Physicians who prescribe opioids should be more vigilant and step up monitoring, but not avoid prescribing these drugs when needed for pain management, according to A. Thomas McLellan, Ph.D. and Barbara J. Turner, M.D., MSED in an editorial appearing in the December 10, 2008 Journal of the American Medical Association (JAMA).

Their editorial accompanied a study in the same JAMA issue by Aron Hall, M.D. and other CDC researchers finding that prescription opioids were involved in 275 of the 295 overdose deaths in West Virginia in 2006, and that less than half of those who died had actually been prescribed the drugs. The findings, which McLellan and Turner called "disturbing," suggest that diversion of expensive and potent pain medications (sold or stolen) can lead to lethal outcomes.

"These findings provide further evidence of how significant abuse and misuse of prescription medications has become to America's drug problem," McLellan said. "We know that legitimate, doctor prescribed and managed opioid use is on the rise because of the high prevalence of chronic pain-causing diseases like arthritis. Very disturbing, however, is the rapid increase in accidental drug overdoses, most from opioid use," he said.

"The real message - from this and other studies - is that physicians should increase monitoring, particularly for patients who admit to a history of substance use/abuse when formally queried," he said, "and they should be queried."

In addition to asking patients about past drug, alcohol, and possibly tobacco use, McLellan and Turner recommended executing agreements where patients assent to: receiving opioid drugs from one physician and one pharmacy; limits on timing of refills; taking the medications as prescribed; and adhering to doctor visits for urine screens and other safety checks. Another necessary monitoring tool, they said, is through statewide or even multi-state prescription monitoring databases that physicians can easily access from their offices. "For 20% of the West Virginia deaths, patients appeared to be 'doctor shopping' (obtaining prescriptions from multiple physicians, sometimes based on fraudulent claims of pain or other symptoms). This makes a compelling case for prescription monitoring programs that span multiple states - but such databases are not widely available," they said.

Copies of the editorial and the CDC study can be obtained from the JAMA website.