What is Tennessee Controlled Substance Prescribing for Acute and Chronic Pain?
Opioid use and misuse for both short-term and chronic pain present significant issues in the United States and specifically, in Tennessee. In fact, overdoses linked to illicit opioid use have seen a significant rise in the United States, with Tennessee being most severely affected. Each year, roughly 2,000 people lose their lives due to opioid overdoses according to the CDC.
Over a quarter of the US population suffers from chronic pain. It is one of the most common reasons people seek medical help at clinics and emergency rooms. The risk of becoming dependent on opioids due to improper management of both short-term and long-term pain can lead to serious health problems and even death. It’s also worth noting that one in every five patients visiting an outpatient clinic comes with a pain-related complaint. We spend over 100 billion dollars a year as a country on dealing with pain management and issues related to opioid dependence, which is more than the expenses for cancer, diabetes, and heart diseases combined.
Chronic pain, defined by The International Association for the Study of Pain, is any pain lasting more than three months. There are multiple reasons why someone might experience chronic pain, and it can significantly reduce the quality of life. The best way to treat it often includes a combination of drug therapies and other kinds of treatment. Chronic pain is also often linked with depression and anxiety, and those suffering from it are at a higher risk of suicide.
Unfortunately, many medical schools and training programs lack proper education regarding pain management, though efforts are being made to incorporate guidelines for prescribing opioids for chronic pain into the curriculum. Knowing how to prescribe opioids correctly is essential to avoid addiction, overdose, and misuse while ensuring the patient’s pain is adequately managed. Health providers need to understand not only the appropriate use of opioids, but also the potential risks including abuse and associated psychological issues.
The American Society of Addiction Medicine describes addiction as a disease that can be treated, involving factors like genetics, a person’s life experiences, and environmental pressures. Signs of addiction include cravings, negative emotional responses, inability to abstain consistently, failure to recognize negative impacts on behavior and relationships, and general impairment in controlling one’s behavior.
Many healthcare providers have a limited or misguided understanding of addiction, and this lack of knowledge also extends to those who are tasked with writing and enforcing laws related to addiction treatment. Better education and use of current terminology would greatly help in effectively addressing the challenges of addiction.
The process of defining addiction has evolved over time, with previously separate terms like “addiction,” “substance abuse,” and “substance dependence” now being replaced by “substance use disorder” in the medical realm.
Pain management faces many challenges, including both under-prescribing and over-prescribing opioids. This is especially the case in chronic pain patients, who may suffer from insufficient pain treatment or the fallout from opioid misuse, including addiction and overdose. This situation can cause healthcare providers to avoid prescribing necessary and safe opioid dosages.
To complicate matters, chronic pain patients often build a tolerance to opioids and can develop significant psychological issues. Prescribing opioids also carries risks for doctors, leading to the potential for medical negligence charges if a provider fails to manage pain adequately or contributes to drug diversion or misuse.
Healthcare providers need better education and training to get the right balance in prescribing opioids, thereby improving patient outcomes and avoiding the legal and social problems that can come from either over-prescribing or under-prescribing opioids.
There are numerous gaps in knowledge on opioid prescribing practices, including understanding addiction, recognizing the populations at risk for opioid addiction, the differences between prescription and non-prescription opioid addiction, and the misconception that opioid addiction merely relates to a chronic painful disease rather than being a complex psychological issue.
With confusion, poor societal and medical education, and inconsistent laws, the prescription of opioids has led to significant challenges that can’t be resolved without considerable education and training.
It’s important to understand the following terms related to opioid misuse: “Abuse” refers to the inappropriate use of opioids for non-medical purposes; “Addiction” is the compulsive use of a drug for relief or reward; “Dependence” is the reliance on a drug triggering withdrawal syndromes when stopping or reducing the dosage; “Diversion” is the unauthorized possession or distribution of a controlled substance; “Misuse” refers to the unauthorized use of a medication; “Pseudo-addiction” is a drug-seeking behavior caused by the need for pain relief, which ends once the pain is controlled; “Tolerance” is the body’s adaption to the effects of a drug.
What Causes Tennessee Controlled Substance Prescribing for Acute and Chronic Pain?
Causes of Pain
Many people experiencing chronic pain usually feel more than one type of pain. For instance, someone with lingering back pain might also be dealing with fibromyalgia. A large number of these patients also struggle with depression and anxiety disorders. In fact, over 67% of chronic pain sufferers also have a mental health disorder.
Pain can be classified into several types, including neuropathic pain, nociceptive pain, musculoskeletal pain, inflammatory pain, psychogenic pain, and mechanical pain.
Neuropathic pain is a result of conditions like post-herpetic neuralgia or diabetic neuropathy, or a consequence of strokes. Nociceptive pain is caused by actual bodily injuries such as burns, bruises, sprains, or fractures. Musculoskeletal pain covers back pain and muscle pain.
Inflammatory pain is a result of autoimmune disorders like rheumatoid arthritis or infections while psychogenic pain is caused by psychological factors like headaches or stomach pain caused by emotional or psychological issues. Mechanical pain, on the other hand, is related to the growth of cancer cells.
Reasons Behind Opioid Misuse and Its Associated Health Risks
Sadly, the treatment of pain can also lead to opioid misuse, which comes with health risks, and sometimes even death. Opioid misuse can be traced back to medical, social, and economic issues.
On the medical and social front, about two decades ago, doctors began to strongly advocate for more aggressive treatments for pain. The undertreatment of pain became a serious concern, and pain started being considered an important health indicator. Around the same time, oxycodone, a pain medication thought to have low addiction risk, was introduced. This led to an increase in the use of prescription opioids as a more respected and safer option than street drugs.
Economically, the rise in opioid use is linked to aggressive marketing strategies targeting consumers, physicians, and pharmacists, as well as illegal production and sale of opioids. Seizing the opportunity to make huge profits, some providers started prescribing opioids with little or no proper documentation, leading to the establishment of “pill mills”. As these sources started to decrease, heroin use began to rise.
The role of opioid manufacturers has also been challenged. For instance, individuals, federal, state, and local governments successfully sued Purdue Pharma for promoting the use of their specific product, a form of oxycodone.
Prescribers who give out prescriptions for chronic, non-cancer pain in doses larger than recommended, without proper follow-ups, and with the use of drugs like methadone for pain relief, have led to an increase in opioid misuse and related health risks.
It’s concerning that some prescribers argue with pharmacists who question unreasonable prescriptions. Pharmacists have non-invasive methods, like checking state databases for opioid use, to voice concern. State-led interprofessional collaboration motivates safer patient care practices.
Risk Factors and Frequency for Tennessee Controlled Substance Prescribing for Acute and Chronic Pain
Chronic pain affects a large number of people, with over 100 million Americans meeting the criteria for chronic pain syndrome. Out of these, 50 million experience severe, debilitating pain, and more than 20 million report that pain hinders their day-to-day activities.
- About 11.1% suffer from regional chronic pain.
- Chronic back pain is experienced by 10.1%.
- Leg and foot pain is reported by 7.1%.
- Arm and hand pain affects 4.1%.
- 3.5% have chronic headaches.
- 3.6% report widespread pain.
Elderly patients receive 25% fewer pain medications than the average population. Chronic pain also has a significant financial impact, costing over $600 billion annually in lost productivity and medical treatment. More than half of adults are impacted by chronic pain at some point in their lives. Of those currently suffering from chronic pain, 40% say their pain is not well managed and over 10% have long-term, disabling pain. Furthermore, studies indicate that suicide attempts and ideation are higher among chronic pain patients, ranging from 5% to 14% and 20% respectively. In the tragic cases where chronic pain patients end their lives, 53.6% died from gun injuries and 16.2% from opioid overdose.
The occurrences of chronic pain are on the rise due to obesity-induced pain, the increased survival rates of trauma victims and surgery patients, an aging population, and increased recognition of pain as a treatable condition.
When it comes to managing chronic pain, opioids are the most common treatment option. These are synthetic substances derived from unrelated compounds, while opiates are derived directly from the sap of the opium poppy. Both function by acting on the body’s opioid receptors which are involved in managing pain and mood.
In the past, opioid prescriptions in the U.S. were limited mostly to chronic cancer pain cases. However, this shifted in the 90s when the American Pain Society started to advocate for treating pain as a significant health indicator, leading to a rise in opioid prescriptions for various chronic pain conditions. Today, opioid sales reach over 7 billion dollars, and the United States consumes more than 80% of all globally produced opioids. Unfortunately, this increase in use has also led to a rise in opioid abuse.
Tennessee, in particular, has seen an impact, especially in relation to the misuse of prescription drugs like Hydrocodone and Oxycodone. With the government’s efforts to reduce inappropriate opioid prescriptions, some individuals have switched to using drugs like heroin and fentanyl. Although prescription drug overdoses have decreased, overdoses related to non-prescription opioids have dramatically increased.
- Approximately 70,000 residents in Tennesse are addicted to opioids.
- There’s been a sharp increase in the use of methamphetamines, heroin, and other street opioids.
- Fentanyl and carfentanil abuse has increased substantially.
- The use of prescription opioids has reduced, but the misuse of other drugs has increased.
Signs and Symptoms of Tennessee Controlled Substance Prescribing for Acute and Chronic Pain
When a patient reports pain, their doctor will gather a detailed history to better understand their symptoms. They will ask about when the pain started, how it feels and what might cause it to get better or worse. The doctor may use a numeric rating scale, where the patient rates their pain from 0 to 10, to help determine the severity of the pain. The doctor will also need to know about related symptoms such as muscle spasms, changes in temperature, and restrictions to movement, among others.
Besides these symptoms, the doctor will also want to know how the pain is affecting the patient’s daily life and their quality of life. Questions might include: Is the pain affecting the patient’s relationships or hobbies? Are they feeling depressed? Can they sleep and exercise as normal? Are everyday activities, like dressing, walking, eating, being affected?
It can be more difficult for the elderly or very young children to give a clear description of their pain. In these cases, doctors use different methods to help understand the pain better. This could include using acronyms to remember what type of information to ask for, or specific tools that assess the quality and severity of the pain.
- Elderly patients might describe pain as soreness or discomfort.
- Children might use pictures of faces showing different levels of distress to express how much pain they feel.
- Non-verbal children, or those with neurological impairment, might show signs of pain in other ways – for example through moaning, crying or changes in behavior.
Apart from these patient-reported symptoms, the doctor will also perform a detailed physical examination to better understand the cause and extent of the pain.
Testing for Tennessee Controlled Substance Prescribing for Acute and Chronic Pain
If you’re dealing with chronic pain, your doctor might not immediately suggest blood tests or imaging. However, they may ask for these tests if they think there are certain causes for your pain. The decision is often made on a case-by-case basis, and sometimes a urine test might be required to make sure prescription drugs are being taken correctly and illegal drugs aren’t being used.
Psychiatric disorders can sometimes make pain feel worse. For example, conditions like depression and anxiety are often seen in patients who deal with chronic pain. For someone suffering from depression, symptoms like tiredness, sleep changes, loss of appetite and less physical activity can all contribute to worsening pain. It’s also worth noting that those with chronic pain are at a higher risk for suicidal thoughts and suicide.
If you have chronic pain, it’s recommended that you also get screened for depression. Therapists and doctors often use the Minnesota Multiphasic Personality Inventory-II or Beck’s Depression Scale to check for this.
In the case of chronic pain, there’s a worry that strong painkillers like opioids might be abused. Your doctor will assess this risk based on your medical history, what your family has to say, any prior records of prescriptions, and different screening tools. This could end up with you being classified as low-risk, moderate-risk, or high-risk:
- Low-risk: you have clear signs and symptoms, your condition can be confirmed by physical examination or imaging like CT or MRI, you don’t have a history of substance abuse individually or in your family, and you’re under 45 years old.
- Moderate-risk: you deal with significant pain, there are clear signs and symptoms, your psychiatric conditions are kept under control, and you participate in therapy.
- High-risk: you often experience significant pain across many regions of your body, have a history of addiction in your family, aren’t willing to participate in multimodal therapy, and aren’t able to function normally.
Before prescribing opioids, your doctor will ask detailed questions about your pain, your medical history, your living conditions and any potential risk factors for opioid abuse. There are also multiple questionnaires – like the Brief Intervention Tool, Opioid Risk Tool, and CAGE questionnaire – that are used to assess risk levels. Your doctor may also request a urine drug test to check for misuse, with the frequency of these tests varying depending on your assessed risk level.
When giving/buying prescription opioids, it’s important to make sure the dose, frequency, and length of the prescription are appropriate for the issue at hand. You should also consider potential drug interactions, allergic reactions, and understand the risks involved. For low-risk patients, a regular check-up may be all that’s needed, but high-risk patients might require more comprehensive monitoring and consultation with an addiction specialist.
All states currently have Prescription Drug Monitoring Programs (PDMPs), which can help healthcare professionals work together to prevent unwanted use of prescription opioids. If you’re prescribed opioids, the providers will check these databases to prevent “doctor shopping” – where one patient collects prescriptions from multiple providers. However, these systems aren’t currently linked together and there is no real-time reporting, so there are some limitations. The future could involve mandatory checks of this database with real-time updates for more accurate information.
Treatment Options for Tennessee Controlled Substance Prescribing for Acute and Chronic Pain
Healthcare professionals treating patients with long-term pain should know the most effective methods for prescribing painkillers, understanding pain, managing it, and correctly using drugs for pain control. They should also consider treatments that don’t involve medications. If someone has long-lasting, severe pain and hasn’t found relief from non-opioid treatments, they could be candidates for opioid treatments. The CDC gives advice on ways to prescribe opioids, including when to start or continue them, how to choose the right one, amount, length of treatment, follow-ups, as well as stopping them and assessing the risks.
When a patient has extremely painful and unmanageable pain, especially when it’s in different spots and requires a mix of treatments, it’s recommended they’re referred to a pain management specialist. Treating both the pain and any co-existing mental health issues can lead to significant reduction in both. Treating pain may also improve depression, especially if the two conditions are occurring together. There’s a variety of ways to deal with long-term, severe pain, from medication to therapies and surgical treatments.
There are many medication options for long-lasting pain, including non-opioid pain relievers such as anti-inflammatory drugs, paracetamol, and aspirin. Other drug options include tramadol, opioids, antiepileptic drugs, antidepressants, topical pain relievers, muscle relaxers, and alpha 2 adrenergic agonists. Each person reacts differently to treatments, and a stepped approach is usually taken to reduce the use of opioid pain relievers as much as possible. Different types of pain might require unique treatment combinations.
Musculoskeletal pain, for example, is usually first treated with paracetamol or anti-inflammatory drugs; these can work well for osteoarthritis and chronic back pain but can be harmful to people with histories of heart or kidney disease, bleeding, or ulcers. Failure to relieve pain with these medications might lead healthcare providers to consider using opioid pain relievers.
However, opioids are considered only after other options have failed. They may be necessary for serious unending pain or cancer-related pain. The use of opioids comes with a caution, and they’re accompanied by significant side effects, like sensitivity to pain, constipation, addiction, and sleepiness. When managing long-lasting musculoskeletal pain, they’re not better than non-opioid pain relievers—and they do not enhance the quality of life unless the pain is impacting it severely.
There’s an estimated 78% risk of side effects from opioids, while the chance of developing severe reactions like weakened immune system or slowed breathing is around 7.5%. Those diagnosed with opioid addiction may be provided buprenorphine for their long-lasting pain as it’s a better alternative for those who haven’t found adequate pain relief.
Neuropathic or nerve pain often requires multiple drug therapies for proper management. The initial treatments are usually gabapentin or pregabalin. Other potential treatments include dual reuptake inhibitors of serotonin and norepinephrine or tricyclic antidepressants, which show a 50% reduction of pain, a significant decrease considering the average decrease in pain from various treatments is 30%.
Aside from medications, there are several non-drug options for chronic pain therapies, including physical treatments like heat and cold, cognitive behavioral therapy, relaxation therapy, exercise, acupuncture, chiropractic treatment, physical therapy, and so on. Other more invasive options like spinal cord stimulation, steroid injections, nerve blocks, and botulinum toxin injections could be considered if other treatments failed to relieve pain.
Techniques such as spinal cord stimulation are viable alternatives for patients who haven’t found relief from other treatments. Stimulators are often used following an unsuccessful back surgery and have shown a 50% reduction of pain compared to continued medication therapy.
What else can Tennessee Controlled Substance Prescribing for Acute and Chronic Pain be?
Pain is often a sign that something isn’t right in the body. It’s like the check engine light on your car – it’s telling you there’s a problem, but not what the problem is. A doctor’s job is to figure out why you’re having pain, what’s causing it. It’s critical to understand what injury or disease is causing the pain, so that they can figure out the best way to treat it. For example, a patient experiencing nerve pain in their legs may be experiencing it because of a problem in their peripheral nerves (the nerves outside of the brain and spinal cord), or in their central nervous system (the brain and spinal cord.)
Let’s say a patient comes in with severe knee pain; the doctor needs to figure out what’s behind it. If it’s due to severe arthritis, the patient might need an injection or possibly a knee replacement. But if the pain is due to a different condition, like rheumatoid arthritis, an infection, gout, pseudogout, or a knee injury, they’ll need a different treatment altogether.
You also need to consider that some people can experience widespread chronic pain as a result of different factors. This can be due to interactions with painkiller drugs, mood disorders like depression, sleep issues such as insomnia, autoimmune diseases, fibromyalgia, and central pain syndromes. Pain can be broadly classified into four types; nerve pain, muscle or bone pain, mechanical pain, and inflammation pain. If left untreated, these painful conditions can become chronic, making pain a problem in and of itself. Hence, it’s crucial to treat acute and short-term pain before it becomes chronic and harder to manage.
What to expect with Tennessee Controlled Substance Prescribing for Acute and Chronic Pain
Current treatments for chronic pain can typically reduce a patient’s pain levels by about 30%. This reduction can have a significant positive impact on a patient’s daily functioning and overall quality of life. However, it’s worth noting that long-term outcomes for those living with chronic pain often show decreased function and quality of life.
It’s been observed that improvements in chronic pain outcomes can happen when any associated mental health conditions are also treated. Chronic pain can lead to higher levels of illness and early death, as well as increase the risk of chronic diseases and obesity. People living with chronic pain also have a significantly higher risk of considering suicide compared to those without chronic pain.
Spinal cord stimulation, a treatment for chronic pain, fails to adequately relieve pain in roughly half of the patients who try it. Additionally, up to 20-40% of patients may develop a tolerance to the treatment, which reduces its effectiveness over time. Similarly, chronic pain patients who rely on opioids often build up a tolerance, needing ever-larger doses for the same effect. This can unfortunately lead to an increased risk of illness and early death.
The most effective approach to chronic pain is prevention. When acute and relatively short-term pain is managed properly, it can stop the progression to chronic pain, sparing the patient from considerable impacts on their quality of life.
Possible Complications When Diagnosed with Tennessee Controlled Substance Prescribing for Acute and Chronic Pain
Chronic pain has severe consequences including depreciated life quality, lesser productivity, wage losses, aggravating chronic diseases, and mental health conditions like depression, anxiety, and substance abuse disorders. It can also amplify suicide risks. The medications used for chronic pain treatment may pose potential risks, side effects, and complications.
Acetaminophen is a common drug for chronic pain and can be consumed alone or combined with an opioid. However, consuming over four grams per day can lead to hepatotoxicity and cause acute liver failure. It’s especially harmful for people with chronic liver diseases, even at therapeutic doses.
Medications like gabapentin or pregabalin, often used with other painkillers, can cause side effects like sedation, swelling, mood changes, confusion, and respiratory depression in older patients. They should be used carefully in elderly patients with painful diabetic neuropathy as they can increase the death rates.
Duloxetine, another medication, can cause mood changes, headaches, and nausea among others and those with liver or kidney disease history should avoid it.
Opioid therapy has its feared complications like addiction, overdose, and resulting breathlessness. Meanwhile, long-term risks and side effects of opioids are constipation, tolerance, dependency, nausea, dyspepsia, arrhythmia, and opioid-induced hormonal dysfunction, leading to amenorrhea, impotence, gynecomastia, and decreased energy and libido.
Spinal cord stimulators also have a high complication rate of 5-40%. Common problems include lead migration, fracture, and seromas that might need surgery. Infections post spinal cord stimulator placement are also common, with a rare occurrence of direct spinal cord trauma, leading to severe complications like a spinal cord abscess or an epidural hematoma that calls for an immediate neurosurgery.
On the other hand, some individuals may misuse prescribed opioids for addiction or financial gains. They may resort to tactics like aggressive demands, asking for opioids by name, increasing medication dosages without permission, using illegal drugs, and obtaining the drugs from nonmedical or multiple medical sources, forging prescriptions, reluctant reduction in opioid dosages, selling prescriptions, unsanctioned dosage escalation, etc.
To counter this, doctors and pharmacies can communicate to avoid “doctor shopping”, educate patients about the dangers of sharing opioids, advise patients on keeping their medications private, report patient prescription to state central databases, etc. They are also advised to get urine drug screening, perform thorough examinations, pill countings, prescribe smaller opioid quantities, and discharge if the patient is found breach the treatment agreement-carefully avoiding patient abandonment charges.
Providers should refer substance abuse or addiction cases to a pain specialist. In case of substance theft or loss, it must be reported to the Drug Enforcement Administration. Any drug diversion activity should be documented and reported to the law enforcement authorities.
Preventing Tennessee Controlled Substance Prescribing for Acute and Chronic Pain
Patients and their families have a crucial role in deciding whether to continue or stop the use of opioid therapy. Family members often notice if a patient appears depressed or is having trouble completing everyday tasks. Key questions to ask family members include: Is the patient constantly focused on taking their pain medication? How often do they take their medication? Does the patient have problems with alcohol or other drugs? Does the patient avoid activity? Do they seem depressed? Can they function regularly?
Important advice for a patient taking opioids includes: Avoid driving or operating heavy machinery. Don’t stop taking opioids suddenly. Refrain from taking other drugs such as alcohol, sedatives, and anxiety medicines that could slow your breathing. If pain medication doesn’t give enough relief, contact the person who prescribed it. Dispose of opioids according to the instructions (usually by flushing them down the toilet or mixing them with cat litter or coffee grounds). Don’t chew tablets. Never share opioids with friends or family members. Always take opioids as directed. Set realistic expectations for pain relief.
Preventing opioid abuse requires collaboration between medical professionals including doctors, pharmacists, and other healthcare workers. These teams ensure the safe and appropriate use of opioids. Initially, doctors evaluate and prescribe the medication. Pharmacists then check the validity and appropriateness of the prescription before dispensing it. It’s crucial to balance the risk of abuse, misuse, or diversion of opioids, against the need to relieve genuine pain. This balanced, team approach often results in best outcomes for patients and society as a whole.