Most people who have chronic pain — a bad back, arthritis, or many other ailments — see their primary care physician for treatment. If ibuprofen doesn't ease the ache, these doctors often prescribe narcotic drugs like Vicodin, Percocet and OxyContin.
Although the drugs, which trace their roots to the opium poppy, reduce pain, they also carry significant risks and can cause breathing to stop in large doses or when mixed with other drugs or alcohol. Yet research shows that many primary care doctors aren't monitoring their patients use of the medicines to make sure they aren't abused or misused.
It's not an academic issue. More people die from accidental overdoses of prescription opioids annually than they do from cocaine and heroin combined: 11,499 in 2007, according to the Centers for Disease Control and Prevention.
Patient monitoring can take many forms, all generally aimed at making sure that patients take only the drugs prescribed to them — and don't share or sell them. Some doctors ask patient to sign "pain contracts" or "opioid treatment agreements" that spell out these measures. But a recent study found that three of the most common strategies to ensure patients comply with their drug regimens aren't usedunderused by primary care doctors.
The study, published in February in the Journal of General Internal Medicine, examined the medical records of 1,612 chronic pain patients at eight primary care clinics in the Philadelphia area over a five-year period ending in 2008. It found that only 8 percent were given urine tests, half were scheduled for office visits at least once every six months, and 76 percent were restricted from refilling their prescriptions early.
Part of the problem is practical. "It's easy to say that it's useful to do prescription monitoring and urine screening, but building this stuff into day-to-day practice is hard," says Perry Fine, president of the American Academy of Pain Medicine.
The other sticking point is a lack of education, of physicians and the general public, about how to prescribe and take these drugs safely, say experts. "Primary care doctors haven't been taught a lot about pain management," says Penney Cowan, founder and executive director of the American Chronic Pain Association, a patient advocacy group. This leads them to sometimes undertreat pain, on the one hand, or prescribe it without proper monitoring, on the other.
"Those who need those drugs should be able to get access," she says. "But if a healthcare provider chooses to give them opoids, then patients need to be educated."