Recent data from the Centers for Disease Control and Prevention (CDC) on national total opioid-related poisoning deaths (without heroin or cocaine) showed that from 1999 to 2002 (the last CDC-calculated year) there was a 129% increase in mortality, from 1,942 deaths in 1999 to 4,451 in 2002.9 Very likely, this figure has substantially increased in each subsequent year. A recent study in the Archives of Internal Medicine taken from drug mortality reports to the Food and Drug Administration (FDA), noted 5,548 oxycodone-related deaths from 1998 to 2005, making oxycodone the most common prescription drug of all drug mortality reports to the FDA.10 The actual number of deaths is probably much higher since most opioid-related deaths are not reported to the FDA. In Florida alone, as reported from the office of the Florida Medical Examiners in 2006, there were more than 4,300 total prescription opioid–related deaths with the three most common from methadone (974), oxycodone (923), and hydrocodone (731). Lethal levels were found in 716 cases of methadone, 496 cases of oxycodone, and 236 cases of hydrocodone, although many opiate-related deaths occurred in the absence of lethal levels but in combination with other central nervous system–active agents.11
A Better Approach to Pain
In view of these statistics, there is a need to use opiate drugs selectively, prudently, cautiously, under close supervision, and for specific clinical indications. However, beneficial non-opioid self-management therapies are often neglected or underused, especially by primary care providers with not enough time to spend with their patients or because of a lack of or inadequate insurance coverage. This has led to a significant increase in the use of opioids (and other psychoactive agents) which has often resulted in polypharmacy and drug-dependent care becoming the rule for patients with every type of chronic non-cancer pain, particularly in rural areas.
I have observed many patients with intractable, non-inflammatory chronic pain, diffuse musculo-skeletal tenderness, and severe underlying psychological distress (particularly depression) who have been inadequately diagnosed and managed solely with opioids and polypharmacy. Many of these patients are drug dependent (and often addicted), dysfunctional both mentally and physically, and frequently on or applying for disability, which is especially common in the Medicaid population. Such patients may have had a better chance of responding to multidisciplinary management if timely specialty referrals were possible and were made at an earlier stage, prior to the start of opioid therapy, which often fosters passive treatment attitudes and “illness behaviors,” especially in the presence of poor coping skills and persistent psychosocial stress.
