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Editor's Note:
In the late 1990s, a perfect storm hit the medical community. The pharmaceutical industry started promoting new opioid formulations for chronic pain conditions, which, when used properly, could be very effective. At the same time, and based on previous success in the surgical, cancer, and palliative care settings, a school of thought formed among pain specialists that opioid analgesics could be used effectively to treat chronic pain -- what many clinicians recall as a genuine attempt at more compassionate pain management. But an unforeseen consequence of increased opioid prescribing and availability was the epidemic of opioid abuse and addiction that ensued. According to the Centers for Disease Control and Prevention, "The unprecedented rise in overdose deaths in the US parallels a 300% increase since 1999 in the sale of these strong painkillers. These drugs were involved in 14,800 overdose deaths in 2008, more than cocaine and heroin combined."
In May 2012, at the 31st Annual Scientific Meeting of the American Pain Society, Dr. Beth D. Darnall, PhD, now Clinical Associate Professor at Stanford University, moderated a panel discussion on translating opioid research into clinical practice. As Part 1 in Medscape's 2-part "Understanding Opioids" series, Medscape recently invited Dr. Darnall to moderate a virtual email discussion among the same panel of experts, further addressing the nuances of opioid prescribing. On the panel are Jane C. Ballantyne, MD, Professor of Education and Research in the Department of Anesthesiology and Pain Medicine at University of Washington Medicine; Michael E. Schatman, PhD, CPE, Executive Director of the Foundation for Ethics in Pain Care; and Charles E. Argoff, MD, Professor of Neurology at Albany Medical College and Director of the Comprehensive Pain Program at Albany Medical Center. What follows is their discussion.
Opioid Prescribing: Introduction
Dr. Darnall: Long-term opioid use has increased substantially in the United States over the past decade. Of note, opioid prescribing practices in Europe are generally quite conservative compared with practices in the United States. What are the factors that explain this difference, given that there is no greater prevalence of chronic pain in Europe compared with the United States?
Dr. Schatman: First and foremost, there is a greater emphasis on adherence to evidence-based medicine in Europe and other Western nations than in the United States, due in great part to American physicians' insistence upon the right to practice autonomously. It has been noted that despite the lack of a viable evidence basis for long-term use for noncancer pain, the increased prescription of opioids has been fueled by the publication of extremely weak evidence of chronic opioid therapy's efficacy and safety. Manchikanti and colleagues interpreted the results of a Danish studythat supported the lack of efficacy of chronic opioid therapy as providing "prima facie evidence that when opioids are prescribed liberally, even if a small number of patients benefit, the overall population does not.". In the United States, access to opioids has become considered a "human right," although few would argue that chronic opioid therapy provides a "societal good." In European medicine, on the other hand, there is more emphasis on societal good vs individual choice than in the United States.
Dr. Ballantyne: I do agree with Dr. Schatman's first point, that the US opioid phenomenon is in part due to US physicians' insistence on practicing autonomously. In fact, as someone who came to the United States from Europe, I have thought long and hard about these differences. There are, of course, many cultural differences that underpin prescribing differences. What I have observed is that US prescribers used to worry much more about the addictiveness of opioids than European prescribers, to the extent that they tended to undertreat pain in the acute setting and at the end of life. I really noticed this undertreatment of pain when I came to the United States from the United Kingdom in 1986. But a powerful factor in changing the prescribing of US physicians was the marketing of "designer"' opioids aimed at the much larger market of chronic pain. Part of the message was that when treating pain, addiction is rare. Gradually, US physicians were persuaded that opioids were not as addictive as they had thought, that patients have a right to receive this treatment, and that to deny this treatment is unethical. I would like to add 2 other factors to Dr. Schatman's comments that have been important: patient autonomy, which is much greater in the United States where there is a free market in healthcare; and aggressive marketing by the pharmaceutical industry, the United States being one of the few countries in the world in which the pharmaceutical industry can market directly to patients.
Dr. Argoff: It has been well documented that long-term opioid use has increased substantially in the United States over the past decade, but why? Both Drs. Schatman and Ballantyne thoughtfully outline several factors that may underlie this practice; however, I must strongly disagree with their assertion that physicians (and potentially other prescribers) prescribe autonomously, and thus I feel that they are missing a key truth about how medicine is currently practiced in the United States. In the state of Washington, where both Drs. Schatman and Ballantyne work, prescribers may be free to prescribe those treatments they feel would be the best treatment approaches for the management of chronic pain for a given patient, but can they be practically instituted if they are not "covered" by the payer? Of course not, in many instances.
In the state of Washington, the state in which multidisciplinary pain management was developed, are all of the multidisciplinary approaches that we know to be available for the management of various conditions associated with chronic pain available to each patient? I think not. The extent to which treatments are actually available for an individual patient from a "what will be paid for?" viewpoint is significantly influential, to the potential severe detriment of the patient. This extends specifically to pharmacotherapy and even more specifically to one subtype of pharmacotherapy, opioid therapy. How can we have a meaningful discussion about opioid therapy in the United States without an honest recognition of the healthcare system factors that underlie it?
If a payer's opioid prescribing policy mandates that methadone, with its relatively short analgesic half-life, be used first line as a "long-acting" opioid regardless of whether or not the prescriber has adequate knowledge regarding the complexities of this drug -- and we now know the true staggering numbers of just how many opioid overdose-related deaths have been related to methadone -- does anyone not see how US healthcare system issues have to be more effectively managed now? To the best of my knowledge, methadone is not actively marketed in a widespread manner in the United States by any pharmaceutical company. Although it's interesting to compare opioid prescribing practices in Europe vs the United States, we need to get to the root causes of why opioids are prescribed in the manner they have been here and address these assertively so that meaningful changes can occur. If chronic pain is truly managed "better" in Europe (multiple distinct countries and healthcare systems), then let us learn from the European experience. But this is not merely a matter of how opioids are prescribed or marketed in the United States compared with Europe.
Dr. Schatman: I agree that the payer issue is a critical one, which I addressed in my article last year in Pain Medicine. One of the factors that makes pain management superior in much of Europe is that the government-run healthcare systems cover interdisciplinary approaches; as the number of programs per capita has decreased dramatically in the United States, we are seeing a rapid increase in the availability of such programs in countries like the United Kingdom and Canada. (See my chapter in the most recent edition of Bonica's Management of Pain). I agree that the lack of availability of access to interdisciplinary programs in the United States has contributed to the overprescription of opioids. Washington State is a particularly problematic place in which to have chronic pain, between the insurance industry's refusal to cover interdisciplinary approaches in conjunction with the WA Opioid Law's approach of "narcoterrorism."
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