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A consensus document from the American Academy of Pain Medicine, the American Pain Society and the American Society of Addiction Medicine.
Background
Health care professional (HCP) concerns regarding the potential for harm to patients, as well as possible legal, regulatory, licensing or other third-party sanctions related to the prescription of opioids, contribute significantly to the mistreatment of pain. HCPs are obligated to act in the best interest of their patients. This action may include the addition of opioid medication to the treatment plan of patients whose symptoms include pain. Though many types of pain are best addressed by non-opioid interventions, opioids are often indicated as a component of effective pain treatment. It is sometimes a difficult medical judgment as to whether opioid therapy is indicated in patients complaining of pain because objective signs are not always present.
A decision whether to prescribe opioids may be particularly difficult in patients with concurrent addictive disorders, or with risk factors for addiction, such as a personal or family history of addictive disorder. For such persons, exposure to potentially rewarding substances may reinforce drug taking behavior and therefore present special risks. It is, nonetheless, a medical judgment that must be made by a HCP in the context of the provider-patient relationship based on knowledge of the patient, awareness of the patient's medical and psychiatric conditions and on observation of the patient's response to treatment. The selection of a particular opioid, or combination of opioids, and the determination of opioid dose and therapeutic schedule similarly must be based on full clinical understanding of a particular situation and cannot be judged appropriate or inappropriate independent of such knowledge. All schedule II-V opioids, including methadone, may be appropriate choices for pain control in different circumstances; it is critical that clinicians understand the special pharmacologic characteristics of each medication in order to prescribe them safely and effectively for pain.
Despite appropriate medical practice, health care providers who prescribe opioids for pain may occasionally be misled by patients who wish to obtain medications for purposes other than pain treatment, such as diversion for profit, recreational use or perpetuation of an addicted state. Physicians who are willing to provide compassionate, ongoing medical care to challenging and psychosocially stressed patients, where that treatment includes the prescription of opioids, assume an additional obligation to understand the risks and management of addictive disease because they risk complications of care more often than physicians unwilling to treat this population.
Addiction to opioids may occur despite appropriate opioid therapy for pain in some susceptible individuals. Persistent failure to recognize and provide appropriate medical treatment for the disease of addiction is poor medical practice and may become grounds for practice concern. Similarly, persistent failure to use opioids effectively when they are indicated as part of the treatment of pain, including in persons with active or recovering addiction, is poor medical practice and may also become grounds for practice concern. It is important to distinguish, however, between HCPs who are knowingly complicit in diversion or other illegal prescribing activities and physicians who may inappropriately prescribe opioids due to misunderstandings regarding addiction or pain. HCPs traditionally have received little or no education on addiction or clinical pain treatment in the course of training. This omission is likely a basis for inadequate detection and management of addiction and inadequate assessment and treatment of pain.