A perfect storm has developed involving prescription opioid medications. Throughout the past few decades, awareness of untreated and unrecognized pain has increased, along with subsequent educational efforts enlisting doctors to assess and treat pain more aggressively. The term opioid phobia was coined to describe doctors’ reluctance to prescribe opioid medications.

Efforts to treat pain more aggressively started in the 1990s and reached full stride around 2000, when even the U.S. Congress proclaimed the years 2000- 2010 the Decade of Pain Control and Research. Both the American Pain Society and the American Academy of Pain Medicine wrote formal position statements endorsing the prescribing and use of chronic opioid therapy (COT) for pain. As a result of these efforts, the prescribing of opioids increased substantially.

The increased availability of opioids appears to have led to unanticipated problems, including an explosion in nontherapeutic opioid use. In fact, a national epidemic in the non-therapeutic use of opioids has emerged in the United States. Deaths from the misuse of prescription opioids currently exceed deaths from heroin overdose. Deaths from prescription opioids account for 18.9% of all drug-related deaths in the United States, compared with 12.6% from heroin. Clark and colleagues reported a 3-fold increase in opioid abuse in recent years. Two-thirds of abused opioids originate from a valid prescription; one-fifth are obtained from more than one physician. Among patients receiving treatment for opioid dependency, 50- 60% obtained the drugs from their physicians.

Between 1992 and 2003, although the U.S. population grew only 14%, the number of people who admitted to prescription analgesic abuse increased 94%. About this same time (1992 to 2002), first-time abuses of prescription opioids among 12- to 17-year-olds in- creased 542%.

Pain is a subjective process, and clinicians must rely on subjective reports from patients to make treatment decisions. Addicted individuals, as part of their disease state, will not provide truthful self-reports if the report could result in their not receiving their drug of choice. Significant data have shown that self-reported drug use in the chronic pain population is often unreliable. Therefore, clinicians must analyze a combination of subjective input and objective observations to assess their patients. Objective observations include pill counts (admittedly difficult to do), prescription monitoring programs, and monitoring for aberrant behaviors. Aberrant behaviors may include early refill requests (self-escalation), reports of “lost or stolen” medications, treatment noncompliance, and UDT that does not include the prescribed drug and may include illicit or non-prescribed controlled substances. Monitoring of aberrant behavior alone is inadequate and frequently results in underestimated aberrant drug-taking behavior. A combination of monitoring for aberrant behavior and use of UDT has been recommended as the best available monitoring strategy.

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