Editor's Note: Thoughts on Pain Management...Are We Doing the Right Things?

Are the controls in place to prevent and fight the prescription drug abuse epidemic really working?

I have been wondering if the right kind of attention is being focused on pain and its management—the topic of this month’s edition of Pharmacy Times. Thinking about this health concern caused me to remember a number of activities throughout my career related to this broad topic. Early in my career as a relatively new pharmacy manager, I had to deal with a pharmacist employee whom I suspected of abusing drugs. He had been my roommate during graduate school and was married to my wife’s nursing school classmate. This was well before impaired pharmacist programs were available for referral. We confronted him and made efforts to help him, but were unsuccessful. We lost a good pharmacist, his marriage dissolved, and he experienced an early death.

This experience compelled me to help start an impaired pharmacist program in North Carolina. How much better things are today—with strong impaired pharmacist programs in most states and examples of recovering pharmacists returning to practice. More than one employer has told me that some of these recovering pharmacists become very dependable and empathetic employees. Yet even though the treatment options are better today, the problem still exists. Are we doing enough, and are we really doing the right things?

Recently, a fellow pharmacist and I were discussing how many pain medications were dispensed in the community pharmacy. It was our impression that there were more prescriptions being written, filled, and hopefully consumed appropriately than in the past. Are there more pathological problems that result in pain symptoms today? Or have we as a society become less tolerant of pain and willing to seek treatment more quickly than previous generations? Has the flood of advertisements conveying the message that “relief is just a swallow away” made us seek pills too quickly, rather than just staying active and trying watchful waiting first? More than one impaired pharmacist told me that he or she got hooked on a pain medication after taking it for a legitimate purpose. Should we be slower to prescribe and dispense pain medication?

In my pharmacy training, like many health professionals of my era, I entered practice with a healthy skepticism of using narcotics to treat pain. This may have had something to do with concern that people might become addicted, or perhaps it was because of all the controls and accountability surrounding narcotics use. The result was that people in pain were often inadequately treated. I became part of an interdisciplinary group that wanted to make pain the fifth vital sign, so that effective pain management would occur. Educational programs in the health sciences were encouraged to include pain management in their curriculum. Today, we have pain clinics, pain management specialists, and a willingness to prescribe larger doses of pain medication, if required, for pain control. In our efforts to improve pain control for our patients, have we improved things or not? Sometimes I wonder.

There are a lot of regulations today surrounding controlled substances. When I spoke to my personal physician recently, he mentioned that he refers chronic pain patients to a specialist. He said that there was too much oversight, too many hoops to jump through, and too much secondguessing about decisions he made. This caused me to reflect on how much trouble we had getting controlled substance prescribing into the electronic age. Is the Drug Enforcement Administration just out of step because they are old fashioned, or are their efforts to control the possible abuse of controlled substances still appropriate?

We can probably all agree that prescription drug abuse is an epidemic in this country. Do all the controls we have in place mean that the problem is not as bad as it would be without them? Would controls that allow more contemporary tools improve practice without making the drug abuse epidemic worse? The purpose of any control system should be the ability to detect misuse. A system designed to prevent misuse can end up being too cumbersome and restricting, and can be hard for legitimate users. Illegitimate users find ways around the controls.

Pain management is an important part of pharmacy practice—and impacts pharmacists both personally and professionally. I wonder if we have really improved things—or just created new problems as we fixed other problems. What do you think? PT

Mr. Eckel is a professor at the Eshelman School of Pharmacy, University of North Carolina at Chapel Hill. He serves as executive director of the North Carolina Association of Pharmacists.