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In 1995, a shocking new book was published titled Prescription Drug Abuse: The Hidden Epidemic, one of the first examinations of the phenomenon of prescription drug abuse and addiction in the United States.1 Now, more than 20 years later, this book sells for $0.01 on Amazon, and prescription drug abuse is far from hidden. Chronic pain is one of the most common reasons for patients to access medical care (up to one-third of US adults suffer from pain, and about 10 % of them suffer from chronic pain), and not infrequently, physician visits end with a prescription for an opioid or other drug with the potential for misuse. For some of these patients, this is the first step down the road of dependency and abuse, and for all too many, it may lead to their death.
Almost two million Americans age 12 or older either abused or were dependent on opioid pain relievers in 2013,2 and more people in the US now die from opioid overdose than from motor vehicle accidents.3 Stories of the epidemic (and the concomitant recent rise in use of heroin, often the drug of last resort for those who are addicted but unable to purchase prescription drugs) are regular features on the nightly news. The stigma associated with this problem also seems to have begun to lift; Ted Cruz, one of the Republican candidates for president, recently spoke emotionally of his half-sister’s battle with addiction in a state (New Hampshire) considered ground zero in the prescription drug and heroin epidemic. This kind of public discussion, particularly from one of the most conservative politicians in the US, would have been unthinkable just a few years ago.
General internists are on the front lines of this epidemic and the management of chronic pain, and over the past few years, JGIM has published some of the leading research in this area. For example, a critical role for outpatient general internists is screening for unhealthy drug and alcohol use, but screening is often difficult to implement in a busy clinic. Brief single-item screening questions (SISQs) for alcohol and other substance use can facilitate screening in health care settings, but are not widely used. In an earlier issue of JGIM, McNeely et al.4 reported on a single-item screening question for unhealthy alcohol and drug use in primary care patients. The drug SISQ asked, “How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons (for example, because of the experience or feeling it caused)?” While they found that the SSIQ was less accurate than longer interviewer-administered instruments, it was much easier to implement and more likely to retain its fidelity in a busy practice setting.
In this issue of JGIM, two new studies examine different aspects of the knotty problem of chronic pain and opioid misuse. Calcaterra et al. investigate opioid prescribing at hospital discharge among opioid-naïve patients.5 This retrospective cohort study of more then 6,000 opioid-naïve medical and surgical patients discharged from a safety net hospital found that opioid receipt at hospital discharge among these patients was associated with future chronic opioid use. Unwittingly perhaps, physicians may contribute to the problem of opioid dependence while searching for solutions.
Also in this issue, Alford et al.6 report on a study of adult patients who screened positive for illicit drug use or prescription drug misuse. Of the 589 participants, 87 % reported chronic pain, with about three-quarters reporting pain-related dysfunction; nearly one-third reported severe pain and severe pain-related dysfunction. Many of these patients reported using alcohol and misusing prescription drugs for self-medication of pain. The authors conclude that primary care doctors must remember to address pain complaints when counseling patients about their substance use.
While prescription opioid sales in the United States have increased by 300 % since 1999, self-reporting of pain among Americans has not changed significantly.7 The undeniable reality is that we aren’t just witnesses to the problem; we are contributors. But we can also be part of the solution—by contributing to research, clinical care, education and policy that seeks to navigate the narrow shoals between two epidemics.
The author declares that he does not have a conflict of interest.