"Trends In Medical Use and Abuse of Opioid Analgesics"

This article challenges the conventional wisdom that drugs used for relief of severe pain - such as morphine - are widely abused. From 1990 to 1996 there were significant increases in the amounts of opioids such as morphine prescribed by physicians in the US. During this period, abuse of opioids remained low and stable, accounting for a small part of the national drug abuse problem.

Citation: Joranson DE, Ryan KM, Gilson AM, Dahl JL. Trends in medical use and abuse of opioid analgesics. JAMA. 2000;283(13):1710-1714.

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JAMA News Release

PPSG Press Release

JAMA News Release

Media Advisory: To contact David E. Joranson, M.S.S.W., call the Pain & Policy Studies Group at (608) 263-7662

Increase in Opioid Analgesic Use Doesn't Necessarily Equate to Increase in Abuse
Study suggests opioid abuse accounting for smaller proportion of all drug abuse

CHICAGO - The use of opioid analgesics (medications with actions similar to opium) to treat pain is increasing; however, new data suggests the abuse of opioid analgesics relative to all drug abuse may be declining, according to an article in the April 5 issue of The Journal of the American Medical Association (JAMA).

David E. Joranson, M.S.S.W., from the Pain & Policy Studies Group at the University of Wisconsin Medical School, Madison, and colleagues obtained information on the extent of medical use of opioid analgesics from 1990 to 1996 using data maintained by the U.S. Drug Enforcement Administration. They used the Drug Abuse Warning Network (DAWN), a nationally representative sample of hospital emergency department admissions resulting from drug abuse, as the source for data on opioid abuse from 1990 to 1996.

The authors found that from 1990 to 1996, there were increases in medical use of morphine (59 percent), fentanyl (1,168 percent), oxycodone (23 percent) and hydromorphine (19 percent) and a decrease in the medical use of meperidine (35 percent). During the same period, reports of abuse decreased for meperidine (39 percent), oxycodone (29 percent), fentanyl (59 percent) and hydromorphone (15 percent) and increased for morphine (3 percent).

The authors write that the present trend of increasing medical use of opioid analgesics to treat pain does not appear to be contributing to increases in the health consequences of opioid analgesic abuse: "To maintain this trend, manufacturers, pharmacies, clinicians, and patients should continue their efforts to improve pain management while exercising care so that the diversion of opioid medications for non-medical use is minimized."

"Concerns related to drug abuse permeate efforts to treat pain with opioids," the authors write. "Patients are concerned about becoming addicted to opioids. Health care professionals may be reluctant to prescribe, administer, dispense, or stock controlled substances for fear of causing addiction or contributing to the drug abuse problem."

The researchers evaluated abuse trends for opioid analgesics as a class, as well as the medical use and abuse of five specific Schedule II opioids: fentanyl, hydromorphone, meperidine, morphine and oxycodone. The DAWN source provided specifics about people visiting hospital emergency departments for problems related to drug use (ie overdose, adverse reactions to drugs, problems due to long-term drug use, etc.).

"For each episode of drug abuse, as many as four different substances, in addition to alcohol, can be recorded. Each is referred to as a mention," the authors explain. The total number of drug abuse mentions per year due to opioid analgesics increased from 32,430 to 34,563 (6.6 percent), although the proportion of mentions for opioid abuse relative to total drug abuse mentions decreased from 5.1 percent to 3.8 percent.

"Several caveats are needed to place these results in context. First, these data also indicate that there is some abuse of opioid analgesics," the authors write. "However, compared with the abuse of other drugs, illicit drugs in particular, the abuse of opioid analgesics appears to be relatively low, accounting for 3.8 percent of total DAWN mentions in 1996. Moreover, even though there were increases in the total number of mentions of abuse for opioid analgesics during the study period, the proportion of mentions for opioid abuse relative to total reports of drug abuse decreased by 25 percent (from 5.1 percent to 3.8 percent)."

"Second, the DAWN system may underestimate the extent of the drug abuse problem. The DAWN system measures only those episodes of drug abuse that result in an admission to an Emergency Department and thus under reports the true extent of all drug abuse, such as drug-related overdoses and deaths occurring out of the hospital....Furthermore, our study primarily addresses changes in abuse trends rather than abuse levels at a single point in time."

(JAMA. 2000;283:1710-1714)

Editor's Note: Mr. Joranson receives honoraria from Knoll Pharmaceutical, Purdue Pharma and Janssen Pharmaceutical. He also receives unrestricted grants from Knoll Pharmaceutical and Purdue Pharma and is a consultant for Purdue Pharma. Dr. Dahl, another of the researchers, serves on the Speakers Bureau for Purdue Pharma and is a consultant for Knoll Pharmaceuticals. This research was supported by a grant from the Robert Wood Johnson Foundation.

PPSG Press Release

April 5, 2000

To contact David E. Joranson, M.S.S.W., call the Pain & Policy Studies Group at (608) 263-7662

Abuse of Narcotic⁽¹⁾ Pain Medications Remains Low as Medical Use Increases

Madison, WI - An article published in the April 5^th Journal of the American Medical Association (JAMA) challenges the conventional wisdom that drugs used for relief of severe pain--such as morphine--are widely abused. The work was done by the Pain & Policy Studies Group (PPSG) of the University of Wisconsin Comprehensive Cancer Center.

First, the study found that from 1990 to 1996 there were significant increases in the amounts of opioids such as morphine prescribed by physicians in the U.S. (Morphine and other opioids are medically essential for the relief of severe pain and are approved for medical use by prescription only.) "Although there are many ways to treat pain, the increased medical use of opioids is a strong indicator that we are making progress to improve pain management," said David E. Joranson, lead author and Director of the PPSG.

Second, the study found that abuse of opioids was low and stable, accounting for a small part (less than 5%) of the national drug abuse problem, as measured by drug overdoses. (Opioids have a potential for abuse and are controlled under federal and state law as controlled substances.) From 1990 to 1996 abuse of opioids increased 6.6 % in contrast to the abuse of the category illicit drugs, including cocaine and heroin which increased by 109 %. "At a time when abuse of illicit drugs continues to increase, it is reassuring that abuse of opioid pain medications is a small part of the U.S. drug problem," said Joranson.

One of the reasons for inadequate pain management is that health professionals fear that opioid medications will be abused. Co-author Karen Ryan, Chief Policy Analyst for the PPSG, said "This study suggests that increased use of opioid pain medications resulting in abuse may be based more on myth than reality. This is exceptionally good news for pain patients and for public health officials."According to Joranson, "However, we must continue to exercise caution with opioids, since there is an illicit demand for these drugs. Health care professionals and patients should continue to exercise appropriate care to avoid diversion and abuse of pain medications."

According to Ms. Ryan, "These results indicate that the U.S. could be a model for how to achieve a balanced controlled substances policy, that is, one which can improve the availability of opioids for medical purposes while limiting abuse."

The article, titled "Trends in Medical Use and Abuse of Opioid Analgesics," examined data from two sources sponsored by the federal government: 1) medical use data from the Automation of Reports and Consolidated Orders System (U.S. Drug Enforcement Administration) that collects information on the national distribution of selected drugs to pharmacies and hospitals, and 2) abuse data from the Drug Abuse Warning Network (Substance Abuse and Mental Health Services Administration) that collects data about drug overdoses from a nationally representative sample of general hospital emergency departments.

For more information about the JAMA article, the Pain & Policy Studies Group, federal and state pain-related policies, and a variety of resources about pain and policy, contact http://www.medsch.wisc.edu/painpolicy/ The Pain & Policy Studies Group is a World Health Organization Collaborating Center for Policy and Communications in Cancer Care. Its mission is the study of public policy in relation to pain management. The PPSG program of policy research, development, and education is funded primarily by the Robert Wood Johnson Foundation.

1. "Narcotic" is an old legal term which is being replaced by the modern medical term "opioid."