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Policy Issues and Imperatives in the Use of Opioids to Treat Pain in Substance Abusers

Published online by Cambridge University Press:  01 January 2021

Extract

A great deal has been learned in the past fifteen years from the study of pain mechanisms. More recently, the relief of pain has begun to receive much needed attention as well. Although most, if not all, acute and cancer pain can be relieved, recent evidence shows that inadequate treatment of pain is still common among the general population—even for pain due to cancer. Inadequate treatment of cancer pain is even more likely if the patient is a member of an ethnic minority, female, elderly, or a child. Evidence also suggests that substance abusers are at risk for poor pain treatment.

A number of barriers which involve problems of knowledge, attitudes, and laws and regulations affect health care professionals, patients, and the health care system; collectively, they contribute to the inadequate treatment of pain.

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Article
Copyright
Copyright © American Society of Law, Medicine and Ethics 1994

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References

Melzack, R., “The Tragedy of Needless Pain: A Call for Social Action,” Scientific American, 262, no. 2 (1988): 2733.CrossRefGoogle Scholar
Dahl, J.L. Joranson, D.E., “Cancer Pain: The US Responds,” Palliative Medicine, 6 (1992): 9497.Google Scholar
Agency for Health Care Policy and Research, Acute Pain Management: Operative or Medical Procedures and Trauma, Clinical Practice Guideline (Rockville: U.S. Department of Health and Human Services, 1992); and Jacox, A. Carr, D.B. Payne, R. et al., Management of Cancer Pain, Clinical Practice Guideline No. 9 (Rockville: U.S. Department of Health and Human Services, Public Health Service, 1994).Google Scholar
See Melzack, , supra note 1; Cleeland, C.S. Gonin, R. Hatfield, A.K. et al., “Pain and Its Treatment in Outpatients with Metastatic Cancer,” The New England Journal of Medicine, 330 (1994): 592–96.Google Scholar
See Cleeland, et al., supra note 4.Google Scholar
See Jacox, et al., supra note 3.Google Scholar
Cleeland, C.S., “Barriers to the Management of Cancer Pain,” Oncology, 1 Supp. (1987): 1926; and see Jacox, et al., supra note 3.Google Scholar
Portenoy, R.K., “Chronic Opioid Therapy in Nonmalignant Pain,” Journal of Pain and Symptom Management, 5, no. 1, Supp. (1990): S46S62; World Health Organization Expert Committee, Cancer pain Relief and Palliative Care (Geneva: WHO, 1990); Weissman, D.E. Joranson, D.E. Hopwood, M.B., “Wisconsin Physicians' Knowledge and Attitudes About Opioid Analgesic Regulations,” Wisconsin Medical Journal, 90 (1991): 671-75; Hill, C.S., “The Negative Influence of Licensing and Disciplinary Boards and Drug Enforcement Agencies on Pain Treatment with Opioid Analgesics,” Journal of Pharmaceutical Care in Pain & Symptom Control, 1 (1993): 43–62; and see Jacox, et al., supra note 3.Google Scholar
See World Health Organization Expert Committee, supra note 8.Google Scholar
World Health Organization, Cancer Pain Relief (Geneva: WHO, 1986); Joranson, D.E., “Federal and State Regulation of Opioids,” Journal of Pain and Symptom Management, 5 (1990): S12–S23; Angarola, R.T., “National and International Regulation of Opioid Drugs: Purpose, Structures, Benefits and Risks,” Journal of Pain and Symptom Management, 5, no. 2, Supp. (1994): S6-S11; see Jacox, et al., supra note 3; and Shapiro, R.S., “Legal Bases for the Control of Analgesic Drugs,” Journal of Pain and Symptom Management, 9, no. 3 (1994): 153-59.Google Scholar
See World Health Organization Expert Committee, supra note 8.Google Scholar
Daut, R.L. Cleeland, C.S., “The Prevalence and Severity of Pain in Cancer,” Cancer, 50, no. 9 (1982): 1913–18; see World Health Organization, supra note 10; International Narcotics Control Board, Report of the International Narcotics Control Board for 1989 (Vienna: United Nations, INCB, 1989); and Cleeland, C.S. Ryan, K.M., “Pain Assessment: Global Use of the Brief Pain Inventory,” Annals of the Academy of Medicine, 23, no. 2 (1994): 129-38.3.0.CO;2-R>CrossRefGoogle Scholar
Ferrell, B., “Cost Issues Surrounding the Treatment of Cancer Related Pain,” Journal of Pharmaceutical Care in Pain & Symptom Control, 1 (1993): 912; and Joranson, D.E., “Are Health-Care Reimbursement Policies a Barrier to Acute and Cancer Pain Management?,” Journal of Pain and Symptom Management, 9, no. 4 (1994): 244-53.CrossRefGoogle Scholar
Narcotic is a legal term that includes other substances, such as cocaine and marijuana, and is used in a legal context. Opioid is a pharmacological term, and is used to refer to codeine, morphine, and other natural and synthetic drugs whose effects are mediated by specific receptors in the central and peripheral nervous systems.Google Scholar
Angarola, R.T. Wray, S.D., “Legal Impediments to Cancer Pain Treatment,” in Hill, C.S. Fields, W.S., eds., Advances in Pain Research and Therapy, Vol. 11 (New York: Raven Press, 1989), pp. 213–31; and see Joranson, , supra note 10.Google Scholar
Weissman, D.E. Haddox, J.D., “Opioid Pseudoaddiction—An Iatrogenic Syndrome,” Pain, 36 (1989): 363–66.Google Scholar
Federation of State Medical Boards of the United States, A Guide to the Essentials of a Modern Medical Practice Act, 5th ed. (Forth Worth: FSMB, 1988).Google Scholar
Federal Register, 48 (1983): 2673.Google Scholar
Federal Register, 40 (1975): 15393–94.Google Scholar
U.S. v. Evers, 453 F. Supp. 1141 (M.D. Ala. 1978) aff'd F.2d 1043 (5th Cir. 1981).Google Scholar
Controlled Substances Act, Pub. L. No. 91–513, 84 Stat. 1242 (1970); Drug Enforcement Administration, Physician's Manual: An Informational Outline of the Controlled Substances Act of 1970 (Washington, D.C.: U.S. Department of Justice, DEA, 1990).Google Scholar
Federal Register, 51 (1986): 17476–78; and Joranson, D.E. Cleeland, C.S. Weissman, D.E. Gilson, A.M., “Opioids for Chronic Cancer and Non-Cancer Pain: A Survey of State Medical Board Members,” Federation Bulletin: The Journal of Medical Licensure and Discipline, 79, no. 4 (1992): 15-49.Google Scholar
See Controlled Substances Act, supra note 21.Google Scholar
21 C.F.R. § 801a(3) (1988), p. 836.Google Scholar
U.S. v. Moore, 423 U.S., 122 (1975).CrossRefGoogle Scholar
21 C.F.R. § 1306.07(a) (1988).Google Scholar
Webb et al. v. U.S., 249 U.S., 96 (1919).Google Scholar
See Controlled Substances Act, supra note 21.Google Scholar
21 C.F.R. § 1306.07(c) (1988), p. 72.Google Scholar
21 C.F.R. § 802(1) (1988), p. 836.Google Scholar
Jaffe, J.H., “Misinformation: Euphoria and Addiction,” in Hill, C.S. Fields, W.S., eds., Advances in Pain Research and Therapy, Vol. 11 (New York: Raven Press, 1989), pp. 163–74; Morgan, J.P., “American Opiophobia: Customary Underutilization of Opioid Analgesics,” in Hill, C.S. Fields, W.S., eds., Advances in Pain Research and Therapy, Vol. 11 (New York: Raven Press, 1989), pp. 181-89; Ferrell, B.R. McCaffery, M. Rhiner, M., “Pain and Addiction: An Urgent Need for Change in Nursing Education,” Journal of Pain and Symptom Management, 7, no. 2 (1992): 117–12; and Joranson, D.E., “Fear of Addiction is an Impediment to Cancer Pain Relief: A Proposal to the World Health Organization Programme on Substance Abuse,” Symptom Control in Cancer Patients, 5 (1993): 52-58 (Japanese article).Google Scholar
See Joranson, , supra note 31.Google Scholar
World Health Organization, WHO Expert Committee on Drug Dependence: Sixteenth Report (Geneva: WHO, 1969).Google Scholar
World Health Organization, WHO Expert Committee on Drug Dependence: Twenty-Eighth Report (Geneva: WHO, 1993).Google Scholar
American Pain Society, Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain (Skokie: APS, 3rd ed., 1992).Google Scholar
21 C.F.R. § 291.505(a)(5) (1988).Google Scholar
See Joranson, , supra note 10, p. S16.Google Scholar
Federal Register, 58 (1993): 37507–08.Google Scholar
Ibid., p. 37507.Google Scholar
See Federation of State Medical Boards of the United States, supra note 17.Google Scholar
Ibid., p. 2.Google Scholar
Alabama State Board of Medical Examiners, § 1306.07(c) (1986).Google Scholar
California Senate Bill, No. 1802, ch. 1588 (1990).Google Scholar
New Jersey Board of Medical Examiners Regulations, 13:35–6.6(g) (1985).Google Scholar
Texas Medical Practice Act, § 5, art. 4495c, § 2(3) (1992).Google Scholar
Virginia Pharmacy Act, § 54.1–3408.1 (1989).Google Scholar
Alabama State Board of Medical Examiners, supra note 43, p. 18.Google Scholar
Federation of State Medical Boards of the United States, supra note 41, pp. 1415.Google Scholar
California Uniform Controlled Substances Act, § 11156 (1989).Google Scholar
Indiana Medical Licensing Board, art. 22.5, ch. 6, 25–22.5-6-2.1, § 21(7) (1987).Google Scholar
New York Administrative Rules and Regulations, pt. 80, § 80.85(a).Google Scholar
Tennessee Division of Health Related Boards, ch. 6, pt. 2, 63-6-214(13) (1989).Google Scholar
Texas Medical Practice Act, subch. C, § 3.08(4c) (1992).Google Scholar
Utah Controlled Substances Rules, R153-37-8(A8) (1988).Google Scholar
Wyoming Medical Practice Act, ch. 26, art. 1, § 33-26-402(a, xi) (1987).Google Scholar
Tennessee Division of Health Related Boards, supra note 53, p. 9.Google Scholar
See California Uniform Controlled Substances Act, supra note 50, p. 31.Google Scholar
Weissman, D.E., “Do Drug Regulations Affect Medical Practice?,” Journal of Pain and Symptom Management, 7 (1992): 257–58; and see Hill, , supra note 8.Google Scholar
See Joranson, et al., supra note 22.Google Scholar
National Conference of Commissioners on Uniform State Laws, Uniform Controlled Substances Act (St. Louis: NCCUSL, 1970).Google Scholar
See Joranson, , supra note 10.Google Scholar
New York State Public Health Law, art. 33, tit. 1, § 3302(1), p. 467.Google Scholar
Maryland Pharmacy Act, art. 27, § 277(n) (1985), p. 41.Google Scholar
See Joranson, , supra note 10.Google Scholar
Montana Board of Pharmacy, Statutes and Rules, 37-2-111(2) (1988), p. 26.Google Scholar
See Weissman, Haddox, , supra note 16.Google Scholar
Tennant, F., “The California Registration System for Habitues to Schedule II Drugs,” in Harris, L.S., ed., Problems of Drug Dependence: Proceedings of the 42nd Annual Scientific Meeting of the Committee on Problems of Drug Dependence (Washington, D.C.: U.S. Government Printing Office, 1981).Google Scholar
Macaluso, C. Weinberg, D. Foley, K.M., “Opioid Abuse and Misuse in a Cancer Pain Population,” Journal of Pain and Symptom Management, 3 (1988): S541; Hoffman, M. Provatas, A. Lyver, A. Kanner, R., “Pain Management in the Opioid-Ad-dicted Patient with Cancer,” Cancer, 68 (1991): 1121-22; Fishbain, D.A. Rosomoff, H.L. Rosomoff, R.S., “Drug Abuse, Dependence, and Addiction in Chronic Pain Patients,” Clinical Journal of Pain, 8 (1992): 77-85; and Gonzales, G.R. Coyle, N., “Treatment of Cancer Pain in a Former Opioid Abuser: Fears of the Patient and Staff and Their Influence on Care,” Journal of Pain and Symptom Management, 7 (1992): 246-49.CrossRefGoogle Scholar
The NIDA technical review, at which this paper was presented, provided a consensus that, while the medical use of controlled substances to treat pain in a substance abuser may be complex, nevertheless, it is a legitimate medical purpose.Google Scholar
Journal of Pain and Symptom Management, 8, no. 5 (1993): 253319.Google Scholar
National Conference of Commissioners on Uniform State Laws, Uniform Controlled Substances Act (Milwaukee: NCCUSL, 1990).Google Scholar
Joranson, D.E., “A New Drug Law for the States: An Opportunity to Affirm the Role of Opioids in Cancer Pain Relief,” Journal of Pain and Symptom Management, 5, no. 5, Supp. (1990): 333–36.CrossRefGoogle Scholar
Washington Controlled Substances Act, Pub. L. No. 69.50.308(g) (1993).Google Scholar
See Jacox, , supra note 3.Google Scholar
Correspondence from Rettig, Richard A., Ph.D., to Joranson, David E., dated November 17, 1993.Google Scholar
Correspondence from Dale Breaden to Joranson, David E., dated November 18, 1993.Google Scholar
Angarola, R.T. Joranson, D.E., “California Sponsors Pain Summit; Maryland Fends Off New Regulations,” APS Bulletin, 4, no. 3 (1994): 1112.Google Scholar
Medical Board of California, “Prescribing Controlled Substances for Pain: A Statement by the Medical Board of California,” May 6, 1994.Google Scholar
Medical Board of California, “Guideline for Prescribing Controlled Substances for Intractable Pain,” July 29, 1994.Google Scholar
California Board of Registered Nursing, “Pain Management Policy,” April 1994.Google Scholar