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Vital Signs

DMS faculty member heads national panel on opioid prescribing

The use of therapeutic opioids-natural opiates and synthetic versions-increased 347% between 1997 and 2006, according to this U.S. Drug Enforcement data.

By Jennifer Durgin

If you don't continue to prescribe to me, I will kill you." That's a threat that more than a few DHMC physicians have heard from patients addicted to prescription opioids, says Dr. Gilbert Fanciullo, director of DHMC's Pain Management Center. At least once a week, he adds, staff in the pain center need to use distress buttons - similar to those at banks - to call security when angry patients demand narcotics.

"Addiction is a terrible disease," Fanciullo admits. But so is chronic pain, which is often why people begin taking opioids-such as methadone, morphine, codeine, and oxycodone. To address the problem of addiction, Fanciullo has helped draft comprehensive guidelines, both nationally and at DHMC, for prescribing opioids. He cochaired a panel of experts from the American Pain Society and the American Academy of Pain Medicine that wrote new national guidelines published recently in the Journal of Pain.

Abusing: Doctors want to be "humane," says Fanciullo, and use opioids as appropriate to treat pain. But they also have to worry about "who is addicted to the drug, who is diverting the drug, who is abusing the drug, . . . and who is misusing the drug inadvertently."

About 27 million Americans suffer from severe chronic pain, according to the American Medical Association (AMA). Clinicians define chronic pain as pain that lasts beyond the usual course of natural healing-from surgery or injury, for example-and that is not associated with a terminal illness. Before the 1990s, opioids were rarely prescribed, even to terminal cancer patients, because of the fear of addiction.

Chronic: Since then, doctors have become more comfortable prescribing opioids for terminal patients, as well as for those with chronic pain, realizing that many patients can benefit from the drugs without becoming addicted.

"But misuse and related ill effects [have increased] as well," the AMA noted in a recent article. "The number of accidental overdose deaths from narcotics or hallucinogens among those 15-64 years old . . . increased 83%, from 5,921 in 1999 to 10,829 in 2005." (For insight into opioid-related deaths in New Hampshire, see "A painful conclusion" and its accompanying web extra.)

Estimates of the total number of Americans using opioids for chronic pain are not readily available. However, the FDA recently reported that in 2007, 21 million prescriptions for long-acting opioids were dispensed to about 3.7 million unique patients. Perhaps of more concern is the fact that 5.2 million people age 12 and older reported using prescription pain relievers for a nonmedical purpose in the past month, in a 2007 survey conducted by the Substance Abuse and Mental Health Services Administration.

Accidental narcotic overdose deaths rose 83% from 1999 to 2005.

Such national trends seem to be showing up locally, says Fanciullo. Many primary-care practices in New Hampshire and Vermont have stopped prescribing opioids entirely, he says. This likely means that more patients are seeking opioids from DHMC—either to treat pain or because they are addicted, or both.

The Pain Management Center is not the only service experiencing this trend. Obstetrics and gynecology has seen an increase in the number of pregnant women on opioids, and the number of opioid-dependent newborns is increasing. Between October 2007 and October 2008, 67 babies admitted to or born at DHMC were diagnosed as being substance-exposed-about 10 more than in the previous 12 months. And Dr. Bonny Whalen, medical director of DHMC's newborn nursery, expects that number to increase to almost 100 this year.

Policy: For providers who treat adults, the national and DHMC guidelines offer advice on how to prevent the abuse and diversion of opioids. DHMC's guidelines include some policy changes, too. Patients prescribed opioids by a Dartmouth provider must now sign a form that outlines the risks and responsibilities associated with taking such drugs and signifies that they agree to undergo periodic urine drug screens in order to confirm that they are taking their medication as directed. The form also tells patients that there are other ways to effectively treat pain, such as physical therapy, psychotherapy, injections, operations, and non-opioid medications.

"Opioids are the final option," says Fanciullo. Or at least they should be.

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