Responsible controlled substance and opioid prescribing.

Opioid use and misuse/abuse for acute and chronic pain are significant problems in the United States (US). The rate of opioid misuse, addiction, and overdose has been increasing over time in the US. In the US in 2017 alone, there were more than 47,000 deaths due to opioid overdose. Furthermore, over 2.1 million people suffer from opioid use disorder in the US.Over one-quarter of United States citizens suffer from chronic pain. It is among the most common complaints seen in outpatient clinics and the emergency department. The failure to manage acute and chronic pain appropriately and the possible complication of opioid dependence related to treatment can result in significant morbidity and mortality. One in five patient complaints in an outpatient clinic is related to pain, with over half of all patients seeing their primary care provider for one pain complaint or another. It is paramount that providers have a firm grasp on the management of patients with chronic pain. As a country, the United States spends well over 100 billion dollars a year on healthcare costs related to pain management and opioid dependence. Pain-related expenses exceed those for the costs of cancer, diabetes, and heart disease combined. How a patient's chronic pain gets managed can have profound and long-lasting effects on a patient's quality of life.The International Association for the Study of Pain defines chronic pain as any pain lasting longer than three months. There are multiple sources of chronic pain. Combination therapy for pain includes both pharmacological therapies and nonpharmacological treatment options. There is a more significant reduction in pain with combination therapy compared to a single treatment alone. Escalation of pharmacological therapy should be in a stepwise approach before opioids are considered for therapy. Comorbid depression and anxiety are widespread in patients with chronic pain and should be taken into consideration. Patients with chronic pain are also at increased risk for suicide. Chronic pain can impact every facet of a patient's life. Thus, learning to diagnose and appropriately manage patients experiencing chronic pain is critical.Unfortunately, studies have revealed an inherent lack of education regarding pain management in most medical schools and training programs. The Association of American Medical Colleges recognized the problem and has encouraged schools to commit to opioid-related education and training by incorporating the Centers for Disease Control and Prevention guidelines for prescribing opioids for chronic pain into the medical school curriculum.Appropriate opioid prescribing includes prescribing sufficient opioid medication through regular assessment, treatment planning, and monitoring to provide effective pain control while avoiding addiction, abuse, overdose, diversion, and misuse. To be successful, clinicians must understand appropriate opioid prescribing, assessment, the potential for abuse and addiction, and potential psychological problems. Inappropriate opioid prescribing may involve not prescribing, under-prescribing, overprescribing, or continuing to prescribe opioids when they are no longer effective. These concerns are particularly prominent in patients with chronic pain. To make the challenges even worse, chronic pain patients often develop opioid tolerance, significant psychological, behavioral, and emotional problems, including anxiety and depression related to under or overprescribing opioids.Clinicians who prescribe opioids face challenges involving medical negligence in either failure to provide adequate pain control or risk of licensure or even criminal charges if perceived they are involved in drug-related diversion or misuse. All providers that prescribe opioids need additional education and training to provide the best patient outcomes and avoid the social and legal entanglements associated with over-and under-prescribing opioids. Provider Opioid Knowledge Deficit There are substantial knowledge gaps around appropriate and inappropriate opioid prescribing, including deficits in understanding current research, legislation, and appropriate prescribing practices. In addition, providers often have knowledge deficits that include: Understanding addiction Populations at risk for opioid addiction Prescription vs. non-prescription opioid addiction The fallacious belief that addiction and dependence on opioids is synonymous The belief that opioid addiction is solely a psychological problem, while in reality, it is likely a complex psychological and physiological issue that may be related to a chronic, painful disease With a long history of misunderstanding, poor societal and provider education, and inconsistent laws, the prescription of opioids has resulted in significant societal challenges that will only resolve with significant education and training. Definitions Abuse - Use of an illegal substance and/or maladaptive pattern of substance use for a non-medical purpose other than pain relief (i.e., for the sake of altering one's state of consciousness) Addiction* - Pursuit of a chemical substance to find relief or reward associated with diminished control over drug use, compulsive use, craving, and/or continued use despite harm Dependence - Physiologic reliance on a drug resulting in a withdrawal syndrome with cessation or reduction in the amount of drug administered Diversion - Transfering a controlled substance from an authorized person's use to an unauthorized person's use for distribution or possession Misuse - Use of a medication in a manner different than how it was prescribed Psuedoaddiction - Pursuit of additional medication due to poor pain control, with the cessation of drug-seeking behavior upon achievement of appropriate pain control Tolerance - The lessened effect of a substance after being exposed to that substance or the need to escalate doses to achieve the same effect *The American Society of Addiction Medicine describes addiction as a treatable chronic disease that involves environmental pressures, genetics, an individual's life experiences, and interactions among brain circuits. Individuals who become addicted to opioids or other medications often engage in behaviors that become compulsive and result in dangerous consequences. The American Society of Addiction Medicines notes that while the following should not be used as diagnostic criteria due to variability among addicted individuals, they identify five characteristics of addiction: Craving for drug or positive reward Dysfunctional emotional response Failure to recognize significant problems affecting behavior and relationships Inability to consistently abstain Impairment in control of behavior Unfortunately, most health providers' understanding regarding addiction is often confusing, inaccurate, and inconsistent due to the broad range of perspectives of those dealing with patients suffering from addiction. While a knowledge gap is present among healthcare providers, it is equally prevalent in politicians writing laws and law enforcement attempting to enforce the laws they write. Additionally, payers are responsible for the expenses associated with the evaluation and treatment of addiction. Persistent lack of education and the use of obsolete terminology continue to contribute to a societal lack of understanding for effectively dealing with addiction challenges.In the past, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders defined "addiction," "substance abuse," and "substance dependence" separately. Over time, the manual has eliminated these terms and now uses "substance use disorder," ranging from mild to severe.