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Annemarie Daly Linares
excerpted from: Annemarie Daly Linares, Opioid Pseudoaddiction: a Casualty of the War on Drugs, Racism, Sexism, and Opiophobia, 15 Quinnipiac Health Law Journal 89 (2011-2012) (261 Footnotes Omitted)(Student Note)
Pain is one of the most pervasively dreaded of all of the symptoms of illness, and yet, the under-treatment of pain occurs frequently. In the United States, under-treated pain occurs in sixty to seventy percent of patients. Since the 1990's, organizations like the American Pain Society have brought the issue of under-treatment of pain to national attention. In 2000, because of increased national attention on pain, the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) adopted minimal pain management standards for healthcare institutions. The U.S. Congress even emphasized the need for adequate pain control by designating the years 2001 to 2010 the Decade of Pain Control and Research. Despite these efforts, the epidemic of under-treated pain, however, continues today.
There is an imbalance between the current war on drugs and the war on pain. The war on pain is undergirded by legitimate opioid prescribing. Opioid medications produce analgesia by binding to opiate receptors in the brain. Individuals that use opioids recreationally are also familiar with their potential for a euphoric effect. The manner in which the Drug Enforcement Agency (DEA) currently fights the war on illicit opioid drug use undermines the war on pain. The war on pain is fought to preserve the pain patient's right to receive the most efficacious pain therapy available to treat his or her pain. Inadequate pain treatment has harmful physical effects including the development of chronic pain, and destroys people's autonomy, dignity, and decision-making capacity. Chronic pain affects one third of the U.S. population annually. The economic cost of inadequately treated chronic pain in the U.S. is estimated at $100 billion annually. Chronic pain is an epidemic leading to vocational, social, and familial malfunctioning of the individual. Opioid pseudoaddiction, which stems from inadequate pain treatment, is a casualty of racism, sexism, and the war on drugs. This Note offers a proposal for reform to win the war on pain without undermining the DEA's war on illegal drug use.
This Note will primarily address chronic pain since long term, high dose opioids are most controversially used for chronic pain. Chronic pain is pain lasting longer than the usual time period expected for tissue healing, usually more than 3-6 months. Chronic pain, unlike acute pain, has no adaptive purpose; it serves no other purpose than suffering.
The most common patient complaint upon seeking medical attention is pain. While the currently available therapies can relieve up to 90% of patients in pain, physicians are unable to take full advantage of the available therapies leaving their pain patients suffering. Inadequately treated pain patients may turn to illicitly obtained opioids to self-medicate their pain. Opioids are currently the most effective method of treatment for managing moderate to severe pain. Although opioids are still underused, the use of opioids has increased ten-fold over the last twenty years because of the pain advocacy movement.
An interesting medical syndrome, opioid pseudoaddiction, has emerged as a result of physician underutilization of opioids for pain treatment. Weissman and Haddox introduced the term opioid pseudoaddiction in 1989 to describe an iatrogenic syndrome of behavioral changes similar to those seen in opioid addiction. The war on drugs causes opioid pseudoaddiction by deterring physicians from adequately prescribing opioids for the treatment of pain.
Opioid pseudoaddiction describes a syndrome in pain patients who falsely appear to be addicted to opiates. Patients with opioid pseudoaddiction appear to be addicted to opiates because their physicians prescribed inadequate opioid doses causing oligoanalgesia - inadequate pain relief. Inadequately treated pain patients with pseudoaddiction may demonstrate the same drug seeking behavior as those individuals with true opioid addiction. Drug-seeking behaviors include using illicitly obtained opioids, deceiving physicians and pharmacists by losing prescriptions or claiming that pharmacies shorted them, or doctor and pharmacy shopping to obtain duplicate prescriptions. Unlike in true opioid addiction, however, where drug-seeking behaviors persist despite adequate pain relief, drug-seeking behaviors subside in opioid pseudoaddiction when patients achieve adequate pain relief.
In contrast to those with opioid addiction, whose function deteriorates when given more opioids, those with opioid pseudoaddiction function better both physically and psychologically when given optimal opioid pain management therapy. The cure for pseudoaddiction requires an optimization in opioid therapy to produce adequate pain relief. Weissman and Haddox propose two steps for prevention and treatment of pseudoaddiction. In the first step, the healthcare provider must trust the patient's report of pain. In the second step, the healthcare provider then optimizes the patient's pain management therapy. This Note proposes that physicians take these two steps only after utilizing appropriate measures to assess the patient's risk for diversion, drug misuse, and abuse such as using screening questionnaires, checking electronic scheduled drug dispensing databases, and performing urine toxicology screens for opioids and illicit substances. Patients receive the majority of diverted drugs from a single physician and most often share these drugs among family and friends. Studies suggest that quantitative urine drug testing is the best method to determine the use of illicit drugs and the presence of diversion versus patient compliance with prescribed opioid dosing.
Another method to counter diversion involves physician-patient contracts. Physicians also frequently employ physician-patient opioid contracts prior to prescribing an opioid drug. These common patient-physician agreements lay out both the dangers of abusing, misusing, and diverting opioid medications and the responsibilities of the patient. Patients' commitment to their responsibilities is important because patient nonadherence to physician instructions regarding medication use significantly contributes to opioid medication-related deaths. Physician-patient opioid contracts normally contain the following requirements: patients must seek opioid prescriptions from a single provider, have opioid prescriptions dispensed from a single pharmacy to allow for ease of monitoring and prevention of duplicate prescriptions, keep their medications away from others who might illegally use or sell them, submit to random urine drug testing, and avoid misusing their extended release medications by crushing or biting them to achieve a surge of drug effect. Although opioid contracting affects physician liability and documents informed consent of the patient, opioid contracting alone has not been shown to definitively deter opioid drug abuse.
The Background section of this Note will discuss the Controlled Substances Act (CSA), physician persecutions, racism, sexism, and opiophobia as they relate to the under-treatment of pain and development of opioid pseudoaddiction. Then this Note will discuss willful blindness as it relates to physician persecution. The Reform Proposals section will develop a proposal for reform, incorporating education and research, cooperation between the DEA and physicians, a safe harbor for physicians from criminal prosecution, tort liability for under-treatment of pain, reform of organizational standards, pharmacy reform, and a greater role for state medical boards in pain management policy and monitoring.