PAIN MEDICINEVolume 6 • Number 2 • 2005

© American Academy of Pain Medicine 1526-2375/05/$15.00/107 107–112

Blackwell Science, LtdOxford, UKPMEPain Medicine1526-2375American Academy of Pain Medicine62107112CommentaryUniversal Precautions in Pain MedicineGourlay et al.

Reprint requests to: Douglas L. Gourlay, MD, MSc,FRCPC, FASAM, The Wasser Pain Management Center,Mount Sinai Hospital, Room 1160 600 University Avenue,Toronto ON M5G 1X5O. Tel: 416-535-8501; Fax: 416-595-6821; E-mail: dgourlay@cogeco.ca.

COMMENTARY

Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain

Douglas L. Gourlay, MD, MSc, FRCPC, FASAM,* Howard A. Heit, MD, FACP, FASAM,† and Abdulaziz Almahrezi, MD, CCFP‡

*The Wasser Pain Management Center, Mount Sinai Hospital, Toronto, Ontario, Canada; †Assistant Clinical Professor of Medicine, Georgetown University School of Medicine, Washington DC; ‡Clinical Fellow, Center for Addiction and Mental

A B S T R A C T

Health, Toronto, Ontario, Canada

Abstract The heightened interest in pain management is making the need for appropriate boundary settingwithin the clinician–patient relationship even more apparent. Unfortunately, it is impossible todetermine before hand, with any degree of certainty, who will become problematic users of pre-scription medications. With this in mind, a parallel is drawn between the chronic pain managementparadigm and our past experience with problems identifying the “at-risk” individuals from aninfectious disease model.

By recognizing the need to carefully assess all patients, in a biopsychosocial model, includingpast and present aberrant behaviors when they exist, and by applying careful and reasonably setlimits in the clinician–patient relationship, it is possible to triage chronic pain patients into threecategories according to risk.

This article describes a “universal precautions” approach to the assessment and ongoing man-agement of the chronic pain patient and offers a triage scheme for estimating risk that includesrecommendations for management and referral. By taking a thorough and respectful approach topatient assessment and management within chronic pain treatment, stigma can be reduced, patientcare improved, and overall risk contained.

Key Words. Pain; Addiction; Universal Precautions; Prescription; Abuse; Misuse; Urine DrugTesting

Introduction

he term “universal precautions” as it appliesto infectious disease came out of the realiza-

tion that it was impossible for a health care pro-fessional to reliably assess risk of infectivity duringan initial assessment of a patient [1,2]. Lifestyle,

Tpast history, and even aberrant behavior defined asnoncompliance with an agreed upon treatmentplan were unreliable indicators that led to patientstigmatization and increased health care profes-sional risk. It was only after research into the prev-alence of such diseases as hepatitis B, hepatitis C,and HIV that we realized that the safest and mostreasonable approach to take was to apply anappropriate minimum level of precaution to allpatients to reduce the risk of transmission ofpotentially life-threatening infectious disease tohealth care professionals. Fear was replaced by

108 Gourlay et al.

knowledge, and with knowledge came the practicewe know as universal precautions in infectiousdisease.

Because the fear of addiction is one of the bar-riers to opioid pain management, the result can beunder- or nontreatment of moderate to severepain [3]. Unfortunately, there are no signs pathog-nomonic of substance use disorders. Addiction isa “brain disease” [4] in which the diagnosis is mostoften made prospectively over time by monitoringthe patient’s behavior and the ability to stay withina mutually agreed upon treatment plan. In view ofthe fact there is no definite test or physical signthat will predict which patient will do well on atherapeutic trial of opioids for pain, it makes senseto take a universal precautions approach to all painpatients, especially those who are considered fora therapeutic trial of opioids, to improve theirquality of life. In order to assist health care pro-fessionals to meet the challenge of chronic painmanagement, we propose adopting a minimumlevel of care applicable to all patients presentingwith chronic pain.

Pain is a common complaint presenting to theclinicians office and is an enormous public healthproblem [5,6]. Approximately 50–70 million peo-ple in the United States are undertreated or nottreated for painful conditions [7]. Currently avail-able data suggest that 3–16% of the Americanpopulation have addictive disorders [8]. There-fore, based on these statistics, as many as 5–7 mil-lion patients with the disease of addiction also havepain. In fact, when studying pain in certain subsetsof the general population, the incidence may beconsiderably greater as has been found in theMethadone Maintenance Treatment population[9]. The goal of pain treatment is to decrease painand improve function while monitoring for anyadverse side effects [10]. If this goal is not achievedby non-opioid and adjunctive analgesics, opioidsmay be indicated.

However, drug addiction is a chronic relapsingdisorder that involves multiple factors. The mostcommon triggers for relapse are states of stress;drug availability; and re-exposure to environmen-tal cues (sight, sounds, smells) previously associ-ated with taking drugs [11]. Inadequate treatmentor no treatment of pain is a powerful stressor andconsequently may trigger relapse to addiction. Itstands to reason that if the patient is in recoveryand the pain is undertreated or not treated at all,they may turn to the street for licit or illicitdrugs, or may use legal drugs such as alcohol tonumb the pain.

Pain and Addiction Continuum

Emerging research is helping to place pain andaddictive disorders on a continuum rather than onthe traditional dichotomy of recent years [12–15].It is clear to a growing number of clinicians thatpain patients can, and sometimes do have concur-rent addictive disorders that decidedly complicatethe management of an already challenging patientpopulation [16–19]. It is possible for pain andaddiction to exist as comorbid conditions such asthe case of the alcoholic with peripheral neuro-pathic pain. However, the chronic pain patientwho suffers from the disease of opioid addictionmay be somewhat different. In this situation, theopioids used to treat the chronic pain may be iden-tified as either “the problem,” “the solution,” or amix of both depending upon the frame of refer-ence used (Addiction Medicine, Pain Manage-ment, or Pain and Chemical DependencySpecialties).

For example, with careful monitoring andtightly set limits, the patient recovering from thedisease of opioid addiction may, quite appropri-ately, be prescribed an opioid class of medicationfor the treatment of either acute or even chronicpain [20,21]. As long as this therapeutic regimenis “doing more for the patient than to the patient,”that is, improving rather than worsening theirquality of life, one can say that the balancebetween pain and addiction is positive. In this con-text, a continuum rather than a comorbid modelmay be more appropriate.

There is no evidence to suggest that the pres-ence of pain is protective against the expressionof an underlying addictive disorder. Similarly,there is no evidence that addiction prevents thedevelopment of chronic pain. Part of this confu-sion comes from the difficulty the clinician hasin screening patients for having, or being at riskof having addictive disorders. Several issues con-tribute to this problem. First, there is inadequateundergraduate training in addiction medicine orpain management [22–24]. Health care profes-sionals cannot diagnose illnesses of which theyhave little or no understanding. Second, there isoften a personal bias that makes it difficult forpractitioners to explore issues around theirpatient’s use of drugs including alcohol. Stereo-typing leads to suboptimal care both in thoseincorrectly identified as likely or unlikely tohave substance use disorders. By continuingto approach pain and addiction as a dichotomy,both the practitioner and the often complex

Universal Precautions in Pain Medicine 109

patient population that they serve will bedisadvantaged.

Substance Use Assessment in the Pain Patient

Beyond the expected inquiry into the presentingcomplaint of pain, every patient should be askedabout their present and past use of both licit andillicit drugs, including alcohol and over-the-counter preparations [25]. While there is no sim-ple relationship between past drug use problemsand aberrant behavior in chronic pain manage-ment, the possibility of such risk should be dis-cussed with the patient in advance of initiation oftherapy especially with medications that may leadto physical dependency and possible misuse. It isimportant to reassure patients that these questionsshould not be interpreted as an attempt to dimin-ish their complaints of pain. When it is clear tothe patient that answering these questions hon-estly will lead to an improvement in, rather thana denial of care, a respectful inquiry into past andpresent drug and alcohol use will not be met withobjection. To the contrary, persons with problem-atic use of drugs including alcohol may be awareof the extent of their problem and be looking fora solution. In this context, the application of auniversal precautions approach to all patientassessments allows for the formulation of individ-ualized treatment plans based on mutual trust andhonesty. By consistently applying this basic set ofprinciples, patient care is improved, stigma isreduced, and overall risk is contained.

Questions related to illicit drug use can poseproblems for patients if the perception is that dis-closing previous use will result in denial of care. Ahistory of illicit drug use is a potentially compli-cating factor in chronic pain management; it is nota contraindication [25]. However, active untreatedaddiction may be an absolute contraindication tothe ongoing prescription of controlled substancesincluding opioids. While acute pain can be treatedin a patient with an underlying active addictivedisorder, in the authors’ opinion, the successfultreatment of a complaint of chronic pain in theface of an active untreated addiction is unlikely. Inorder to satisfactorily treat either condition, thepatient must be willing to accept assessment andtreatment of both. Thus, the diagnosis of a con-current addictive disorder, where it exists, is vitalto the successful treatment of chronic pain.

An unwillingness to follow through with rec-ommended specialist referrals, preference forimmediate release opioids where alternatives exist,

or a “philosophical” opposition to urine drug test-ing should be considered as red flags requiringfurther investigation before initiation or continu-ation of prescription of medications with highmisuse liability. In the current medicolegal cli-mate, both the prescriber and patient must acceptthe reality that initiation or continuation of con-trolled substances in the face of illicit drug use iscontraindicated. Failure to inquire into, or docu-ment illicit drug use or problematic use of licitdrugs is not consistent with optimal pain manage-ment. Beyond this point, the question remainswhether to continue prescribing opioids in theface of social drinking.

Drinking no more than two standard drinks,defined as 12 ounces of beer, 5 ounces of wine, or1.5 ounces of 80 proof liquor [26] in 24 hours toa maximum of 14 drinks per week for men andnine drinks per week for women, has been termed“low-risk.” However, this recommendation canvary in the context of patients’ other coexistingmedical conditions such as with the use of pre-scription drugs including “pain killers” [26]. Thusit is left to the treating health care professional andpatient to determine the role that social drinkingmay play in the context of their individual chronicpain management regimen. Clearly, the safest levelof alcohol use, especially within the context ofconcurrent prescription drug use, is zero. Theissue of continued prescription of controlled sub-stances in the context of the use of prescribedbenzodiazepines obtained from another prescriberis also worth examining. In some cases, the con-current use of opioids and sedatives may be quiteappropriate while in other cases, this is clearlyproblematic. Risk can often be reduced by clearand documented communication with all pre-scribing health care professionals. Otherwise,the very real possibility exists for loss of controlof prescription monitoring by multiple prescri-bers, increasing the risk of adverse drug–druginteractions.

Universal Precautions in Pain Medicine

The following universal precautions are recom-mended as a guide to start a discussion within thepain management and addictions communities.They are not proposed as complete but rather asa good starting point for those treating chronicpain. As with universal precautions in infectiousdiseases [1], by applying the following recom-mendations, patient care is improved, stigma isreduced, and overall risk is contained.

110 Gourlay et al.

The Ten Steps of Universal Precautions in Pain Medicine

1. Make a Diagnosis with Appropriate DifferentialTreatable causes for pain should be identified,where they exist, and therapy directed to the paingenerator. In the absence of specific objective find-ings, the symptoms can, and should be treated.Any comorbid conditions, including substance usedisorders and other psychiatric illness, must alsobe addressed.

2. Psychological Assessment Including Risk of Addictive DisordersA complete inquiry into past personal and familyhistory of substance misuse is essential to ade-quately assess any patient. A sensitive and respect-ful assessment of risk should not be seen in anyway as diminishing a patient’s complaint of pain.Patient-centered urine drug testing (UDT) shouldbe discussed with all patients regardless of whatmedications they are currently taking. In thosepatients where an opioid trial is considered, wherethe response to therapy is inadequate, and period-ically while on chronic opioids, UDT can be aneffective tool to assist in therapeutic decision mak-ing [10,25]. Those found to be using illicit orunprescribed licit drugs should be offered furtherassessment for possible substance use disorders.Those refusing such assessment should be con-sidered unsuitable for pain management usingcontrolled substances.

3. Informed ConsentThe health care professional must discuss with,and answer any questions, the patient may haveabout the proposed treatment plan includinganticipated benefits and foreseeable risks. Thespecific issues of addiction, physical dependence,and tolerance should be explored at a level appro-priate to the patient’s level of understanding [2].4. Treatment AgreementWhether in writing or verbally agreed, expecta-tions and obligations of both the patient and thetreating practitioner need to be clearly under-stood. The treatment agreement, combined withinformed consent, forms the basis of the therapeu-tic trial. A carefully worded treatment agreementwill help to clarify appropriately set boundarylimits, making possible early identification andintervention around aberrant behavior [27,28].

5. Pre- and Post-Intervention Assessment of Pain Level and FunctionIt must be emphasized that any treatment planbegins with a trial of therapy. This is particularly

true when controlled substances are contemplatedor are used. Without a documented assessment ofpre-intervention pain scores and level of function,it will be difficult to assess success in any medica-tion trial. The ongoing assessment and docu-mentation of successfully met clinical goals willsupport the continuation of any mode of therapy.Failure to meet these goals will necessitate reeval-uation and possible change in the treatment plan.

6. Appropriate Trial of Opioid Therapy +/– Adjunctive MedicationAlthough opioids should not routinely be thoughtof as treatment of first choice, they must also notbe considered as agents of last resort. Pharmaco-logic regimens must be individualized based onsubjective, as well as objective, clinical findings.The appropriate combination of agents, includingopioids and adjunctive medications, may be seenas “Rational Pharmacotherapy” and provide astable therapeutic platform from which to basetreatment changes.

7. Reassessment of Pain Score and Level of FunctionRegular reassessment of the patient, combinedwith corroborative support from family or otherknowledgeable third parties, will help documentthe rationale to continue or modify the currenttherapeutic trial.

8. Regularly Assess the “Four A’s” of Pain MedicineRoutine assessment of analgesia, activity, adverseeffects, and aberrant behavior will help to directtherapy and support pharmacologic options taken[29]. It may also be useful to document a fifth “A”:affect [30].

9. Periodically Review Pain Diagnosis and Comorbid Conditions, Including Addictive DisordersUnderlying illnesses evolve. Diagnostic testschange with time. In the pain and addiction con-tinuum, it is not uncommon for a patient to movefrom a dominance of one disorder to the other. Asa result, treatment focus may need to change overthe course of time. If an addictive disorder pre-dominates, aggressive treatment of an underlyingpain problem will likely fail if not coordinated withtreatment for the concurrent addictive disorder.

10. DocumentationCareful and complete recording of the initial eval-uation and at each follow up is both medicolegallyindicated and in the best interest of all parties.Thorough documentation, combined with an

Universal Precautions in Pain Medicine 111

appropriate doctor–patient relationship, willreduce medicolegal exposure and risk of regula-tory sanction. Remember, if you do not documentit, it did not happen.

Patient Triage

One of the goals in the initial assessment of a painpatient is to obtain a reasonable assessment of riskof a concurrent substance use disorder or psycho-pathology. In this context, patients can be strati-fied into three basic groups. The following textwill offer the reader a practical framework to helpdetermine which patients they may safely managein the primary care setting, those which should becomanaged with specialist support, and those thatshould be referred on for management of theirchronic pain condition in a specialist setting.

Group I—Primary Care PatientsThis group has no past or current history of sub-stance use disorders. They have a noncontributoryfamily history with respect to substance use disor-ders and lack major or untreated psychopathology.This group clearly represents the majority ofpatients who will present to the primary carepractitioner.

Group II—Primary Care Patients with Specialist SupportIn this group, there may be a past history of atreated substance use disorder or a significant fam-ily history of problematic drug use. They may alsohave a past or concurrent psychiatric disorder.These patients, however, are not actively addictedbut do represent increased risk which may be man-aged in consultation with appropriate specialistsupport. This consultation may be formal andongoing (comanaged) or simply with the optionfor referral back for reassessment should the needarise.

Group III—Specialty Pain ManagementThis group of patients represents the mostcomplex cases to manage because of an activesubstance use disorder or major, untreated psycho-pathology. These patients are actively addictedand pose significant risk to both themselves and tothe practitioners, who often lack the resources orexperience to manage them.

It is important to remember that Groups II andIII can be dynamic; Group II can becomeGroup III with relapse to active addiction, whileGroup III patients can move to Group II with

appropriate treatment. In some cases, as moreinformation becomes available to the practitioner,the patient who was originally thought to be lowrisk (Group I) may become Group II or evenGroup III. It is important to continually reassessrisk over time.

Conclusion

By adopting a universal precautions approach tothe management of all chronic pain patients,regardless of pharmacologic status, stigma isreduced, patient care is improved, and overall riskis contained. Careful application of this approachwill greatly assist in the identification and inter-pretation of aberrant behavior and, where theyexist, the diagnosis of underlying addictive disor-ders. In those found to have, or be at risk of havingcomplicating addictive disorders, treatment planscan be adjusted on a patient-by-patient basis.Adopting a universal precautions approach to themanagement of chronic pain will be an importantstep in raising the standard of care in this oftencomplex patient population.

References

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3 Choiniere M, Melzack R, Girard N, Rondeau J,Paquin MJ. Comparisons between patients’ andnurses’ assessment of pain and medication efficacyin severe burn injuries. Pain 1990;40(2):143–52.

4 Leshner AI. Addiction is a brain disease, and itmatters. Science 1997;278(5335):45–7.

5 Glajchen M. Chronic pain: Treatment barriers andstrategies for clinical practice. J Am Board FamPract 2001;14(3):211–18.

6 Good PM, Joranson DE, Orloff Kaplan K, et al.Prescription Pain Medications: Frequently AskedQuestoins (FAQ) and Answers for Health Care Pro-fessionals and Law Enforcement Personnel: TheDrug Enforcement Administration (DEA), LastActs Partnership, and Pain & Policy Study Group;2004 August 2004. Available at: http://www.stoppain.org/faq.pdf. Accessed September 11, 2004.

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16 Black RG. The chronic pain syndrome. Surg ClinNorth Am 1975;55(4):999–1011.

17 Fishbain DA, Rosomoff HL, Rosomoff RS. Drugabuse, dependence, and addiction in chronic painpatients. Clin J Pain 1992;8(2):77–85.

18 Halpern L. Substitution-detoxification and its rolein the management of chronic benign pain. J ClinPsychiatry 1982;43(8 Part 2):10–14.

19 Savage SR. Assessment for addiction in pain-treatment settings. Clin J Pain 2002;18(4 suppl):S28–38.

20 Weaver M, Schnoll S. Abuse liability in opioid ther-apy for pain treatment in patients with an addictionhistory. Clin J Pain 2002;18(4 suppl):S61–9.

21 Heit HA. The truth about pain management: Thedifference between a pain patient and an addictedpatient. Eur J Pain 2001;5(suppl A):27–9.

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28 Heit H. Creating implementing opioid agreements.Dis Manage Digest 2003;7(1):2–3.

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National Center for Injury Prevention and Control Division of Unintentional Injury Prevention

PRESCRIPTIONPAINKILLEROVERDOSES

POLICYIMPACT{

WHAT’S THE ISSUE?In a period of nine months, a tiny Kentucky county of fewer than 12,000 people sees a 53-year-old mother, her 35-year-old son, and seven others die by overdosing on pain medications obtained from pain clinics in Florida.1 In Utah, a 13-year-old fatally overdoses on oxycodone pills taken from a friend’s grandmother.2 A 20-year-old Boston man dies from an overdose of methadone, only a year after his friend also died from a prescription drug overdose.3

These are not isolated events. Drug overdose death rates in the United States have more than tripled since 1990 and have never been higher. In 2008, more than 36,000 people died from drug overdoses, and most of these deaths were caused by prescription drugs.4

100One hundred people die from drug overdoses every day in the United States.4{ }______

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1990 2008200019981994 20041992 1996 2002 2006

Drug overdose death rates in the US have more than tripled since 1990.5

*Deaths are those for which poisoning by drugs (illicit, prescription, and over-the-counter) was the underlying cause.

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WHAT DO WE KNOW?The role of prescription painkillersAlthough many types of prescription drugs are abused, there is currently a growing, deadly epidemic of prescription painkiller abuse. Nearly three out of four prescription drug overdoses are caused by prescription painkillers—also called opioid pain relievers. The unprecedented rise in overdose deaths in the US parallels a 300% increase since 1999 in the sale of these strong painkillers.4 These drugs were involved in 14,800 overdose deaths in 2008, more than cocaine and heroin combined.4

The misuse and abuse of prescription painkillers was responsible for more than 475,000 emergency department visits in 2009, a number that nearly doubled in just five years.6

More than 12 million people reported using prescription painkillers nonmedically in 2010, that is, using them without a prescription or for the feeling they cause.7

The role of alcohol and other drugs About one-half of prescription painkiller deaths involve at least one other drug, including benzodiazepines, cocaine, and heroin. Alcohol is also involved in many overdose deaths.8

Commonly Abused MedicationsOpioidsDerived from the opium poppy (or synthetic versions of it) and used for pain relief. Examples include hydrocodone (Vicodin®), oxycodone (OxyContin®, Percocet®), fentanyl (Duragesic®, Fentora®), methadone, and codeine.

BenzodiazepinesCentral nervous system depressants used as sedatives, to induce sleep, prevent seizures, and relieve anxiety. Examples include alprazolam (Xanax®), diazepam (Valium®), and lorazepam (Ativan®).

Amphetamine-like drugsCentral nervous system stimulants used to treat attention deficit hyperactivity disorder (ADHD). Examples include dextroamphetamine/amphetamine (Adderall®, Adderall XR®), and methylphenidate (Ritalin®, Concerta®).

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For every 1death there are...

825 nonmedical users7

people who abuse or are dependent7

32 emergency dept visits for misuse or abuse6

10 treatment admissions for abuse9

In 2008, there were 14,800 prescription painkiller deaths.4

130

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How prescription painkiller deaths occurPrescription painkillers work by binding to receptors in the brain to decrease the perception of pain. These powerful drugs can create a feeling of euphoria, cause physical dependence, and, in some people, lead to addiction. Prescription painkillers also cause sedation and slow down a person’s breathing.

A person who is abusing prescription painkillers might take larger doses to achieve a euphoric effect and reduce withdrawal symptoms. These larger doses can cause breathing to slow down so much that breathing stops, resulting in a fatal overdose.

5,500In 2010, 2 million people reported using prescription painkillers nonmedically for the first time within the last year—nearly 5,500 a day.7____________________________

____________

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_______

Where the drugs come fromAlmost all prescription drugs involved in overdoses come from prescriptions originally; very few come from pharmacy theft. However, once they are prescribed and dispensed, prescription drugs are frequently diverted to people using them without prescriptions. More than three out of four people who misuse prescription painkillers use drugs prescribed to someone else.7

Most prescription painkillers are prescribed by primary care and internal medicine doctors and dentists, not specialists.10 Roughly 20% of prescribers prescribe 80% of all prescription painkillers.11, 12,13

Obtained free from friend or relative 55%

Prescribed by one doctor 17.3%

Bought from friend or relative 11.4%

Took from friend or relative without asking 4.8%

Got from drug dealer or stranger 4.4%

Other source 7.1%

People who abuse prescription painkillers get drugs from a variety of sources7

55

55%

Who is most at riskUnderstanding the groups at highest risk for overdose can help states target interventions. Research shows that some groups are particularly vulnerable to prescription painkiller overdose:

People who obtain multiple controlled substance prescriptions from multiple providers—a practice known as “doctor shopping.”14,15

People who take high daily dosages of prescription painkillers and those who misuse multiple abuse-prone prescription drugs.15,16,17,18,19

Low-income people and those living in rural areas.

- People on Medicaid are prescribed painkillers at twice the rate of non-Medicaid patients and are at six times the risk of prescription painkillers overdose.20,21 One Washington State study found that 45% of people who died from prescription painkiller overdoses were Medicaid enrollees.20

People with mental illness and those with a history of substance abuse.19

Where overdose deaths are the highestThe drug overdose epidemic is most severe in the Southwest and Appalachian region, and rates vary substantially between states. The highest drug overdose death rates in 2008 were found in New Mexico and West Virginia, which had rates nearly five times that of the state with the lowest rate, Nebraska.4

Drug overdose death rates by state, 20084

Age-adjusted rate per 100,000

NH 9.3VT 10.9MA 11.8RI 17.2CT 10.8NJ 8DE 14.5MD 11.9DC 9.4

5.5 - 9.4

9.5 - 12.3

12.4 - 14.8

14.9 - 27.0

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9.7

19.6

18.4

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18.1

15

17.9

15.1

15

25.8

16.5

14.7

11.7

14.4

14.610.4

7.3

5.5

8

8.6

7.2

10.5

7.1

13.1

13.1

10.5

12.2

13.2

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12.6

12.9

9.1

8.4

12.3

13.1

9.4Florida is in the highest range

WHAT CAN WE DO?

There are many different points of intervention to prevent prescription drug overdoses. States play a central role in protecting the public health and regulating health care and the practice of the health professions. As such, states are especially critical to reversing the prescription drug overdose epidemic.

The following state policies show promise in reducing prescription drug abuse while ensuring patients have access to safe, effective pain treatment.

CDC RECOMMENDATIONS

Prescription Drug Monitoring Programs Prescription Drug Monitoring Programs (PDMPs) are state-run electronic databases used to track the prescribing and dispensing of controlled prescription drugs to patients. They are designed to monitor this information for suspected abuse or diversion—that is, the channeling of the drug into an illegal use—and can give a prescriber or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help prescribers and pharmacists identify high-risk patients who would benefit from early interventions.

CDC recommends that PDMPs focus their resources onpatients at highest risk in terms of prescriptionpainkiller dosage, numbers of controlled substance prescriptions, and numbers of prescribers; and prescribers who clearly deviate from acceptedmedical practice in terms of prescription painkiller dosage, numbers of prescriptions for controlled substances, and proportion of doctor shoppers among their patients.

CDC also recommends that PDMPs link to electronic health records systems so that PDMP information is better integrated into health care providers’ day-to-day practices.

36{ }Thirty-six states have operational PDMPs.22

State Rx Monitoring

Program only tells us if the

EXPERIMENTAL

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NOT if the patient is compliant

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Rx is filled

Patient review and restriction programs State benefits programs (like Medicaid) and workers’ compensation programs should consider monitoring prescription claims information and PDMP data (where applicable) for signs of inappropriate use of controlled prescription drugs. For patients whose use of multiple providers cannot be justified on medical grounds, such programs should consider reimbursing claims for controlled prescription drugs from a single designated physician and a single designated pharmacy. This can improve the coordination of care and use of medical services, as well as ensure appropriate access, for patients who are at high risk for overdose.

Health care provider accountabilityStates should ensure that providers follow evidence-based guidelines for the safe and effective use of prescription painkillers. Swift regulatory action taken against health care providers acting outside the limits of accepted medical practice can decrease provider behaviors that contribute to prescription painkiller abuse, diversion, and overdose.

Laws to prevent prescription drug abuse and diversion States can enact and enforce laws to prevent doctor shopping, the operation of rogue pain clinics or “pill mills,” and other laws to reduce prescription painkiller diversion and abuse while safeguarding legitimate access to pain management services. These laws should also be rigorously evaluated for their effectiveness.

Better access to substance abuse treatment Effective, accessible substance abuse treatment programs could reduce overdose among people struggling with dependence and addiction. States should increase access to these important programs.

These recommendations are based on promising

interventions and expert opinion. Additional research is

needed to understand the impact of these interventions

on reducing prescription drug overdose deaths.

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For more information on Prescription Drug Overdose, contact the Centers for Disease Control and Prevention:

For references, visit: www.cdc.gov/homeandrecreationalsafety/rxbrief

The amount of prescription painkillers sold in states varies4

Policy Impact is a series of issue briefs from CDC’s Injury Center highlighting key public health issues and important, science-based policy actions that can be taken to address them.

November 2011

The quantity of prescription painkillers sold to pharmacies, hospitals, and doctors’ offices was 4 times larger in 2010 than in 1999. Enough prescription painkillers were prescribed in 2010 to medicate every American adult around-the-clock for one month.

Kilograms of prescription painkillers sold, rates per 10,000 people

3.7 - 5.9 6.0 - 7.2 7.3 - 8.4 8.5 - 12.6