Chronic Noncancer Pain Management and Opioid Overdose: Time to Change Prescribing Practices
Authors: A. Thomas McLellan
Journal: Annals of Internal Medicine (2010)

Editorials19 January 2010Chronic Noncancer Pain Management and Opioid Overdose: Time to Change Prescribing PracticesFREEA. Thomas McLellan, PhD and Barbara J. Turner, MSEd, MD, Executive Deputy EditorA. Thomas McLellan, PhDFrom the White House Office of National Drug Control Policy; Washington, DC 20503; and Executive Deputy Editor and Barbara J. Turner, MSEd, MD, Executive Deputy EditorFrom the White House Office of National Drug Control Policy; Washington, DC 20503; and Executive Deputy EditorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-152-2-201001190-00012 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail At this writing, opioids are the most commonly prescribed class of medication in the United States (1). Prescription of some opioids, such as methadone, has increased more than 800% in the past 10 years (2). This increase in opioid prescribing has caused an increase in overdoses and deaths. Opioid overdose is among the most common causes of accidental death nationwide (3). The increase in deaths due to prescription opioids is a major public health priority and not just a concern for individual physicians and their patients.It is easy to blame the growing epidemic of opioid overdose and death on manipulative patients who misrepresent pain symptoms to obtain drugs to abuse or sell. A recent report (4) on overdose deaths in West Virginia found that 51% occurred in persons who had never actually been prescribed an opioid (that is, prescription diversion) and that another 20% occurred in persons who had received prescriptions from 5 or more physicians (that is, "doctor shopping"). In an accompanying editorial (5), we acknowledged the role of the patient in adverse events from opioids but also suggested opportunities for physicians to stem the rise in prescription opioid deaths.In this issue, Dunn and colleagues (6) identify a potential role for physicians in reducing prescription opioid overdose and death. The authors examined stably insured patients with a range of noncancer pain diagnoses in the Group Health Cooperative network in Washington. Doctor shopping with multiple opioid prescriptions was probably minimal in this setting, which had a systemwide electronic health record. Patients most likely to seek drugs from multiple physicians probably left the system, as did one third of the study sample during the 4-year follow-up. Yet, even in this closed system, the rates of documented serious overdose incidents and deaths were substantial (117 and 17 per 100 000 person-years, respectively). True rates were probably even higher because of inevitable gaps in the reporting of these events.A disturbing observation from Dunn and colleagues' study was that many overdose incidents might have been averted by changes in prescriber practices. First, the raw data (unadjusted) revealed more overdoses in patients who were diagnosed with depression or substance abuse or who were concurrently prescribed sedative-hypnotics (for example, benzodiazepines). It is unknown whether these patients were first treated, as they should have been, with alternative nonopioid pharmacologic and nonpharmacologic approaches (for example, physical therapy) to manage chronic pain. Regardless, depression, substance use, and benzodiazepine use are all well-known risks for adverse events from opioids (7); therefore, these persons require substantial education and close oversight if opioids are prescribed.The authors did not evaluate other risk factors for opioid misuse, including history of illicit drug use (because it is infrequently entered as a diagnosis). When alcohol use is recorded, it is located in the social history, where it rarely affects prescribing (8). Substance abuse screening and brief intervention protocols have been shown to reduce substance use–related problems (9) but have not been widely incorporated into physician practice (10). Physicians may fear finding an addiction, which many are unprepared to treat (11). But brief screening discussions about substance use—not just addiction—are needed to reduce opioid overdose as well as other drug–alcohol or drug–drug interactions.A unique contribution of this study is the examination of the relationship between overdose events and the timing and morphine-equivalent dose of the prescribed drug. As expected, the authors found that risk for an adverse event was greatest shortly after the initial opioid prescription or after a refill. These data reinforce the importance of closely monitoring patients who are prescribed opioids. The authors also report a dose–response relationship between higher morphine-equivalent doses and risk for opioid-related overdose. Although the highest dose of opioids (≤100-mg morphine equivalents) was received during only 2% of the follow-up, the associated annual overdose rate was very high during that period: 1791 per 100 000 person-years. Low doses rarely resulted in adverse events. Prescribing opioids at high doses is both dangerous and questionable for indications other than methadone treatment of opioid dependence.Opioid therapy can be monitored by making an opioid agreement with the patient when therapy is initiated. The agreement is updated whenever therapy is modified. Typically, these agreements not only set out the responsibilities of both patient and provider when these drugs are used but also make clear the potential dangers of using these drugs other than as prescribed. Dunn and colleagues' findings reinforce the importance of goal-directed opioid therapy, in which continued or increased doses of opioid therapy should be contingent on clear improvements in function and quality of life (for example, resuming more normal activities) (7). Long-term opioid therapy carries too many risks to justify use without improvements in health status.Of note, the patients in Dunn and colleagues' study received prescriptions primarily for short-acting opioids, namely hydrocodone and oxycodone. Although not specified, these drugs were probably in formulations with acetaminophen. Not only are short-acting opioids associated with greater risk for tolerance and dependence (12), a recent panel of the U.S. Food and Drug Administration (13) recommended that these combination drugs be removed because of acetaminophen-related hepatotoxicity. Acetaminophen poisoning was not examined in this study but represents yet another risk that patients and physicians should seek to reduce.Finally, Dunn and colleagues' findings strengthen the argument for an easy-to-use, real-time, prescription-drug monitoring program in which physicians can track all opioid prescriptions for a patient. Two promising systems, one designed by the Department of Health and Human Services and one by the Department of Justice, are in testing now. However, neither is fully satisfactory. To be successful, the program needs to be readily accessible for all health care clinical information systems, including pharmacies. The White House Office of National Drug Control Policy and other federal agencies are actively collaborating on development of this key resource to help physicians reduce patient abuse of prescriptions (for example, doctor shopping) and adverse drug interactions.It is easy to suggest time-consuming, unreimbursed approaches to improve the safety of opioid prescribing without specifying how they can be incorporated into already overburdened clinical settings. Frankly, we do not know how to increase clinical diligence without additional work, time, or money, although technology can facilitate some of these suggested practice changes. The threat to patient safety is too great to allow current pain management and opioid-prescribing practices to remain as they are. Dunn and colleagues' data show the need to assess the risk for opioid misuse, provide close oversight, dose judiciously, and continually reevaluate the benefit of these potentially risky drugs. Smarter, more responsible practices are the only hope to avoid tragic, avoidable deaths.A. Thomas McLellan, PhDWhite House Office of National Drug Control PolicyWashington, DC 20503Barbara J. Turner, MSEd, MDExecutive Deputy EditorReferences1. Kuehn BM. Opioid prescriptions soar: increase in legitimate use as well as abuse. JAMA. 2007;297:249-51. [PMID: 17227967] MedlineGoogle Scholar2. U.S. Department of Justice Drug Enforcement Administration. ARCOS: Automation of Reports and Consolidated Orders System. Accessed at www.deadiversion.usdoj.gov/arcos/index.html on 7 December 2009. Google Scholar3. Centers for Disease Control and Prevention (CDC). Unintentional poisoning deaths—United States, 1999-2004. MMWR Morb Mortal Wkly Rep. 2007;56:93-6. [PMID: 17287712] MedlineGoogle Scholar4. Hall AJ, Logan JE, Toblin RL, Kaplan JA, Kraner JC, Bixler D, et al. Patterns of abuse among unintentional pharmaceutical overdose fatalities. JAMA. 2008;300:2613-20. [PMID: 19066381] CrossrefMedlineGoogle Scholar5. McLellan AT, Turner B. Prescription opioids, overdose deaths, and physician responsibility [Editorial]. JAMA. 2008;300:2672-3. [PMID: 19066389] CrossrefMedlineGoogle Scholar6. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, et al. Opioid prescriptions for chronic pain and overdose. A cohort study. Ann Intern Med. 2010;152:85-92. LinkGoogle Scholar7. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6:107-12. [PMID: 15773874] CrossrefMedlineGoogle Scholar8. Turner BJ, McLellan AT. Methodological challenges and limitations of research on alcohol consumption and effect on common clinical conditions: evidence from six systematic reviews. J Gen Intern Med. 2009;24:1156-60. [PMID: 19672662] CrossrefMedlineGoogle Scholar9. Madras BK, Compton WM, Avula D, Stegbauer T, Stein JB, Clark HW. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend. 2009;99:280-95. [PMID: 18929451] CrossrefMedlineGoogle Scholar10. Compton WM, Volkow ND. Major increases in opioid analgesic abuse in the United States: concerns and strategies. Drug Alcohol Depend. 2006;81:103-7. [PMID: 16023304] CrossrefMedlineGoogle Scholar11. Miller NS, Sheppard LM, Colenda CC, Magen J. Why physicians are unprepared to treat patients who have alcohol- and drug-related disorders. Acad Med. 2001;76:410-8. [PMID: 11346513] CrossrefMedlineGoogle Scholar12. Zacny J, Bigelow G, Compton P, Foley K, Iguchi M, Sannerud C. College on Problems of Drug Dependence task force on prescription opioid non-medical use and abuse: position statement. Drug Alcohol Depend. 2003;69:215-32. [PMID: 12633908] CrossrefMedlineGoogle Scholar13. Kuehn BM. FDA focuses on drugs and liver damage: labeling and other changes for acetaminophen. JAMA. 2009;302:369-71. [PMID: 19622807] CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Howard G KornfeldPain Medicine Fellowship Program, University of California, San Francisco1 March 2010 RE: CHRONIC NONCANCER PAIN MANAGEMENT AND OPIOID OVERDOSE:TIME TO CHANGE PRESCRIBING PRACTICES Drs. McLellan and Turner were thoughtful to reply to my letter and to that of Dr. Gelfand. I had taken issue with the statement, made in their editorial that, "Prescribing opioids at high doses is both dangerous and questionable for indications other than methadone treatment of opioid dependence." Dr. Gelfand had expressed a number of concerns about the use of opioids, including their use in patients with mental health disorders. Drs. McLellan and Turner characterized my remarks as supporting the use of high dose opioids. I want to clarify that what I support, in both my role as an addiction medicine physician and an ABMS certified pain medicine specialist, is the inclusion of a range of doses of opioid medication as being appropriate over a wide spectrum, given the vast clinical variation present in chronic pain patients. Higher doses, prescribed long term, should generally be prescribed to a minority of the patients with chronic non-cancer pain. Drs. McLellan and Turner suggest that I did not distinguish between cancer and non-cancer pain. Although they are correct, and indeed their editorial was aimed at non-cancer pain, it is also true that the broad statement in their editorial that I took issue with likewise did not distinguish between the two. Furthermore, concerns and issues around appropriate opioid treatment in cancer pain can often significantly overlap, if not become indistinguishable from, concerns and issues with respect to opioid management of chronic non-cancer pain. A strategy for the management of pain that is infrequently discussed in the American pain literature and one that may confer excellent efficacy, as well as much greater safety than full opioid agonists, is the use of buprenorphine, a partial mu opioid agonist, in the management of chronic pain. Although buprenorphine is best known in the United States in recent years as a treatment for opioid addiction, it has a thirty-year history of use as an analgesic around the world. In the U.S. it has been available as a parenteral analgesic since 1981, and in Europe it has been available as a sublingual tablet over this same time period. For the past ten years, transdermal buprenorphine has enjoyed a growing application in Europe for chronic cancer and non-cancer pain and has been the subject of commensurate attention in published studies and reports (1-6). It appears to have significant utility in those chronic non-cancer pain syndromes that have raised the most concern including neuropathic pain, hyperalgesia, and those associated with aberrant or addictive behaviors. And to the issue studied by Dunn, et al, buprenorphine is much less prone to be associated with overdose death due to its much more limited depression of the central respiratory drive. Understandings of the "ceiling effect" of buprenorphine are evolving towards greater appreciation of its efficacy in chronic human pain, approaching the effectiveness of full agonist opioids. Perhaps this controversy over the statement made in the editorial by McLellan and Turner can stimulate us to explore the unrealized potential for buprenorphine and, in particular, motivate greater study and interest of this medication for pain in the United States. References 1. Kress H. Clinical update on the pharmacology, efficacy and safety of transdermal buprenorphine. Eur J Pain. 2009 Mar;13(3):219-30. 2. Sittl R. Transdermal buprenorphine in cancer pain and palliative care. Palliative Med. 2006;20:s25-s30. 3. Vadivelu N, Hines RL. Management of chronic pain in the elderly: focus on transdermal buprenorphine. Clin Inter Aging. 2008;3(3):421-430. 4. Malinoff HL, Barkin RL, Wilson G. Sublingual buprenorphine is effective in the treatment of chronic pain syndrome. Am J Ther. 2005;Sep- Oct;12(5):379-84. 5. Johnson RE, Fudala PJ, Payne R. Buprenorphine: Considerations for pain management. J Pain Symp Management. 2005;29(3):297-326. 6. Vadivelu N, Hines RL. Buprenorphine: A unique opioid with broad clinical applications. J Opioid Management. 2007;3(1):49-58. Conflict of Interest: None declared Stephen G. Gelfand, MD, FACPAppalachian Regional Rheumatology, Boone, NC18 February 2010 RE: CHRONIC NONCANCER PAIN MANAGEMENT AND OPIOID OVERDOSE:TIME TO CHANGE PRESCRIBING PRACTICES In addition to the overdose and mortality risks from prescription opioids discussed in the Editorial of January 18th edition of the Annals [1], three additional opioid-related issues require attention. These include: the real possibility that many people who have overdosed or died from illegally diverted prescription opioids [or heroin]initially became addicted through the use of a legitimate prescription, the prominent role of psychological disorders which have significantly contributed to the overprescription of opioid analgesics, and the likelihood that extended- release and long-acting opioids carry greater risks for addiction, overdose and death than shorter-acting agents. It appears that there is a significant volume of people who overdosed or died from diverted prescription opioids or heroin [obtained either from the street or from friends or relatives] who may have initially been prescribed an opioid for some type of pain which lead to addiction, and then to the above drug-seeking behaviors associated with this disease. Likewise, many of the addicts who now obtain most of their opioids through illegal 'doctor shopping' may have developed their addiction through an initial or continued legal prescription for pain. These common situations underscore the importance of prudent, selective prescribing of opioids for specific clinical indications for chronic noncancer pain [if at all], with close attention to the risk/benefit ratio and to recently established guidelines, as well as to careful monitoring and knowing when to discontinue or taper patients off these potent brain-active drugs. As stated in the Editorial, opioid overdose and death was associated with depression, benzodiazepine use and history of substance abuse. This suggests that there is a significant volume of opioid prescriptions written for chronic noncancer pain in which psychological disorders are present but often missed, such as a spectrum of anxiety syndromes and depressive disorders. Since psychological co-morbidities are common in chronic noncancer pain disorders, particularly in the setting of fibromyalgia [2,3], treatment with nonopioid agents and nonpharmacological approaches are indicated, which may also include referral for psychological/behavioral therapies [4]. My own observations from clincial practice and as a national disability peer-reviewer in rheumatology, is that there is a large population of patients with undiagnosed or underdiagnosed psychological disorders which have been inadequately addressed by focusing mainly on chronic pain symptoms misattributed solely to a somatic structure such as degenerative discs, 'arthritis' or muscle tissue such as in fibromyalgia. These somatic 'labels' then become the indication to prescribe opioids for presumed tissue pain, while the psychological disorders underlying the pain often go unrecognized. This then predisposes to the persistence of symptoms, drug dependence, continued dysfunction, and also increases the quest for long-term disability. These factors have become a major contributor to the rising tide of healthcare costs currently affecting our nation, and unless recognized, will continue to fuel the prescription opioid epidemic and all its adverse consequences, including addiction, overdose, and death. Finally, as noted in the Editorial, the Dunn study[5] focused on short-acting opioids used by over 90% of the cohort, but if extended- release and long-acting opioids like Oxycontin and methadone had been the predominent drugs studied, the outcomes would most likely have been worse, especially since oxycodone and methadone have resulted in the highest reported mortality figures[6]. It is hoped that the Annals articles will stimulate further studies and discussions about the problems of prescription opioids which continue to take a large toll on the public health and social systems of our nation. References: [1]McLellan AT, Turner BJ. Chronic noncancer pain management and opioid overdose: Time to change prescribing practices. Ann Intern Med. 2010; 152:123-124. [2]Winfield JB. Psychological determinants of fibromyalgia and related syndromes. Curr Rev Pain. 2000; 4:276-286. [3]Arnold LM et al. Comorbidity of fibromyalgia and psychiatric disorders. J Clin Psychiatry. 2006; 67:1219-1225. [4]Thieme K et al. Responder criteria for operant and cognitive-behavioral treatment of fibromyalgia syndrome. Arthitis Rheum. 2007; 57:830-836. [5]Dunn KM et al. Opioid prescriptions for chronic pain and overdose. A cohort study. Ann Intern Med. 2010; 152:85-92. [6] Florida Department of Law Enforcement. 2009 interim report of drugs identified in deceased persons by Florida Medical Examiners. Nov. 2009. [www.fdle.state.fl.us/publications/Examiners/2009DrugReport.pdf]. Conflict of Interest: None declared Michael, Whitworth, Pain Medicine PhysicianAPM2 April 2012 Re:Re:What about those who benefit from this therapeutic option? The draconian pronouncement of high dose opioids as universally unsafe unfortunately demonstrates the author's inability to stratify risks, and tacitly assumes physicians and patients lack the intelligence to assume certain risks during treatment. Certain surgical procedures are high risk, yet are routinely performed because the patients are given the informed consent that weigh the risk. The risk: benefit ratio of such surgeries are often undetermined yet the surgeries may provide a reduction in suffering that would not otherwise be available. Opioids, even high dose opioids, may provide similar therapies, and absurd pronouncements such as this is an affront to those physicians and patients who appropriately manage such risk. The article was designed to denigrate and destroy via a biased interpretation of data with unidentified prescribing models being employed by the physicians in the study. If controls on follow-up frequency, use of concurrently known sedative drugs (74% of your population was using concurrent sedative-hypnotics), and employment of monitoring modalities (UDS, pill counts, PMP queries) were used, I submit the overdose proclivity would drop dramatically. Most conscientious pain physicians know this. However even if there were not employment of such strategies, the idea that patients, when informed consent is obtained outlining such risks, should be precluded from the use of high dose opioids because of a governmental or journal sanctioned inflammatory proclamation is not only overreaching into the doctor-patient decision- making but is actually bad medicine. It is not lost on the readers that such proclamations will have long term effects on policies around the country that in effect will deny patients the right to determine if the risk is appropriate for them.Conflict of Interest:None declared Tom J, Cuddy, musiciancaregiver19 January 2012 Re:A "High Dose" Intractable Pain Patient Responds I find it revealing that virtually none of the many articles about the "prescription drug crisis" give more than lip service to patients who benefit from opioid therapy. They interview doctors, government officials, addicts in recovery anyone except for patients who suffer, and suffer barely touches it, from intractable pain. One pain scale I saw rated severe neuralgia type pain ( such as RSD) as the equivalent of limb amputation without anesthesia. Even if a patient has been successfully restored to mobility and has no problems with keeping an opioid contract they will be pressured to change modality, even to risky and extreme treatments such is intra-spinal ketamine. The actions of the DEA and State medical boards make it now impossible for patients who need opioids to get them. Pain of this intensity kills. I guess their lives are worth less than the lives of someone who overdoses. Tom CuddyConflict of Interest:I am the caregiver for an intractable pain patient diagnosed RSD failed back surgery syndrome. Darren McKinleynone26 September 2011 opinions generally do not constitute historical value There are glaring defects that undermine the value of "Chronic Noncancer Pain Management and Opioid Overdose: Time to Change Prescribing Practices". Doesn't the ONDCP have more important issues to deal with, like the war on illegal drugs. It is already really, really hard to find a doctor that will prescribe narcotics long term. That in and of itself is proof the DEA and other agencies have scared doctors into under- prescribing or not prescribing. In the end, the article was published as an editorial (opinion) by a person that is against drugs and is for drug rehabilitation. Conflict of Interest: chronic pain and pain medicine Betts TullyChronic pain patient16 March 2010 From one Pain Patient to another: Survival vs. "Rights" Response to pain patient Heather Grace First, I would like to congratulate Dr.'s Mclellan and Turner, as well as all the other Dr.'s, who have supported their position on this long overdue attention to the responsibility/role physicians must take in prescribing opioids for chronic non-cancer pain. I am a former medically prescribed "pain patient", treated for 8 years with high dose opioids. I say former because I took myself off of all narcotic pain relievers in 2008, much to the dismay of my "pain management" doctor. I am currently on a non-narcotic regimen to treat my pain. My etiology is 2 back surgery's, and degenerative disc disease. In 2001,within a 10 month period, I was put on OxyContin, starting with 20mg and escalating to 280mg daily, with 8 Norco breakthrough. No other medical regimen was employed. When it became evident that I was horribly addicted to this drug, my doctor abandoned me. My life was forever altered by that event. I have never taken an opioid/narcotic drug outside the medical setting. Nor have I ever "doctor shopped". As I read Ms. Grace's comment/position on her impassioned defense of taking opioids for pain, I was immediately struck with compassion for the delusions she seems to suffer from, in relation to her own medical care. It reminded me of myself 7 years ago, when I desperately tried to get medical information on the situation I found myself in. I had gone from a productive person dealing with back pain, to a zombie, for lack of a better description, constantly in need of pain medications, just to get through the day. Like her, I constantly worried more about "not getting my drugs". I sympathized with all those patients, like me, who were just trying to get some "pain relief". I was told not to worry about addiction, since I had "real" pain. I used the word "medication", not opiate or narcotic. I assumed my doctors knew what they were doing, and would not do anything to harm me. But in the long run, I had to admit that I was addicted to narcotics, regardless of whether I had pain or not, or under a physicians care. Not dependant, addicted. Physically, and emotionally addicted. A condition that, eventually, far outwieghed any benefits of relieving my back pain. It took me years to understand what had really happened to me. And accept responsibility for my own survival. I could have been one of the thousands of medically prescribed pain patients, who have either died, or are still struggling with the added burden of an unwanted addiction. But I am here to tell you that, in my estimation, the medical profession, as well as regulatory agencies, who should have kept me safe, as well as medically informed, let me down. They allowed self-serving pharmaceutical companies to influence and manipulate standard medical practice. They over-prescribed, and under-treated my chronic pain. Through self education, I have realized the many different ways in which my pain can be treated, outside of opioid therapy The sheer statistics regarding medically prescibed opiates in relation to overdose and addiction are self-evident. They can no longer be ignored. The once tauted "less than 1% of chronic pain patients become addicted" is, today, a medical mirage. The studies that should have been done prior to the radical change in opioid prescribing practices in the late 90's, are now emerging, and as does this editorial, they all call for "caution", not "agression" when dealing with chronic pain and opioids. For many, this common advice, is too late. I thank all the doctors, who will speak out about this crisis, and who will work to re-engineer the education of physicians, as well as patients, on the risks and benefits of long term opiate therapy for non- cancer patients. At the very least, doctors who wish to operate in this field should be trained/educated, based on sound medical principal, not on junk science coming out of pharmaceutical companies. Perhaps then you will not hear patients or pain foundations talk to you about their concerns about the "DEA",or the odd behavior of defending the extremely small percentage of doctors, who have gone to jail, or the latest one, an analogy of diabetes to pain. Especially, since insulin, to my knowledge , does not have the side effect of addiction, as opiates do. I hope McLellan and Turner's message is the beginning of the end of this epidemic, and that we see that there are many more dedicated doctors, who will work to turn this sorry situation around. I hope that all the Heather Grace's, who have been so obviously effected by mis-information, will learn that they must become their own advocate and that good medical practice, based in sceintific evidence, is in her best interest. They could begin by looking up the definition of iatrogenic addiction, instead of listening to Fox's John Stossel, or any of the other heavily Pharma funded pain foundations, who do not have her best interest in mind. I hope she does not ever become a name in a medical report for "accidental" overdose like the pain patient, who was found dead by her daughter recently. NCBI report below. The "real" danger, Heather, is in being treated (for anything), without adequate, studied, reliable, and appropriate information. The protection of your supply of narcotics should not be your only medical concern. Good doctors will not dismiss your pain. Good doctors will treat your condition on the whole, not just your pain. That should be your goal also. And above all, please know that you have a "right" to proper management of your disease and your pain, not a "right" to narcotics. NCBI report: http://www.ncbi.nlm.nih.gov/pubm