John is a 52-year-old male patient of Dr. Al Peigngone. His case exemplifies the complex challenges chronic pain and opioids present for both patients and PCPs. For the past 6 months, John has been receiving Vicodin from Dr. Peigngone for help with his chronic back pain. In addition, John has a number of other chronic conditions, including obesity, diabetes, hypertension, and depression. He has been on disability for the last 5 years because of his chronic pain and depression. When he first presented for care with Dr. Peigngone, he was already using Vicodin occasionally for pain. John said that a pain clinic had started him on that prescription a few years earlier and that John’s previous PCP had continued it. Dr. Peigngone was somewhat reluctant to continue prescribing the Vicodin, but John was insistent that it be continued. He said he had been to physical therapy as well as a back strengthening program, had been tried on many other medications for the pain, and had even tried biofeedback for a brief stint. Despite all this, his back pain continued to be so severe that John did not feel able to work or even to engage in many daily chores around the house. He insisted that the only relief he obtained was with the Vicodin.

Dr. Peigngone could see that John was often in pain, but he was at a bit of a loss regarding what to do about it. He could find no clear explanation for John’s pain and found it hard to see Vicodin as an essential part of treatment for chronic back pain. He had received records from John’s previous PCP, which verified that John had been receiving Vicodin from his former PCP, but the records contained no other insights regarding a good treatment plan. Unfortunately, John had gone to that PCP for only several months before coming to Dr. Peigngone, and the pain clinic that reportedly started John on Vicodin never sent Dr. Peigngone’s office any records. Thus, Dr. Peigngone had limited information about past treatments. He considered various non-opioid treatments, but John refused every one, claiming to have already tried them all without success.

Dr. Peigngone was also quite concerned about the state of John’s diabetes and hypertension; both were, for the most part, poorly controlled. By the time he addressed these conditions during visits, little time was left for discussing John’s back pain. Given all of this, Dr. Peigngone fell into a habit of simply refilling John’s Vicodin at each visit. He reasoned that at least it seemed to help John’s pain, and frankly, he suspected that trying to stop or reduce the Vicodin would result in protests from John that would add more time to an already typically lengthy visit. Dr. Peigngone dreaded visits with John because of the complexity of John’s problems and his typically grumpy demeanor, so he had little interest in making the situation more complex.

After around 9 months, John began asking Dr. Peigngone to increase the dosage of his Vicodin or to allow him to take it more frequently. He was very frustrated that his pain was still so disabling. He had dropped out of most meaningful life activities, spending most of his days inside watching TV. His weight continued to increase, and he continued to have problems controlling his blood pressure and blood glucose levels. Most of his friends had stopped visiting him because he was not much fun to be around, and most family members had lost patience with him, calling him “lazy” and accusing him of faking his pain. John was convinced that more Vicodin was the answer to fixing these problems.

Dr. Peigngone initially agreed to increase John’s Vicodin, hoping it would help. However, John then started showing up early for refills, claiming he had used more than prescribed because it had been a “bad month.” After two such occurrences, Dr. Peigngone refused to refill John’s medication early, which severely rankled John. He accused Dr. Peigngone of being insensitive and, for a short time, refused to leave the exam room without a refill. Two months later, he again requested an early refill this time claiming someone had stolen the Vicodin from his bathroom. He suspected it had been a friend who he knew had a drug problem. This prompted Dr. Peigngone to ask John to complete a urine drug screen (to test for street drugs and prescription medications). He was concerned about John’s deterioration over the past several months and wondered if John might be abusing Vicodin and/or other substances. John became extremely angry at this request and refused to leave a urine sample. He accused Dr. Peigngone of treating him “like a criminal” and stormed out of the clinic without completing the visit.

The next day, Dr. Peigngone received a call from John’s wife. She expressed concern about John’s status. She told Dr. Peigngone that John had a history of drug problems and she was concerned that he had been abusing his Vicodin. She said that John had left doctors in the past because they refused to refill his Vicodin due to concerns he was overusing it and possibly using it in conjunction with street drugs. She had noticed his functioning deteriorating in recent months and wanted to ensure that Dr. Peigngone knew this part of John’s history. Upon hearing this news, Dr. Peigngone felt betrayed and worried. He was concerned that he had inadvertently contributed to a substance abuse problem and felt guilty he had not discovered it earlier. He asked John’s wife to encourage John to return to the clinic, where they could talk about these problems, but John never returned.

The case of John and Dr. Peigngone will probably sound familiar to many PCPs. Like these two, many patients and PCPs have gotten swept up in medication misuse and abuse problems that have reached epidemic proportions. The Centers for Disease Control estimates that prescription of opioids in the United States has increased 400% since 1999 (see Web Link 1), mostly in response to a well-intended effort to better help individuals with chronic pain. The United States now consumes more opioid medication than the rest of the world combined (Kenan, Mack & Paulozzi, 2012). Opioids have long been considered an important component of managing chronic pain in patients with cancer. But as awareness grew during the 1990s of the problems related to other types of chronic pain (e.g., chronic musculoskeletal pain in the back, neck, knees, etc.), logic suggested expanding the use of opioids to help with these problems as well. For example, in 2000, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) began requiring healthcare providers to make pain the “5th vital sign.” This meant that providers were required to assess for the presence of pain at each patient visit in order to obtain JCAHO accreditation.

While intentions might have been good, the outcome was not. As the rate of opioid prescribing increased dramatically the past couple of decades, the rate of prescribing for non-opioid pain medication remained stable or even declined (Alexander, Kruszewski & Webster, 2013). In other words, our efforts to better treat chronic pain have mostly focused on flooding the country with opioids, not aspirin. PC has been a key player in all of this. Dentists and PCPs prescribe the overwhelming majority of opioid medications (Volkow, McLellan, Cotto, Karithanom & Weiss, 2011).

As a direct result of the increased opioid supply, many people have developed problems from misuse and/or abuse of opioids. From 1994 to 2001, there was a 117% increase in the number of ER visits related to opioid abuse, and from 2004 to 2011, these visits increased by another 183% (SAMHSA, 2013). A SAMHSA report (2011) found that in 2009, about 700,000 people sought substance abuse treatment for opioid abuse/dependence, far more than for any other prescription medication.

Worse yet, many people do not survive this problem. Since 1990, the number of deaths due to drug overdose has tripled, with opioids implicated in three out of every four (Centers for Disease Control and Prevention, 2012). In 2014, the Centers for Disease Control reported that death related to overdose has become the leading cause of accidental death in many areas of the country (see Web Link 1). The Appalachian region and the southwest United States tend to have the most problems, but no part of the country is immune (see Web Link 1). The problem also shows little sign of abating. Results from the 2012 National Survey on Drug Use and Health found that many people continue to join the ranks of those abusing opioids, with an abuse initiation rate second only to marijuana for people aged 12 and older (SAMHSA, 2011; see Web Link 2).

As noted above, the vast majority of legitimate (i.e., prescribed) opioid use originates from the prescription pad of a PCP or dentist. It may be no surprise, then, that the majority of medications implicated in abuse and overdose events originate from that same pad. In the case of medication abuse, the opioids are most often obtained from a family member or friend who has a legitimate prescription. In the case of overdose events, the person was typically receiving multiple prescriptions from different prescribers or was being maintained on a very high daily dose of opioids from one prescriber (see Web Link 1). Thus, efforts to reduce abuse and overdose events need to focus on ensuring that patients safeguard their medications, use only one prescriber, and use the lowest dose possible. We return to these and other strategies for reducing opioid abuse later in the chapter.

Controlled substances include not only opioids but also benzodiazepines (typically used for anxiety and sleep problems) and stimulants (typically used for ADHD). Benzodiazepines are technically classified as Central Nervous System (CNS) depressants, along with barbiturates. But because barbiturates are far less commonly encountered in PC, we will focus only on benzodiazepines here. Also worth noting is that opioids are sometimes also referred to as narcotics or opiates, and there are technical reasons to use one label over another. Most commonly, the term opioid refers to the painkiller medications that this chapter focuses on. Table 14.1 lists the generic (and brand) names, and other characteristics, of the more commonly used controlled substances.

As illustrated in Table 14.1, all controlled substances are associated with some risk of abuse, which is why their use is more tightly controlled than other medications. There are actually five categories, or schedules, of controlled substances. Medications are assigned to a given schedule based on their perceived medical usefulness as well as their potential for abuse. The DEA decides which schedule a medication is placed into. Schedule 1 contains drugs that are deemed to have no medical utility and a very high potential for abuse; these generally cannot be prescribed. Schedule 5 contains drugs that are deemed to be helpful medically and have the least potential for abuse. Most of the opioids used for chronic pain are in Schedule 2 and 3. More anxious chronic pain patients may end up using some of the Schedule 4 medications. Table 14.2 shows a sampling of the medications listed as controlled substances in each schedule.

One important point is that while all of these drugs have the potential for abuse, opioids are overwhelmingly the largest cause for concern. Stimulants, for example, were involved in only about 31,000 of the more than 1,400,000 ER visits associated with prescription drug abuse in 2011. Opioids, by contrast, were involved in about 420,000 of those visits (Substance Abuse and Mental Health Services Administration, 2011). Further, as noted above, opioids are responsible for the vast majority of overdose deaths. Benzodiazepines, while commonly abused, are rarely abused in isolation. Usually alcohol and/or opioids are abused simultaneously (Substance Abuse and Mental Health Services Administration, 2011; SAMHSA, 2013). Benzodiazepines potentiate, or enhance, the effects of both of these substances, so their abuse may be motivated by a desire to feel more intoxicated. Additionally, benzodiazepines can alleviate opioid withdrawal symptoms, so opioid-dependent individuals often use benzodiazepines for this reason. Given all of this, if a clinic is vigilant about detecting and avoiding opioid abuse, odds are good that benzodiazepine abuse will also be detected and avoided.