licensure or even criminal charges if they are perceived to be involved in drug diversion or misuse. All providers that prescribe opioids need education and training to provide the best patient outcomes and avoid the social and legal entanglements associated with under and overprescribing opioids. Opioid prescribing providers may have knowledge gaps in multiple areas, including current research, legislation, and appropriate prescribing practices. Specific opportunities for education include: Definition of addiction. Knowledge of at-risk populations. Distinction between prescription and non-prescription opioid addiction. Clarification of the difference between addiction and dependence. Dispelling the myth that opioid addiction is a psychologic problem rather than related to chronic, painful disease. The practice of opioid prescription has long been surrounded by misinformation, education deficits, and inconsistent laws, resulting in societal challenges that must be addressed with education and training.