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“Nonmedical” prescription opioid use in North America: a call for priority action Voon, Pauline; Kerr, Thomas Dec 1, 2013

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COMMENTARY Open Access“Nonmedical” prescription opioid use in NorthAmerica: a call for priority actionPauline Voon1 and Thomas Kerr1,2*AbstractNearly four years after the United States Congress heralded a “decade of pain control and research”, chronic painremains a mounting public health concern worldwide. The escalating prevalence of chronic pain in recent yearshas been paralleled by a rise in prescription opioid availability, misuse, and associated human and social costs.However, national monitoring surveys in the U.S. and Canada currently fail to differentiate between prescriptionopioid misuse for the purposes of euphoria versus pain or withdrawal management. Furthermore, there is a lack ofevidence-based guidelines for pain management among high-risk individuals, and a glaring lack of education forpractitioners in the areas of pain and addiction medicine. Herein we propose multiple avenues for interventionand research in order to mitigate the individual, social and structural problems related to undertreated pain andprescription opioid misuse.Keywords: Nonmedical prescription opioid use, NMPOU, NAPOU, Not-as-prescribed opioid use, Prescriptionopioid misuse, Prescription drug abuse, Diversion, Pain, Substance abuse, AddictionBackgroundNearly four years after the U.S. Congress heralded a“decade of pain control and research” (for the period of2001 to 2010) [1-3], chronic pain management remainsa mounting public health concern worldwide. Globally,over 1.5 billion people suffer from chronic pain [4]. Inthe U.S., pain is the most common reason for seekingmedical care [5-7], and the 100 million Americans suf-fering from chronic pain outweighs the number ofAmericans with diabetes, heart disease, stroke and can-cer combined [8-11]. In Canada, the estimated preva-lence of chronic pain is between 15-29% [12-14].Consequently, the cost of pain due to lost productivityand health care costs is estimated to range at least$560-635 billion USD annually [8].The escalating problem of chronic pain has been paral-leled by a distinct rise in prescription drug misuse particu-larly in North America [15], with a 140.5% increase inreported prescription drug misuse among the U.S. popula-tion from 7.8 million in 1992 to 15.1 million in 2003. Thisrepresents approximately 6% of the U.S. population, whichexceeds the combined number of people in the U.S. whouse cocaine, hallucinogens, inhalants, and heroin com-bined [16]. Canadian data, which have only recently beencollected at a national level, estimate that approximately4.8% of the general population used prescription opioidsnon-medically in 2009 [17,18]. As the demand for pre-scription opioids (POs) has risen, so has the availability ofdiverted POs and the prevalence of morbidities and mor-talities associated with opioid use [19].Importantly, of the 4.8% of the Canadian populationthat reported nonmedical PO use, only 2.3% (0.4% of theCanadian population) reported using POs “to get high”[17]. Thus, the remaining majority of nonmedical POuse can be attributed to factors that have been underex-plored [16]. One such factor that may be fuelling the in-creasing demand for and availability of diverted POs isundertreated pain. One recent systematic review andmeta-analysis found a 48% pooled prevalence of painamong PO misusers [20], and several studies have dem-onstrated a positive association between chronic painand non-medical PO use [21,22], particularly among in-dividuals with a history of substance misuse [23,24] whoare significantly more likely to receive inadequate painmanagement within clinical settings [25,26]. Distinctionsbetween PO use for euphoria versus pain or withdrawal* Correspondence: uhri-tk@cfenet.ubc.ca1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,608-1081 Burrard Street, V6Z 1Y6 Vancouver, BC, Canada2Department of Medicine, University of British Columbia, St. Paul’s Hospital,608-1081 Burrard Street, V6Z 1Y6 Vancouver, BC, Canada© 2013 Voon and Kerr; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedicationwaiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwisestated.Voon and Kerr Substance Abuse Treatment, Prevention, and Policy 2013, 8:39http://www.substanceabusepolicy.com/content/8/1/39management must be further investigated and appropri-ately addressed [27], since the latter may be effectivelymanaged with medical treatment regimes (e.g., opioidagonist therapies, directly observed treatment) that mayallay PO misuse and diversion. Herein, we outline sev-eral priority recommendations that may serve to miti-gate the growing health and social costs of prescriptionopioid misuse.Main textRe-defining “nonmedical prescription opioid use”The U.S. National Survey on Drug Use and Health(NSDUH) defines nonmedical PO use (NMPOU) as “usewithout a prescription of the individual’s own or simplyfor the experience or feeling the drugs cause”, while theCanadian Alcohol and Drug Use Monitoring Survey(CADUMS) defines NMPOU as past-year PO use “on atleast one occasion to get high [or] obtained from a pre-scription written for someone else, bought from some-one else, or obtained from any other source” [28,29].Alternatively, the U.S. National Epidemiologic Survey onAlcohol and Related Conditions (NESARC) definesNMPOU as use “to feel more alert, to relax or quietnerves, to feel better, to enjoy [oneself], to get high orjust to see how [POs] would work” [30]. These varyingand complex definitions “rely on a mix of objective andsubjective measures that are difficult to verify” [29], suchas subjective PO use measures including “to feel better”(NESARC) or “simply for the experience or feeling thedrugs cause” (NSDUH) combined with objective PO usemeasures such as the individual’s source of POs [28,30].These definitions are also problematic because they ag-gregate motives for and means of possessing POs intoone definition and assume that PO use is a largely “non-medical” issue despite the small proportion of PO usefor euphoria [17], while the majority of PO use may bethe result of medical issues such as undertreated pain orwithdrawal. Thus, current definitions of NMPOU maylead to inaccurate data collection, interpretation, andcounterproductive approaches such as denying POs tothose with undertreated pain or withdrawal.An improved definition may be derived from the U.S.Monitoring the Future (MTF) survey, which simply de-fines NMPOU as PO use “without a doctor’s orders dur-ing the past 12 months” and later differentiates variousmotives for PO use in the survey instrument [31]. How-ever, this definition may not capture those who have alegitimate prescription but may take their medicationsnot as indicated (e.g., increased dose or frequency, or al-ternate route or indication for administration). There-fore, we suggest the term “not-as-prescribed opioid use”(NAPOU), which recognizes that opiate use may not be“nonmedical” in nature, and includes opioid use not asindicated for the individual whether by use of someoneelse’s prescription or use of one’s own prescription out-side of prescribed parameters (Table 1). Within thisbroader definition, in-depth data collection should be under-taken to dichotomize the various motives for (e.g., euphoriaversus pain versus withdrawal) and means of PO use(e.g., diverted medication from street-based markets,use of another’s prescription, use of one’s own pre-scription outside of prescribed parameters).Developing evidence-based guidelines for pain managementamong high-risk individualsDespite the high prevalence of pain among individualswith substance use disorders and psychosocial comor-bidities [32,33], there is a severe lack of evidence to in-form clinical guidelines for pain management amongthese complex populations. For instance, the AmericanPain Society’s guidelines for chronic pain managementexplicitly state that their recommendations for high-riskindividuals are based on “low-quality evidence” and “an-ecdotal experience” [34]. While these guidelines reflectthe state of evidence at the time (2009), there remains apaucity of high-quality research on effective pain man-agement approaches among substance-using popula-tions. This is reflected by the Cochrane Collaboration’sreview on long-term opioid management for chronicnon-cancer pain, in which the majority of studies reviewedexcluded participants with a history of substance use[35]. Therefore, high-quality research on pain manage-ment for individuals with a history of substance use isurgently needed to inform evidence-based clinical practiceguidelines.Educating practitioners in pain and addiction medicineA U.S.-wide audit found that 40% of physicians and 48%of pharmacists received formal training in identifyingprescription drug abuse, yet 74% of physicians and 83%of pharmacists refused to prescribe or dispense a con-trolled drug due to concerns regarding addiction, diver-sion or misuse [16]. Deficiencies in practitioner trainingin pain and addiction medicine likely contribute toTable 1 Suggested definition to replace “nonmedical prescription opioid use”Suggested definition DescriptionNot-as-prescribed opioid use (NAPOU) The authors suggest the term not-as-prescribed opioid use (NAPOU), which recognizes that opioiduse may not be “nonmedical” in nature (e.g., undertreated pain or withdrawal), and includes opioid usenot as indicated for the individual whether by the use of someone else’s prescription or the use of one’sown prescription outside of prescribed parameters (e.g., alternate dose, frequency, route, or indication).Voon and Kerr Substance Abuse Treatment, Prevention, and Policy 2013, 8:39 Page 2 of 4http://www.substanceabusepolicy.com/content/8/1/39inappropriate pain management and a growing opioidmisuse epidemic [36]. For example, a lack of cliniciantraining to inform patients about safe handling of POsmay be contributing to the majority of adolescents (74%)with unsupervised access to prescription medications[37]. Furthermore, a recent policy by the U.S. Food andDrug Administration has required manufacturing com-panies to develop Risk Evaluation and Mitigation Strat-egies that involve providing education to patients andproviders on the safe use and prescribing of extended-release and long-acting opioids, but this policy has notbeen effectively translated into clinical practice [38].Therefore, pain and addiction training should be in-cluded in core medical school and residency curricula,and pain and addiction specialists should be formallyrecognized and incorporated into acute and community-based health care settings [36].ConclusionsPrescription opioid misuse remains a growing publichealth concern for which urgent action is required to re-define the problem at hand, develop evidence-basedguidelines, and scale up education for practitioners inpain and addiction medicine. Further investigation intothe role of undertreated pain as a contributor to pre-scription opioid misuse affords considerable opportunityto reduce personal suffering and healthcare costs. Thereare multiple avenues for intervention and research, andif acted upon, much of the individual, social and structuralproblems related to undertreated pain and prescriptionopioid misuse could be meaningfully addressed.AbbreviationsCADUMS: Canadian Alcohol and Drug Use Monitoring Survey;PO: Prescription opioid; MTF: Monitoring the Future; NAPOU: Not-as-prescribedopioid use; NESARC: U.S. National Epidemiologic Survey on Alcohol and RelatedConditions; NMPOU: Nonmedical prescription opioid use; NSDUH: U.S. NationalSurvey on Drug Use and Health.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsPV and TK conceptualized the commentary and drafted the manuscripttogether. Both authors read and approved the final manuscript.AcknowledgmentsThe authors thank Tricia Collingham and Deborah Graham for theiradministrative assistance.Received: 12 October 2013 Accepted: 26 November 2013Published: 1 December 2013References1. U.S. Congress: One HUndred Sixth Congress of the United States of America.H.R. 3244, Title VI, Sec. 1603. Washington: Government Printing Office; 2004.2. Lippe PM: The decade of pain control and research. Pain Med 2000, 1:286.3. Gallagher RM: The pain decade and the public health. Pain Med 2000,1:283–285.4. The American Academy of Pain Medicine: AAPM Facts and Figures onPain [Internet]. Chicago (IL): American Academy of Pain Medicine; 2013.http://www.painmed.org/PatientCenter/Facts_on_Pain.aspx.5. U.S. Department of Health and Human Services, National Institutes ofHealth: Pain Management: Fact Sheet. 2010. http://report.nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=57.6. Loeser JD, Melzack R: Pain: an overview. Lancet 1999, 353:1607–1609.7. 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Ross-Durow PL, McCabe SE, Boyd CJ: Adolescents’ access to their ownprescription medications in the home. J Adolesc Health 2013, 53:260–264.38. Salinas GD, Robinson CO, Abdolrasulnia M: Primary care physicianattitudes and perceptions of the impact of FDA-proposed REMS policyon prescription of extended-release and long-acting opioids. J Pain Res2012, 5:363–369.doi:10.1186/1747-597X-8-39Cite this article as: Voon and Kerr: “Nonmedical” prescription opioid usein North America: a call for priority action. Substance Abuse Treatment,Prevention, and Policy 2013 8:39.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitVoon and Kerr Substance Abuse Treatment, Prevention, and Policy 2013, 8:39 Page 4 of 4http://www.substanceabusepolicy.com/content/8/1/39


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