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New document presents DEA's stand on pain management


According to new guidelines, clinicians cannot be arrested for properly prescribing and dispensing opioids for the treatment of pain associated with conditions such as cancer and AIDS, and among the terminally ill. This document spells out for the first time the exact steps clinicians should take to ensure that patients receive appropriate medical care without attracting Drug Enforcement Administration (DEA) scrutiny. The guidelines were developed by the DEA, Last Acts Partnership, and the Pain and Policy Studies Group at the University of Wisconsin-Madison Medical School. They are available on the Pain and Policy Studies Group Web site at


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New document presents DEA's stand on pain management

The undertreatment of chronic pain is a significant public health problem in the United States. It accounts for more than $100 billion in healthcare costs and lost productivity, and the cost is expected to continue increasing. Uncontrolled pain also has a negative impact on the physical, emotional, and economic well-being of patients and their families.

A new document from the Drug Enforcement Administration spells out for the first time the exact steps clinicians should take to ensure that patients receive appropriate medical care without attracting DEA scrutiny.

This educational tool was developed by the DEA, in partnership with the Last Acts Partnership and the Pain and Policy Studies Group at the University of Wisconsin-Madison Medical School. Prescription pain medications: Frequently asked questions and answers for health care professionals and law enforcement personnel is available on the Pain and Policy Studies Group Web site at http://www.medsch.wisc.edu/painpolicy via a link on the homepage, and on the DEA Office of Diversion Web site at http://www.deadiversion.usdoj.gov.

"The document developed as a result of communication between the government and professional societies in the healthcare field, which indicated that some inappropriate concern or fear exists on the part of healthcare professionals regarding the use of opioids, and misinformation exists on the part of all parties," said Arthur Lipman, Pharm.D., a professor of pharmacotherapy at the University of Utah College of Pharmacy in Salt Lake City. He is also a member of the committee that reviewed the document. The quality of information regarding pain management and communication among clinicians, regulators, and law enforcement officials needs to improve, he said.

"Unfortunately, much of what is taught in pharmacy and medical schools today regarding opioids and pain management is inaccurate," Lipman continued. "It is taught by basic scientists who lack clinical experience or knowledge. Concepts that may hold true for laboratory animals, but are not true for humans, are commonly taught," he explained. "As a result, a tremendous amount of misinformation regarding opioids and other controlled substances is being disseminated among healthcare professionals. The purpose of this document is to rectify that situation."

June Dahl, Ph.D., a professor of pharmacology at the University of Wisconsin-Madison Medical School and another member of the review committee, also expressed concern regarding pharmacists' education. "A survey was done here in Wisconsin, and, frankly, the results indicated that many pharmacists in the state did not understand what addiction is or what the risk of addiction is," she said.

Pharmacists need to recognize that addiction, dependence, and tolerance are three very different phenomena, Lipman stressed. Dependence is a physiological and pharmacological phenomenon that occurs with different classes of drugs, such as steroids—not just opioids, he said. Addiction, a behavioral phenomenon, is characterized by compulsive drug use despite harm, and a total obsession with the drug, Dahl explained. Tolerance is defined as a decreasing response to repeated constant doses of a drug, or the need for increasing doses to maintain a constant response.

Pharmacists must make sure they have up-to-date information on pain management, Lipman said. It should really be a major focus of continuing education, including journal reading and coursework. In addition, pharmacy schools should increase their emphasis on pain management education, he contended.

Issues surrounding the adverse effects associated with opioids are of importance to pharmacists, who should be checking for drug-drug interactions and asking about constipation, a significant problem with these agents, Dahl said. Pharmacists, she added, can reassure patients that these adverse effects either can be treated or will resolve on their own. Many pharmacies afford very little privacy, so pharmacists are not given the opportunity to provide patients with adequate counseling regarding their opioid prescription. "I hope the publication of this document marks the beginning of improved communication between clinicians and law enforcement and regulatory officials," Dahl commented.

Concluded David Joranson, MSSW, director of the Pain and Policy Studies Group and a member of the writing group that developed this educational tool, "We do have a drug abuse problem in this country, and this document should help to insulate pain management from the war on drugs."

Charlotte LoBuono


Charlotte LoBuono. New document presents DEA's stand on pain management. Drug Topics Sep. 13, 2004;148:25.

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