Inappropriate prescribing trends and wasteful medication decisions can also have a significant detrimental economic impact. Research shows that the most costly prescribing decisions disproportionately affect the poorest states. The country’s lowest median household income is found in the state of Mississippi, which also has the most wasteful medication-related spending at $1,622.76 per resident.13

Other low-income states that have wasteful medication-
related prescribing include Alabama, Arkansas, Kentucky, Louisiana, New Mexico, Oklahoma, South Carolina, and Tennessee. Interestingly, states with the highest utilization rates of narcotic medications include Alabama, Mississippi, Oklahoma, Tennessee, and West Virginia.14

The highest spending per capita related to narcotics, including cost-per-prescription and utilization, is found is Alabama, Nevada, Oklahoma, Ohio, and Utah.14


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Schedule classifications of controlled substances


Controlled substances are determined by the U.S. Drug Enforcement Administration and are classified into five schedules that are based on the drug’s accepted medical use, the drug’s relative potential for abuse, and the likelihood of dependency following abuse of the drug.15

For example, Schedule I controlled substances have the highest abuse potential, and Schedule V controlled substances have the lowest abuse potential. There are also narcotic and non-narcotic categories within the schedules. Narcotics are defined as psychoactive analgesic compounds that affect the central nervous system (CNS) and are known to have sleep-inducing or pain-relieving properties.

Such opioids as heroin and morphine as well as similar substances that are derived from these opioids (e.g., hydrocodone), are considered narcotics. Non-narcotic controlled substances are substances that do not affect the CNS. Examples of non-narcotic substances include anabolic steroids, ketamine, benzphetamine, and phendimetrazine.


Schedule I controlled substances have a high abuse potential, a lack of accepted safety for use under medical supervision, and a high potential for abuse.15 Examples of Schedule I controlled substances include marijuana, methylenedioxymethamphetamine (MDMA, commonly known as Ecstasy or Molly), heroin, methaqualone, and lysergic acid diethylamide (LSD). 


Schedule II controlled substances have a high potential for abuse that may lead to severe psychological or physical dependence and include such narcotics as hydromorphone (Dilaudid, Exalgo), oxycodone, meperidine (Demerol), morphine, fentanyl (Durgesic), opium, and codeine, in addition to such non-narcotic stimulants as methamphetamine, amphetamine, and methylphenidate (Concerta, Metadate, Methylin, Ritalin). 


Schedule III controlled substances have a lower potential for abuse than substances in Schedules I or II, and abuse may lead to moderate or low physical dependence or high psychological dependence. Examples of Schedule III narcotics include combination-type products comprised of <15 mg hydrocodone per unit dose, <90 mg codeine per unit dose, and buprenorphine (Subutex). Schedule III non-narcotics include ketamine, benzphetamine, phendimetrazine, and anabolic steroids. 


Schedule IV controlled substances have a lower abuse potential in relation to Schedule III controlled substances and include lorazepam (Ativan, Lorazemap Intensol), diazepam (Valium, Valrelease), alprazolam (Alprazolam Intensol, Niravam, Xanax), clonazepam (Klonopin), clorazepate (Gen-Xene, Tranxene), midazolam (Versed), triazolam (Halcion), and temazepam (Restoril).

Schedule V controlled substances mainly consists of preparations that contain limited amounts of specific narcotics. Examples of Schedule V controlled substances include cough preparations that contain <200 mg codeine per 100 mL or per 100 g.15

Types of opioids


Opioids are available in short-acting and long-acting forms. Short-acting opioids include rapid-onset medications, and long-acting opioids include extended-release or sustained-release medications. Short-acting opioids are used to treat pain for brief periods of time and are taken by patients as needed for pain.

Long-acting opioids may be used to manage pain that is persistent and chronic in nature. Long-acting opioids lead to prolonged pain relief that lasts for several hours, as these medications are taken on a consistent scheduled basis at the same time every day.


Mechanism of action


Opioids relieve pain by binding with opioid receptors in the body. Opioid receptors are specific proteins on the surface of cells, located mainly in the CNS, the peripheral nervous system, and the GI tract. The most common opioid receptors are epsilon, mu, delta, sigma, and kappa; however, an opioid may bind and act on several different opioid receptors at the same time, which means patient response will vary with each opioid.16

Once an opioid binds to an opioid receptor, it blocks the transmission of pain signals to the brain. The use of opioids does not eliminate the pain, but leads to a reduction and alteration in the perception of pain. Opioids also affect the limbic system of the brain, which creates an alteration in the emotional response to pain.


Determining treatment of pain with opioids


Deciding whether to treat pain with opioids begins with a comprehensive evaluation of the patient’s medical history that includes background information regarding the chief complaint, followed by a thorough physical examination, complete pain assessment, appropriate diagnostic laboratory tests, and imaging.

It is also important to find out if the patient is under the care of another practitioner for the treatment of acute or chronic pain. The prescribing practitioner should also inquire about a history of substance abuse, risky drug-related behavior, and the presence of psychosocial conditions. Addressing these points will encourage an evidence-based and patient-centered approach regarding the treatment of pain and the need to prescribe opioids.


Comprehensive assessment of pain


A thorough pain assessment provides the health-care practitioner with an objective measurement of a patient’s pain, which is very subjective in nature. The patient’s self-reporting of pain is the hallmark of pain assessment. An extensive pain evaluation begins with obtaining a thorough history of the complaint.

This assessment should include the following questions: Where is the source of the pain? Is there a specific precipitating factor? Is the pain acute or chronic in nature? What is the quality of the pain? What is the duration of the pain? What increases or decreases the pain? How does the patient rate the pain on a scale of 0 to 10?


Acute pain occurs suddenly, may be intermittent, and usually does not last beyond six months in duration. Musculoskeletal fractures, ligamentous injuries, surgical procedures, and burns are examples of events that may lead to acute pain.

Chronic pain lasts longer than six months. Examples of sources of chronic pain include traumatic injuries that cause alterations in normal function, osteoarthritis, neurogenic disorders, and cancer. 


A comprehensive evaluation of pain should also include an assessment of the quality of the pain and patient description of his or her pain. Determining the specific type of pain will guide the clinician toward appropriate interventions.

Neuropathic pain, which is poorly managed with opioids, is typically described as shooting, burning, radiating, tingling, and numbness. Somatic pain is characterized as throbbing, dull, and achy, in addition to being localized in nature, and may require a multimodal treatment approach. Visceral pain is characterized as dull, deep, cramping, or squeezing.

Visceral pain is most often seen following surgery of the abdominal or thoracic areas. This type of pain may also be present as a secondary result of liver metastases. Visceral pain will likely require opioids for adequate relief and may require a multimodal approach as well.


Quantification is an extremely valuable tool when it comes to treating acute and chronic pain. The universal use of the Numeric Rating Scale (NRS) to assess pain intensity in adults is highly recommended.17 The NRS allows health-care practitioners to quantify the patient’s perceived intensity of the pain (i.e., 0 represents no pain and 10 represents the worst pain).

The NRS may not be appropriate for children, the elderly, or patients with language barriers. In such cases, the Wong-Baker FACES Pain Rating Scale, a visual version of the NRS, is a good alternative.18

When determining the location of pain, the practitioner can ask the patient to point directly to the area. Also, ask if pain is felt in more than one area. Assess for the duration of pain by asking whether the discomfort is constant or intermittent. Breakthrough pain is transient pain that occurs even though the patient is on a pain-management regimen of analgesics.

It is also important to inquire about specific aggravating and alleviating factors related to the pain. Finally, ask the patient about sleeping habits, changes in appetite, changes in lifestyle activities, sexual dysfunction, irritability, or anger. The presence of these factors may indicate such underlying mental health comorbidities as depression and anxiety.


Recommended prescribing practices


The initiation of a pain treatment plan of care should always begin with such OTC and non-narcotic analgesics as acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID) in tandem with such conservative modalities as heat/ice application, topical analgesics, a therapeutic exercise regimen, acupuncture, or formal physical therapy modalities. The CDC recommends prescribing opioids for acute or chronic pain only when other conservative treatments have failed.5

If an opioid is prescribed as an adjunct, always start with the lowest dose and monitor the patient’s response before increasing the dosage, and remember to prescribe the smallest quantity of opioid necessary to treat pain. Close follow-up and monitoring is also required to determine the effectiveness of the treatment plan.

In most cases, acute conditions require a small quantity of opioids for a short period of time, which may not be the case with chronic pain. Whenever a patient requests an increase in the quantity of opioids or continues to ask for prolonged pain treatment with opioids (in the absence of a chronic condition), a thorough follow-up assessment is warranted. 


The World Health Organization (WHO) designed a useful tool called the analgesic ladder (Figure 1).19 The purpose of the analgesic ladder is to guide practitioners in following recommended prescribing practices by providing a logical treatment plan for managing pain in a variety of cases.

 

The WHO analgesic ladder also helps clinicians understand the practice of multimodal analgesia by dividing the prescribing of opioids into four groups: simple analgesics, weak opioids, strong opioids, and adjuvants. The basis of each step of the WHO analgesic ladder consists of nonopioid analgesics, which creates a multimodal approach to pain treatment.

Based on the WHO analgesic ladder, acetaminophen or an NSAID should be prescribed with weak or strong opioids. By providing more effective pain management that requires lower amounts of opioids, this multimodal approach reduces the risk of side effects and adverse events.


Special considerations 


Practitioners should always exercise caution when prescribing opioids to a patient with a history of addiction or a patient with CNCP. Clinicians should also be aware of the potential for adverse effects pertaining to the use of opioids. It is vital to follow recommended standards of prescribing to ensure appropriate pain treatment with opioids and safe self-administration of opioids among patients who are at risk for abuse.


Pain treatment in a patient with a 
substance use disorder


IN some situations, controlled substances are a necessary part of a treatment plan of care for the patient with a history of addiction. Extreme caution must be used when prescribing controlled substances to such individuals. The use of controlled substances in recovering patients can lead to cravings that can trigger a relapse to active addiction.