n the early 1990s, an oncologist in West Virginia was investigated by the Board of Medicine for over-prescribing opioids to a patient in severe pain caused by metastatic bone cancer. This case was representative of the problem of undertreatment of pain throughout the United States at that time. Many similar cases led to an increased awareness of the need to liberalize opioid policy. Several medical boards wrote new regulations to improve the access of patients to narcotic medications, and the Federation of State Medical Boards gave national recommendations on this issue. These new regulations applied to all patients and were not written exclusively for cancer diagnoses. Publications at this time encouraged the theory of treating “to effect or side effect.”

As the 1990s came to an end, we saw a much more open attitude toward opioids, very aggressive pharmaceutical companies who marketed their products to primary care specialists as first-line therapy and more open insurance formulary policies. These factors led to a dramatic escalation in the use of potent controlled substances. The problem is highlighted by data that show that the United States, with only a small fraction of the world’s population, uses more than 80 percent of the global prescribed opioids. Many social problems have arisen because of this ubiquity of opioids.

History of Use and Abuse
Drug abuse and addiction is not a new phenomenon to the United States or to the world. The euphoric and medicinal effects of opioids were described in ancient cultures such as the Sumerians (4,000 B.C.E.) and Egyptians (2,000 B.C.E.). In modern times, opium addiction became such an issue in China that in 1909 President Theodore Roosevelt convened the Shanghai Opium Commission to help the Chinese solve this problem. A few years later, governmental control of the use of opioids in the United States was initiated by President Woodrow Wilson when he signed the Harrison Act in 1913. This law was developed to control the “dope doctors,” as the legislation described the physicians and dentists who wrote for opioids and cocaine. It required all prescriptions to be recorded in writing and made available to the Bureau of Internal Revenue. This process evolved into our current Drug Enforcement Administration (DEA) with our modern regulation and monitoring system. While DEA monitors aberrant behavior by physicians, it cannot and should not control all areas of medical practice, and it is up to physicians to police themselves in some fashion to maintain appropriate standards of care.

In the past few years, we have seen an explosion of methadone clinics, rapid detoxification programs and crime related to drug diversion and addiction. We have seen DEA restate its policies on frequently asked questions to further increase awareness of these problems, and we have seen several pain societies publish recommendations on the proper use of controlled substances. Why has this occurred? Have doctors in the United States become too liberal with their prescribing practices and failed to monitor the use of these substances properly?

The use of opioids in noncancer patients is an acceptable practice. It is not acceptable to continue to escalate the dose with no recorded change in functional ability or pain assessment values. It is not acceptable to see patients infrequently, avoid drug screening and not enforce a firm opioid agreement. We should seek other methods of pain control when possible, including interventional techniques, physical medicine and nonaddictive medications.

Good Time to Be in Pain
This is a tremendous time to be involved in the field of pain medicine. New developments in drug therapy include medication to more effectively treat neuropathic pain, headaches, arthritis, spasm and pain-related depression. Injection techniques such as transforaminal epidural injections have shown improved outcomes when coupled with physical medicine. Advances in spinal cord stimulation, such as the advent of multi-electrode leads and rechargeable generators, allow treatment of more advanced pain conditions and new disease states. New nonopioid intrathecal drugs are being developed such as ziconotide, octreotide, adenosine and gabapentin. Kyphoplasty and vertebroplasty have been beneficial to those with painful compression fractures. Percutaneous disc decompression can be performed in those with small disc herniations, and intradiscal electrothermoplasty can be used for annular disease. These are just a few of the many new options for our patients. With this great number of evolving therapies available, the use of opioids should become less necessary, and the escalation of the doses should be rare.

The use of oral and transdermal opioids is an important part of the treatment continuum for patients with chronic pain. The decision to use these medications chronically should be based on a firm diagnosis, risk assessment of the patient for addiction and side effects, and establishment of a treatment plan. The treatment plan should include follow-up and assessment on a regular basis, random drug screens and intermittent examination of the patient to update his/her condition and rule out new causes of pain. The prescribing of these medications should not be taken lightly, and we as pain treatment experts should always remember our responsibility to our patients to alleviate suffering and improve function; however, we should balance that goal with social responsibility.

Meeting in the Middle
With these goals in mind we can improve patient care while simultaneously limiting access of opioids to those who are interested in diversion or troubled with addiction. If we do not act to swing the pendulum back to a more conservative practice, the access to opioids to all patients may be eventually challenged. We cannot allow our patients or our colleagues to be bridled with that type of regulation in the future, so we must act now.

Timothy R. Deer, M.D., is President and CEO, The Center for Pain Relief, and Clinical Professor, West Virginia University, Charleston, West Virginia.