March 2015, Vol 3, No 3 - Inside Pain Management
Attila Mihalik, PharmDc

The United States—one of the most developed and technologically advanced nations in the world—continues to struggle with healthcare costs.1-4

In 2013, the United States spent almost $3 trillion on healthcare.1,2,5 Compared with other nations, the United States had the highest healthcare spending per gross domestic product, 17.9%.1 Part of this problem is the ever-increasing number of prescriptions and their diversion, specifically in the opioid class.4 In 2012, healthcare providers wrote 259 million painkiller prescriptions, enough for every adult in the country to receive their own pill bottle.6 As a country comprising approximately 5% of the global population, the United States consumes 80% of the world’s opioid supply.1,2,4

Even though these drugs continue to get prescribed, healthcare professionals should be aware of the issues associated with illicit drugs.

Confronting Substance Abuse

Pain medicine, drug overprescribing, drug overdose, and healthcare costs have all significantly increased in the past decade.4,5,7 According to the Centers for Disease Control and Prevention (CDC), drug overdose was the leading cause of injury leading to death in 2012.7 In the past 20 years alone, opioid painkiller use has increased by at least 10-fold.8 Substance abuse treatment admission rate was 6 times higher in 2009 than in 1999.9 The Department of Justice estimates that the direct and indirect costs of illicit drug use exceeded $193 billion.10

The majority suffers at the expense of illicit drug users who become savvy with the system and how to abuse it.11 In 2010, more than 12 million individuals used painkillers nonmedically.12 One of the most significant cases of wrongful prescribing was the Florida “Pill Mill” brothers, where Christopher and Jeffrey George successfully created an oxycodone distribution center. In 2 years, more than 20 million oxycodone pills were prescribed, making it the largest organization in illegal painkiller distribution in the United States.13 According to South Florida’s District Attorney, 32 people were charged as part of the criminal organization.

Although most painkillers are prescribed by primary care physicians abusing their scope of practice, according to the CDC, most prescriptions are obtained through friends, relatives, or other sources.11 The Cardinal Health distribution center in Lakeland, FL,14 raised numerous red flags, including 2 CVS pharmacies in Sanford, FL, that ordered more than 3 million dosage units of oxycodone in 1 year; the average pharmacy orders about 69,000 units, according to the US Food and Drug Administration.14 After a Drug Enforcement Administration investigation of CVS and Cardinal Health’s ban on supplying controlled substances in Florida, the Drug Enforcement Administration resolved the issue with various reporting requirements and settling lawsuits with both companies.

Monitoring controlled substances is very important in retail pharmacy and clinics. The industry is intertwined, from distributors to prescribers to dispensers, and it is everyone’s responsibility that proper medication get to the patients who rightly need it.

Battling Abuse and Misuse

Transformation and change must occur inside of the healthcare professional team for drug abuse and misuse to improve. Although state prescription drug monitoring programs are improving across the nation, they are still not enforced everywhere.15 By requiring these programs through legislation, physician shopping or early refills can be avoided, leading to less wrongfully written and dispensed medications.

As patients become more involved in their daily health, healthcare professionals, such as pharmacists and retail clinicians, must take the time to educate them about the risks and benefits of pain treatments, alternatives, and proper abuse treatments. By providing these services—keeping in mind the proper level of health literacy—patients are much less likely to have problems from abuse or misuse.16

Furthermore, it is critical for physicians, pharmacists, physician assistants, nurses, and other healthcare professionals to follow best practices, such as monitoring medication combinations, using lowest effective doses, and screening for possible abuse potential and mental health problems.6 Healthcare professionals, especially community pharmacists, need to be aware of the individual and his or her particular situation leading to pain management therapy. By understanding what type of pain the patient is experiencing, some treatments may be more optimal than others.


Although some patients may be at risk for medication abuse, healthcare professionals must use their best judgment to not reject those who are truly suffering.

I practice in a small town with 2 pharmacies. The primary population is on the lower socioeconomic side. The pharmacy has low medication adherence for blood pressure, diabetes, and other chronic diseases. This impacts the completeness and accuracy of many profiles within our computer system. Many uncertainties can arise about new pain prescriptions, especially because the major medical centers are far from the town. Even though it is important to carefully analyze all prescriptions that enter our pharmacy, it is equally important to ensure that there is no harm done to patients by denying their legitimate pain prescriptions.

I challenge you to consider the following argument by Sir William Blackstone for patients abusing pain medicine to those who need it and are possibly turned away: “It is better that 10 guilty persons escape than that one innocent suffer.”


  1. The World Bank. World DataBank. Accessed March 5, 2015.
  2. United Nations Statistics Division. National Accounts Main Aggregates Database. Updated December 2014. Accessed March 5, 2015.
  3. United Nations Development Programme. Human Development Reports. Updated 2014. Accessed March 5, 2015.
  4. Manchikanti L, Fellows B, Ailinani H, et al. Therapeutic use, abuse, and nonmedical use of opioids: a ten-year perspective. Pain Physician. 2010;13:401-435.
  5. Centers for Medicare & Medicaid Services. National health expenditures 2013 highlights. lights.pdf. Accessed February 3, 2015.
  6. Centers for Disease Control and Prevention. Opioid painkiller prescribing. scribing. Updated July 1, 2014. Accessed February 3, 2015.
  7. Centers for Disease Control and Prevention. Prescription drug overdose in the United States: fact sheet. Updated January 9, 2015. Accessed February 3, 2015.
  8. American Society of Interventional Pain Physicians. The American Society of Interventional Pain Physicians (ASIPP) fact sheet. FactSheet101111.pdf. Accessed February 3, 2015.
  9. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report (MMWR). Published November 4, 2011. Accessed January 22, 2015.
  10. US Department of Justice. The economic impact of illicit drug use on American society. Published April 2011. Accessed February 3, 2015.
  11. Centers for Disease Control and Prevention. Policy impact: prescription painkiller overdoses. Updated July 2, 2013. Accessed February 3, 2015.
  12. Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on drug use and health: summary of national findings, NSDUH Series H-41, HHS Publication No. (SMA) 11-4658. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2011.
  13. US Department of Justice. Thirty-two indicted in Broward and Palm Beach counties in second coordinated pill mill takedown. Published August 23, 2011. Accessed March 5, 2015.
  14. US Drug Enforcement Administration. DEA revokes two CVS retailers’ ability to sell controlled substances. Published September 12, 2012. Accessed March 5, 2015.
  15. Rutkow L, Turner L, et al. Most primary care physicians are aware of prescription drug monitoring programs, but many find the data difficult to access. Health Aff (Millwood). 2015;34:484-492.
  16. Gill PS. Prescription painkillers and controlled substances: an appraisal of drug information provided by six US pharmacies. Drug Health Patient Saf. 2013;5:29-36.
Related Items
Opioid-Induced Constipation
Amanda R. McFee Winans, PharmD, BCPS, Jayne Pawasauskas, PharmD, BCPS, Leah Sera, PharmD, BCPS
January 2016, Vol 4, No 1 published on January 28, 2016 in Inside Pain Management
Acetaminophen Lacks Effectiveness in Knee Osteoarthritis
March 2015, Vol 3, No 3 published on April 16, 2015 in Inside Pain Management
Last modified: May 15, 2015
  • American Health & Drug Benefits
  • The Journal of Hematology Oncology Pharmacy
  • Lynx CME
  • The Oncology Pharmacist