CHAPTER 70: The Interface of Pain Management and Chemical Dependency

INTRODUCTION

With the passage of the Harrison Narcotics Tax Act in 1914, the United States federal government put states, as well as physicians, nurses, and patients, on notice that treatment of those with “narcotic addiction” with drugs, specifically opiates and cocaine, was outside the purview of medical practice and was henceforth illegal.¹ Those who championed the Harrison Act saw a distinction between those with addiction and those with pain and saw the law as necessary to halt what many in the United States saw as a headlong slide into producing generations of opioid, cocaine, and marijuana addicts. Several years later, a political coalition of many of the same advocates saw the Volstead Act ratified as a Constitutional amendment banning the use of alcohol for recreational purposes. That “Great Experiment” lasted barely 13 years; drug prohibition, however, has continued.²

It was not until 60 years later with the adoption of the Narcotic Addict Treatment Act of 1974 that physicians could prescribe opioids to those with opioid addiction, but only in the context of federal and state licensed methadone treatment programs. In the interim 60 years, the use of prescribed opioids to treat pain was generally limited to acute pain of injury or surgery and in patients with chronic pain related to cancer and other terminal conditions. Even for these latter groups, great concern was expressed about the addictive nature of these medications, and such drugs were used sparingly.

In the last four decades, however, there has been a growing movement to extend pain treatment, particularly with opioids (as well as sedatives/benzodiazepines and other potentially dependency-producing medications) to those with nonterminal painful conditions.^3,4 In the last 10 years, the prescribing of opioids has increased fourfold, with a similar increase in overdose deaths, with grave concerns among the public, government officials, and the medical profession about these trends. A growth industry of pain clinics, many of which were no more than for-profit opioid and benzodiazepine dispensaries, has prompted some law enforcement and regulatory action, with calls for more.^5-7

Original concerns expressed about the increasing availability of opioids for pain treatment were muted by assertions from experts that the prevalence of addiction in those who were treated for pain was astonishingly low.⁴ Portenoy et al. asserted that undertreatment of pain and specifically “opiophobia” were greater concerns than overprescribing.^3,8 The Joint Commission on Accreditation of Health Care Organizations (JCAHO) declared pain as “the fifth vital sign” and judged hospitals by how well they addressed it.⁹ However, in recent years, many experts have expressed concerns and admitted that overprescription and misuse, as well as outright abuse, have become significant problems, with associated mortality and morbidity^5-7 They advocate specially trained physicians to prescribe opioids in long-term nonmalignant pain,^10-11 and/or to develop risk evaluation and mitigation strategies for opioid prescribers.^12-...