Band 107, Heft s5

In the United States, many visits to physician offices are for complaints of pain. Patients who have moderate to severe pain can be effectively treated with different modalities, including opioids. Proper management requires that physicians be open-minded and thorough. Physicians should take a complete history and perform a complete physical evaluation including an osteopathic structural examination to develop a comprehensive treatment plan. This strategy should include follow-up visits for continued assessment of therapy. Continued reassessment of treatment and patient responsiveness have been shown to be most beneficial to both physician and patient. Using the osteopathic medical model of treatment, physicians should identify psychosocial as well as somatic dysfunctions and appropriately treat patients for them. They should not avoid prescribing opioids because of fear of a patient's becoming addicted, but instead, integrate the use of such important analgesics in a multidisciplinary treatment plan. However, it must be recognized that opioids are powerful medications that require monitoring and dosing according to patient response.

The Drug Addiction Treatment Act of 2000 (DATA 2000) was established to create a new paradigm for medication-assisted treatment of persons with opiate addiction in the United States. Before enactment of DATA 2000, the use of opioid medications to treat patients with opioid addiction was permissible only in federally approved treatment programs, ie, “methadone clinics.” The only medications permitted were Schedule II drugs (eg, methadone hydrochloride and l -α-acetylmethadol [LAAM]), which could only be dispensed, not prescribed. Under provisions of DATA 2000, qualified physicians in a medical office and other appropriate settings outside the opioid treatment program system may prescribe and/or dispense Schedule III, IV, and V opioid medications for treating persons with opioid addiction if such medications have been specifically approved by the US Food and Drug Administration for that indication. Opioid addiction treatment programs were commonly known as methadone clinics. Such programs now may also dispense buprenorphine hydrochloride and the buprenorphine hydrochloride-naloxone combination. The information in this article is extracted (with revision) from: Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction . Treatment Improvement Protocol (TIP) Series 40. DHS Publication No. (SMA) 04-3939. Rockville, Md: Substance Abuse and Mental Health Services Administration; 2004. The Clinical Guidelines document is in the public domain except for material indicated as reprinted from a copyrighted source. The author served on both the Expert Panel and the Consensus Panel that produced the guidelines, available in portable document format at http://buprenorphine.samhsa.gov/Bup%20Guidelines.pdf. In refreshing this article for on-line only publication, two illustrative case presentations of anecdotal patients have been added.

Not all patients are treated equally for their pain with some therefore being undertreated. Discrepancies still exist in the way physicians treat special populations of patients such as racial minorities, women, and substance abusers. All healthcare providers need to be aware of the not so readily apparent disparities resulting from stereotyping, bias, ageism, and socioeconomic considerations. Physicians can best provide appropriate and equal care by following pain management guidelines; however, they may receive contradictory information and be apprehensive about prescribing opioids, especially to substance abusers. In this “refreshed” article, the authors describe patient encounters with patients of color and offer some goals for removing inequality and inequity from clinical settings.

As osteopathic physicians care for patients with complaints of pain, they commonly prescribe controlled substances. The use of these agents presents special challenges for providers, patients, and communities. The US Drug Enforcement Administration (DEA) has provided testimony to the US Congress in regard to the growing problem of diversion and misuse of such medications. Joseph T. Rannazzisi, the deputy assistant administrator in the Office of Diversion Control, appeared before the House Government Reform Committee's Subcommittee on Criminal Justice, Drug Policy, and Human Resources on July 26, 2006. This review summarizes the important points that Mr Rannazzisi raised in the DEA's testimony, “Prescription Drug Abuse: What Is Being Done to Address This New Drug Epidemic?” (http://www.dea.gov/pubs/cngrtest/ct072606.html). Excerpts have been edited to conform with the JAOA 's house style. In addition, the author has added some details to the excerpts for clarification. One relevant addition notes the law that now requires physicians to use tamper-proof prescription pads to reduce counterfeiting and forging prescriptions, thus helping to reduce diversion of prescription drugs. The author has also added a bar chart to illustrate abuse of two leading painkillers by teenagers and anecdotal case scenarios illustrating abuse and diversion of controlled prescription drugs.

Medical and psychosocial problems related to substance use disorders (SUDs) remain a major source of national morbidity and mortality. This situation exists despite greater understanding of genetic, neurobiologic, and social underpinnings of the development of these illnesses that has resulted in many advances in addiction medicine. The value of assessment and brief intervention of this disease is well documented. Patients need to be identified and engaged in order for them to be treated. A variety of evidence-based pharmacologic and psychotherapeutic treatments are now available. Strong evidence exists that treatment of patients for SUDs produces results similar to or better than those obtained from treatment for other chronic illnesses. It is also clear that physicians can play a pivotal role in helping to reduce the burden of disease related to SUDs However, to do this, physicians need to be better educated. Through such education comes greater confidence in identification and providing treatment. Also, the discomfort and stigma often associated with this disease are reduced. The federal government—through the Office of National Drug Control Policy, the Surgeon General, the Center for Substance Abuse Treatment, the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism, and the National Highway Traffic Safety Administration of the Department of Transportation (DOT)—is expending concerted efforts to improve physician education in addiction medicine. These efforts culminated in the Second Leadership Conference on Medical Education in Substance Abuse in December 2006. The osteopathic medical profession was represented at this conference. This article reviews not only the recommendations from this meeting, but also the nature of the problem, how members of the osteopathic medical profession are currently addressing it, and a strategy for improvement endorsed by the American Osteopathic Academy of Addiction Medicine.