The use and abuse of prescription medications have been in the news and of much concern to pain patients for quite some time now. What had been a problem took on the proportions of a crisis when OxyContin abuse seemed to start running rampant. Patient with legitimate pain and urgent need for pain management began having problems getting medications. Some doctors began to be concerned about prescribing narcotics. Already suspicious attitudes toward people who went to the emergency room in pain became even worse.

In the wake of all of this, dozens of the nation’s pain experts in collaboration with the Drug Enforcement Administration (DEA), recently released a Frequently Asked Questions (FAQs) document intended to provide answers to important questions about treating pain patients while recognizing and addressing problems associated with the diversion and abuse of prescription pain medications.

The new document, Prescription Pain Medications: Frequently Asked Questions and Answers for Health Care Professionals, and Law Enforcement Personnel, is intended for primary care clinicians and law enforcement officers so that both groups can better understand the treatment of pain, and the law enforcement and regulatory efforts to prevent prescription pain medications from being diverted and becoming a source of harm or abuse.

“We have two serious societal problems – the undertreatment of pain, and drug abuse and diversion – that are intertwined through prescription pain medications. We address both problems in this document, and hope it will bring some clarity to the issue,” said Russell Portenoy, M.D., Chairman, Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, and lead pain expert on the project.

In a media briefing statement, David E. Joranson, MSSW, Senior Scientist, Director, Pain & Policy Studies Group, University of Wisconsin, Madison Medical School, commented:

"I want to emphasize a few points. This is an important educational initiative. Among clinicians, law enforcement and those who regulate drugs and professional practice, there is a need to update their knowledge about pain management with accurate information about pain, drugs and addiction.

But it is more than that. The medical and regulatory environment for pain management is worsening: We already knew that for years physicians have been concerned about being investigated if they prescribed controlled substances, but now we hear that doctors are becoming even less willing to prescribe, because they fear the profession-ending high-profile arrests that they are hearing more about. Even if they are acquitted of state charges, as some have been, their profession in medicine is damaged if not finished. We already knew that some patients were wary of using pain medications, but now we hear that patients can’t find a physician who will prescribe opioids, or are being cut back or dropped entirely. We knew that some pharmacies did not carry opioids, but now we hear that some have posted signs that say this! In some ways, pain management has become a crime story rather than a health care story."

The FAQs include 30 questions and answers and an appendix with key definitions. They provide relevant and current references and Internet resources for each answer. Some of the questions relate to risk assessment, how opioid treatment works, patient behavior, abuse, addiction, rules and laws, and clear descriptions of how and why the DEA may prosecute a clinician.

The questions in the FAQs are:

1. What are the key addiction-related terms used in discussing pain medications and risk management?

2. Why is pain management important?
3. What are the goals of pain management?
4. How can a clinician assess a patient’s pain?
5. When should a primary care physician turn to a pain medicine specialist to manage a patient’s pain?
6. How are opioids used to manage chronic pain?
7. What outcomes should be assessed when judging whether opioid therapy is successful?
8. Where can clinicians find educational material on prescribing opioid analgesics
9. What are the common side effects associated with opioid therapy, and how can they be managed?
10. What information do patients need about using opioids for chronic pain?
11. What kinds of problems might patients encounter when obtaining opioid prescriptions, in having them filled, or in taking the medications properly?
12. Can more than one opioid at a time be prescribed to a patient?
13. What is “opioid rotation,” and when is it appropriate?
14. What are “tapering” and “drug holidays”?
15. Is a written agreement between the clinician and the patient required before instituting treatment with an opioid?
16. What should be documented when prescribing opioids?
17. What is the extent of prescription opioid abuse?
18. What are the common ways opioids are diverted to illicit uses?
19. How can clinicians assess for risks of abuse, addiction, and diversion and manage their patients accordingly?
20. What behaviors are potential indicators of problems for patients on long-term opioid therapy?
21. If a patient receiving opioid therapy engages in an episode of drug abuse, is the physician required by law to discontinue therapy or report the patient to law enforcement authorities?
22. Is it legal and acceptable medical practice to prescribe long-term opioid therapy for pain to a patient with a history of drug abuse or addiction, including heroin addiction?
23. What strategies can be used to treat pain successfully in patients who are currently abusing drugs?
24. What requirements must physicians and pharmacists meet to comply with federal and state laws regulating opioids?
25. What regulations do physicians need to know and observe when prescribing opioid analgesics for pain?
26. Can methadone be used for pain control and, if so, is a clinician required to have a special license to prescribe it?
27. Under what circumstances will the federal Drug Enforcement Administration (DEA) investigate and prosecute a doctor or pharmacist or refer cases to other agencies?
28. Should efforts to address diversion avoid interfering with medical practice and patient care?
29. When should a law enforcement officer turn to a pain medicine specialist for advice?
30. Does the number of patients in a practice who receive opioids, the number of tablets prescribed for each patient, or the duration of therapy with these drugs by themselves indicate abuse or diversion?

Under the tenth question, there's a section of "Dos" and "Don'ts" for patients:

• Do talk to the doctor and other health care professionals involved in your pain care about the pain; keep notes and write down questions to ask about the pain.
• Do talk to the doctor if the medication is not working.
• Do talk to the doctor if there are problems with side effects.
• Do talk to the pharmacist openly about this therapy if he or she could potentially help with information about the pain or the management of side effects.
• Do keep the medications in a safe place and out of children’s reach.
• Do look for another physician, or request referral to a specialist, if the pain is not taken seriously.
• Do use the medication only as it is prescribed and handle the therapy with a high level of responsibility.
• Do notify the physician if you are planning to become pregnant or are already pregnant.
• Don’t allow others to use the prescription medication; the patient is the only person who is legally permitted to have the prescribed opioids.

Also under that question, you'll find a statement about patients' rights and a list of what patients should know. Hopefully, this will lead to better doctor/patient communication and patient education. However, if you have questions, and your doctor doesn't offer information, don't hesitate to ask questions. If your doctor won't answer questions, you need a new doctor.

By itself, Prescription Pain Medications: Frequently Asked Questions and Answers for Health Care Professionals, and Law Enforcement Personnel cannot and will not solve the problems of prescription drug misuse and abuse or the problems cause by lack of adequate doctor/patient communication and patient education. However, it can indeed be a strategic tool to accomplishing the goal of adequate and compassionate treatment of pain for all patients. Although it was intended for physicians and law enforcement officials, I encourage all pain patients to copy it to your computers so you can print it out, read it, and provide copies to your doctors or others you feel could benefit from reading it. Here are links to copies of the FAQs for your use. You can simply click to open and read or right click to save them to your computer.

• FAQ in PDF format
• FAQ in Word format

NOTE: The DEA removed the FAQ from their web site on October 6, 2004, and requested that the University of Wisconsin Pain & Policy Studies Group remove it from theirs as well. Since this document was posted on a governmental web site, with no notice of copyright or exception, I consider it to be a document that was released into the public domain. Therefore, it remains on this site. For more information on this situation, click HERE.

To the team of medical professionals and DEA officials whose hard work produced these FAQs, thank you. To my fellow pain sufferers, let's take this as a sign of better times to come. We must continue educating ourselves and being active participants in our health care, but with this document available, we can hope that being heard and getting relief for our pain will become easier.

Press Release: U.S. Drug Enforcement Agency and The Pain and Policy Studies Group. "Consensus Document on the Use and Abuse of Prescription Pain Medications." August 11, 2004.

Prescription Pain Medications: Frequently Asked Questions and Answers for Health Care Professionals, and Law Enforcement Personnel.

Last Updated August 21, 2004