Prescription Drug Monitoring and Drug Abuse - Literature review Example

Prescription Drug Monitoring and Drug Abuse A severe problem in the United s over the past decade has been the abuse of opioid analgesics. Oftentimes, this abuse leads to addiction to the medications. This problem has grown even more severe over the past few years. The problem appears to have grown, at least in part, because of prescribing practices, easy access via the Internet, and drug formulation changes (Fishman, et al, 2000 and Simoni-Wastila, Tompkins, 2001). According to Compton and Volkow (2005), "Though the use of opioid analgesics for the treatment of acute pain appears to be generally benign, long-term administration of opioids has been associated with clinically meaningful rates of abuse or addiction. Important areas of research to help with the problem of opioid analgesic abuse include the identification of clinical practices that minimize the risks of addiction, the development of guidelines for early detection and management of addiction, the development of opioid analgesics that minimize the risks for abuse, and the development of safe and effective non-opioid analgesics. With high rates of abuse of opiate analgesics among teenagers in the United States, a particularly urgent priority is the investigation of best practices for treating pain in adolescents as well as the development of prevention strategies to reduce diversion and abuse." This addresses the issue of the abuse and misuse of prescription drugs. Purpose Determining whether or not a person is abusing or is addicted to a prescription medication can be a daunting task for officials. This is particularly true for patients receiving chronic pain relievers such as opioids (Compton, Darakjian, and Miotto, 1998). Prescription drugs that are commonly prescribed for this purpose include fentanyl, hydromorphone, meperidine, morphine, and oxycodone. Opioid analgesics appear to be the prescription drugs most commonly abused (Weaver and Schnoll, 2002 and Zachny, et al, 2003). "In 2002, opioid analgesics accounted for 9.85% of all drug abuse, up from 5.75% in 1997. Increase in medical use of opioids is a general indicator of progress in providing pain relief. Increases in abuse of opioids is a growing public health problem and should be addressed by identifying the causes and sources of diversion, without interfering with legitimate medical practice and patient care" (Gilson, Ryan, Joranson, and Dahl, 2004, pg. 1). Search Strategies Since this manuscript is academic in nature, only academic journals were used as reference material. An Internet search was conducted utilizing a keyword search of 'prescription drug monitoring and drug abuse.' When the results were returned via the Google search engine, 'scholarly resources' for the keyword string was chosen and the resources were carefully picked from that subcategory according to content and relevance. Background/Significance According to Bedell (2000, pg. 2129), "Misuse of medications is a major cause of morbidity and mortality. Few studies have examined the frequency of, and factors associated with, discrepancies between what doctors prescribe and what patients take in actual practice. Discrepancies among recorded and reported medications were common and involved all classes of medications, including cardiac and prescription drugs. Older age and polypharmacy were the most significant correlates of discrepancy. The pervasiveness of discrepancies can have significant health care implications, and action is urgently needed to address their causes. Such action would likely have a positive impact on patient care." Chronic, nonmalignant pain is often treated with opiate drugs. Due to the addictive nature of opiates, this practice is quite controversial. One study on the problem took place at Seattle's VA Medical Center. It was designed to "create opiate abuse criteria, test inter-rater reliability of the criteria, apply the criteria to a group of chronic pain patients, and correlate the risk of opiate abuse with the results of alcohol and drug testing" (Chabal, et al, 1997, pg. 150). Conclusions showed that opiate abusers could not be pinpointed, at least in this study, based on past opiate or alcohol abuse (Chabal, et al, 1997). Integrated Literature Review Cicero, T.; E.H. Adams; A. Geller; J.A. Inciardi; et al. (1999). A postmarking surveillance program to monitor Ultram (tramadol hydrochloride) abuse in the United States. Elsevier Science Ireland Ltd. This study was conducted on the prescription drug Tramadol HCl (Ultram). When this drug was first introduced into the pharmaceutical market, it had been determined that the risk of abuse and/or addiction to the drug was relatively low. It was introduced in 1995 on a non-scheduled status. Approval for the non-scheduled status depended upon a surveillance program being developed. This program was to be overseen by a steering committee that would be able to detect levels of abuse that were deemed to be extensive. "The postmarketing surveillance program consisted of systematic collection and scientific evaluation of reports of suspected abuse in high-risk populations surveyed through an extensive key informant network of drug abuse specialists and all spontaneous reports of abuse received through the FDA MedWatch system" (Cicero, et al, 1999). The conclusions read that most abusers of this drug had prior substance abuse records. Very few individuals abused this drug without having abused drugs previously. Furthermore, the abuse cases appear to be located in isolated areas of the country that do not show to have large numbers of street drug abusers. Therefore, it appears that tramadol is not a significant threat in the area of abuse and should not be scheduled (Cicero, et al, 1999). Cicero, T.J.; J.A. Inciardi; and A. Munoz. (2008). Trends in abuse of OxyContin and other opioid analgesics in the United States: 2002-2004. Washington University Pain Center. According to this article, "Over the past 5 years, there have been reports, frequently anecdotal, that opioid analgesic abuse has evolved into a national epidemic. In this study, we report systematic data to indicate that opioid analgesic abuse has in fact increased among street and recreational drug users, with OxyContin and hydrocodone products the most frequently abused. Steps need to be taken to reduce prescription drug abuse, but very great care needs to be exercised in the nature of these actions so the legitimate and appropriate use of these drugs in the treatment of pain is not compromised as a result" (Cicero, Inciardi, and Munoz, 2008). In 1995, OxyContin was released as a slow-release formulation of oxycodone hydrochloride. This slow-release formulation was thought to have a much lower risk of abuse and/or addiction than its fast-release counterpart, and, thus, had been deemed as being a safer alternative. However, reports soon surfaced of its abuse as well, and this occurred on a widespread basis. In response, the RADARS (Researched Abuse, Diversion and Addiction-Related Surveillance) system was developed as a means to survey the reported abuse. This article focused on one branch of the RADARS system, which was the utilization of key informants. "The results indicate that prescription drug abuse has become prevalent, with cases reported in 60% of the zip codes surveyed. The prevalence of abuse was rank ordered as follows: OxyContin > hydrocodone > other oxycodone > methadone > morphine > hydromorphone > fentanyl > buprenorphine. In terms of the magnitude of abuse (>5 cases/100,000 persons in a 3-digit zip code), modest growth was seen with all analgesics over the 10 calendar quarters we monitored, but was most pronounced with OxyContin and hydrocodone. These results indicate that OxyContin abuse is a pervasive problem in this country, but that it needs to be considered in the context of a general pattern of increasing prescription drug abuse" (Cicero, Inciardi, and Munoz, 2008). Fraser, A.D. (1998). Use and abuse of the benzodiazepines: Proceedings of the Fifth International Congress of Therapeutic Drug Monitoring and Clinical Toxicology. Therapeutic Drug Monitoring, 20(5): 481-489. This article discusses the abuse and addiction problems associated with benzodiazepines. They have been around a long time-since 1961-and have since proven to be effective in treating a variety of disorders. "This drug class for the central nervous system has been considered one of the safest in use for 35 years, especially when the benzodiazepines are compared with the barbiturates they often replaced" (Fraser, 1998, pg. 481). This article covers the availability and distribution of benzodiazepine drugs today. The article tracks the drug all the way around the globe, and also takes a look at how these drugs are used clinically. The article also presents cases of overdoses, long-term therapeutic use, and various adverse effects of the drug. Also discussed is Triazolam, which was taken off of the United Kingdom market in 1991. "Benzodiazepines will continue to have an important role in clinical medicine. Their clinical use, however, should be monitored more closely because of the greater awareness of their adverse effects after long-term use and because of the potential for misuse and abuse" (Fraser, 1998, pg. 481). Friedman, R.A. (2006). The changing face of teenage drug abuse-The trend toward prescription drugs. The New England Journal of Medicine, 354(14): 1448-1450. This article covers the fact that teenage drug abuse is showing a trend away from illicit drugs and more towards prescription drugs. It tells the tale of an 18-year-old man in San Francisco named Eric. Eric claims that it is easy for him to get Vicodin on the streets. He explains, "I can get prescription drugs from different places and don't ever have to see a doctor. I have friends whose parents are pill addicts, and we borrow' from them. Other times I have friends who have ailments who get lots of pills and sell them for cheap. As long as prescription pills are taken right, they're much safer than street drugs" (Friedman, 2006, pg. 1448). Joranson, D.E., G.M. Carrow; K.M. Ryan; L. Schaefer, et al. (2002). Pain management and prescription monitoring. U.S. Cancer Relief Committee. This article discusses how important it is to have prescription medications such as controlled substances available to patients who legitimately need them, while preventing abuse of the drugs at the same time is a daunting task. This goal is of utmost importance in the United States today. Prescription monitoring programs, or PMPs, have been set up around the country as a means of preventing, identifying, and monitoring drug abuse, especially when it comes to controlled substances. PMPs are not meant to interfere with legitimate prescribing of these drugs to those who really need them, yet some feel that they do (Joranson, et al, 2002). The article discusses "a collaborative project initiated by the Pain & Policy Studies Group that brought together regulatory and pain management representatives twice in 1998 to share perspectives and reconcile differing views on the effects of PMPs. The ultimate goals of this project are to provide accurate information to healthcare clinicians about PMPs, better define the balance between preventing drug diversion and providing pain management, and promote continued dialog and cooperation among the groups" (Joranson, et al, 2002). Kirsh, K.L.; L.A. Whitcomb; K. Donaghy; and S.D. Passik. (2002). Abuse and addiction issues in medically ill patients with pain: Attempts at clarification of terms and empirical study. Clinical Journal of Pain, Addiction and Pain: Assessment and Treatment Issues, 18(4): S52-S60. All patients who suffer from chronic pain need to be carefully managed in order to ensure that they are not abusing their prescription medications, but that they are receiving adequate care. For this to be done successfully, it requires careful assessment of outcomes that are related to addiction. It is particularly hard to manage those patients who have chronic pain and a history of drug abuse. The article also discusses pseudoaddiction, which appears on the surface to be addiction. In these cases, unrelieved pain drives patients to take too much of their prescription medication (Kirsh, Whitcomb, Donaghy, and Passik, 2002). In order for patients to continuously receive safe and adequate therapy with their prescription medications such as controlled substances, substance abuse-related behaviors must be carefully monitored and managed. Those who abuse these drugs put those who really need them at risk for not being able to receive adequate pain treatment. Unfortunately, it will still take quite a while for the medical community and it's regulating authorities to devise a clear plan that draws a line between the two. The article discusses how a great deal of research needs to be done that addresses prescription-taking behaviors among patients experiencing different types of pain (Kirsh, Whitcomb, Donaghy, and Passik, 2002). "This article focuses on some of these issues as well as recounting attempts by our research group to address these issues systematically in hopes of shedding light on the nature of abuse issues in the medically ill. Although advances have been made, there is a definite need for large-scale studies that address the issues of identification and treatment of aberrant behavior in medically ill patients in the effort to provide the best possible outcomes for patients with chronic pain" (Kirsh, Whitcomb, Donaghy, and Passik, 2002, pg. S52). McLellan, A.T.; D.C. Lewis; C.P. O'Brien; and H.D. Kleber. (2000). Drug dependence, a chronic mental illness: Implications for treatment, insurance, and outcomes evaluation. JAMA, 284(13): 1689-1695. This article addresses the commonly held thought that drug abuse is a social problem rather than a medical problem because of the viewpoints commonly held regarding the effects that drug abuse has on communities and other social systems. This has led to a severe lack of medical attention regarding drug abuse treatment and prevention. The article examines "evidence that drug (including alcohol) dependence is a chronic medical illness. A literature review compared the diagnoses, heritability, etiology (genetic and environmental factors), pathophysiology, and response to treatments (adherence and relapse) of drug dependence vs type 2 diabetes mellitus, hypertension, and asthma. Genetic heritability, personal choice, and environmental factors are comparably involved in the etiology and course of all of these disorders. Drug dependence produces significant and lasting changes in brain chemistry and function. Effective medications are available for treating nicotine, alcohol, and opiate dependence but not stimulant or marijuana dependence" (McLellan, Lewis, O'Brien, and Kleber, 2000, pg. 1689). Dependence on drugs is typically treated as an acute illness. Across the illnesses discussed above, addiction and relapse is similar. The article concludes that careful management of long-term pain treatment and continuous monitoring are the keys to proper care. Drug dependence should be treated as any other type of illness would be (McLellan, Lewis, O'Brien, and Kleber, 2000). Manchikanti, L. (2006). Prescription drug abuse: What is being done to address this new drug epidemic Testimony before the Subcommittee on Criminal Justice, Drug Policy and Human Resources. Pain Physician, 9(4): 283-5. This is a review of the widespread illicit and prescription drug abuse problem today, and is based on a 2006 Congressional Hearing. According to the article, "Prescription drug abuse today is second only to marijuana abuse. In the most recent household survey, initiates to drug abuse started with prescription drugs (especially pain medications) more often than with marijuana. The abuse of prescription drugs is facilitated by easy access (via physicians, the Internet, and the medicine cabinet) and a perception of safety (since the drugs are FDA approved). In addition to the personal toll of drug abuse using prescription drugs, indirect costs associated with prescription drug abuse and diversion include product theft, commission of other crimes to support addiction, law enforcement costs, and encouraging the practice of defensive medicine" (Manchikanti, 2006, pg. 283). The article covers what is being done to address the problem today, as well as what is being planned for the future. These included programs that monitor prescription drugs, the reduction of malprescriptions, educating the public, getting rid of pharmacies that are accessible via the Internet, and the development of non-addictive and tamper-resistant future drugs (Manchikanti, 2006). The article then introduces a number of individuals who lost their children to drugs. Each of these individuals presented their own life stories and experiences, offered strategies that would work against drug abuse, tried to reach other individuals that were at all educational levels, praised the development of non-addictive drugs, and endorsed pain treatment with prescription painkillers that did not contain opioids. Other individuals presented issues including various measures to prevent drug abuse, statistics on teen drug abuse, educational programs, NASPER, multiple-level education, and the DEA (Manchikanti, 2006). Michna, E.; E.L. Ross; W.L. Hynes; S.S. Nedeljkovic; et al. (2004). Predicting aberrant drug behavior in patients treated for chronic pain: Importance of abuse history. U.S. Cancer Pain Relief Committee. According to this article, "Physicians can encounter problems in prescribing opioids for some patients with chronic pain such as multiple unsanctioned dose escalations, episodes of lost or stolen prescriptions, and positive urine drug screenings for illicit substances. This study explored the usefulness of questions on abuse history in predicting problems with prescribing opioids for patients at a hospital-based pain management program" (Michna, et al, 2004). This article covered a study of 145 patients who were using opioids for both short- and long-term periods. They were, based on specific interview questions, labeled as either low- or high-risk. They saw no variances in demographics between low- and high-risk participants. Those who showed a history of substance abuse showed to be more prone to abusing the opioids, as well as to having mental health problems, smoking more cigarettes, took more opioids, had fewer side effects, and had more car accidents (Michna, et al, 2004). O'Connor, P.G. and A. Spickard, Jr. (1997). Physician impairment by substance abuse. W.B. Saunders Company. Physicians are placed under a microscope regarding their physical and mental abilities because of the nature of their duties. "Physician impairment refers to situations in which they are rendered unable to perform their professional responsibilities adequately because of a variety of health problems, including medical disease, psychiatric problems, or substance abuse. This article focuses exclusively on physician impairment because of substance abuse. Similar to other conditions that may cause physician impairment, substance abuse is a chronic disease characterized by exacerbations that are responsive to treatment. Among the defining elements of substance abuse disorders are the resultant behavioral dysfunction, medical complications, and psychiatric disease." (O'Connor and Spickard, 1997, pg. 1). Conclusion "The controversy surrounding the, long term use of opioid drugs in patients with nonmalignant pain has intensified in recent years. This debate is driven by a new willingness to consider the potential -benefits of an approach that has been traditionally rejected as invariably, ineffective and unsafe. The published literature continues to be very limited, but a growing clinical experience, combined with a critical reevaluation of issues related to efficacy, safety, and addiction or abuse, suggests that there is a subpopulation of patients with chronic pain that can achieve sustained partial analgesia from opioid therapy without the occurrence of intolerable side effects or the development of aberrant drug-related behaviors" (Portenoy, 1996). In order to prove or disprove the impression that has been formed, further clinical trials and research must be carried out. Until this is done, physicians must be very careful when prescribing drugs to their patients. They must understand the issues at hand and have a clear grasp of the treatment guidelines, as well as monitoring that has already been proven. References Bedell, S.E.; S. Jabbour; R. Goldberg; H. Glaser; et al. (2000). Discrepancies in the use of medications: Their extent and predictors in an outpatient practice. Arch Intern Med, 160(14): 2129-2134. Retrieved July 8, 2008, from http://archinte.ama-assn.org/cgi/content/abstract/160/14/2129 Chabal, C.; M. Erjavec; L. Jacobson; A. Mariano; et al. (1997). Prescription opiate abuse in chronic pain patients: Clinical criteria, incidence, and predictors. Clinical Journal of Pain, 13(2): 150-155. http://www.clinicalpain.com/pt/re/clnjpain/abstract.00002508-199706000-00009.htm;jsessionid=LyVZvngkX2Tb5TV7qGrJK2HXMhvzy0Qp88mw39vSgTjTfnz7MFvt!-607823098!181195629!8091!-1 Cicero, T.; E.H. Adams; A. Geller; J.A. Inciardi; et al. (1999). A postmarking surveillance program to monitor Ultram (tramadol hydrochloride) abuse in the United States. Elsevier Science Ireland Ltd. Retrieved July 8, 2008, from http://www.sciencedirect.com/science_ob=ArticleURL&_udi=B6T63-3XJK9PK-2&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=c7c542948689898c3e5b87088e9467ba Cicero, T.J.; J.A. Inciardi; and A. Munoz. (2008). Trends in abuse of OxyContin and other opioid analgesics in the United States: 2002-2004. Washington University Pain Center. Retrieved July 8, 2008, from http://paincenter.wustl.edu/c/BasicResearch/documents/CiceroJPain2005.pdf Compton, P.; J. Darakjian; and K. Miotto. (1998). U.S. Cancer Pain Relief Committee. Retrieved July 8, 2008, from http://www.sciencedirect.com/science_ob=ArticleURL&_udi=B6T8R-3VF941H-3&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=f8a39956e4053eccf2a5fce0a1b14009 Compton, W.M. and N.D. Volkow. (2005). Major increases in opioid analgesic abuse in the United States: Concerns and strategies. Elsevier Ireland Ltd. Retrieved July 8, 2008, from http://www.sciencedirect.com/science_ob=ArticleURL&_udi=B6T63-4GMGW9X-1&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=7893681796dc6b7a9401e255c7f1cfb0 Fishman, S. M.; B. Wilsey; J. Yang; G.M. Reisfeld; et al. (2000). Adherence monitoring and drug surveillance in chronic opioid therapy. U.S. Cancer Pain Relief Committee. Retrieved July 7, 2008, from http://www.sciencedirect.com/science_ob=ArticleURL&_udi=B6T8R-41C2T3V-9&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=7c862b4a77de62fc0ffb04e4115f07f5 Fraser, A.D. (1998). Use and abuse of the benzodiazepines: Proceedings of the Fifth International Congress of Therapeutic Drug Monitoring and Clinical Toxicology. Therapeutic Drug Monitoring, 20(5): 481-489. Retrieved July 8, 2008, from http://www.drug-monitoring.com/pt/re/tdm/abstract.00007691-199810000-00007.htm;jsessionid=LyXQ7VhXNQ3jjw2QKDpXvVGppRkMfs1ZlMnnd7hv2vQVqJwN812R!447927974!181195628!8091!-1 Friedman, R.A. (2006). The changing face of teenage drug abuse-The trend toward prescription drugs. The New England Journal of Medicine, 354(14): 1448-1450. Retrieved July 8, 2008, from http://content.nejm.org/cgi/content/extract/354/14/1448 Gilson, A.M.; K.M. Ryan; D.E. Joranson; and J.L. Dahl. (2004). A reassessment of trends in the medical use and abuse of opioid analgesics and implications for diversion control: 1997-2002. U.S. Cancer Pain Relief Committee. Retrieved July 8, 2008, from http://www.sciencedirect.com/science_ob=ArticleURL&_udi=B6T8R-4CXFDBK-B&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=c48514187c2c2e823f61062390135773 Joranson, D.E., G.M. Carrow; K.M. Ryan; L. Schaefer, et al. (2002). Pain management and prescription monitoring. U.S. Cancer Relief Committee. Retrieved July 8, 2008, from http://www.sciencedirect.com/science_ob=ArticleURL&_udi=B6T8R-45B5F94-B&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=84744db33a404c99809954b92a78977e Kirsh, K.L.; L.A. Whitcomb; K. Donaghy; and S.D. Passik. (2002). Abuse and addiction issues in medically ill patients with pain: Attempts at clarification of terms and empirical study. Clinical Journal of Pain, Addiction and Pain: Assessment and Treatment Issues, 18(4): S52-S60. Retrieved July 8, 2008, from http://www.clinicalpain.com/pt/re/clnjpain/abstract.00002508-200207001-00006.htm;jsessionid=LyXNVLpHZRcGxzVyMc8n3vQQ1zT3kGLcDVKCLVhGQbBMwv4hDnpH!-607823098!181195629!8091!-1 McLellan, A.T.; D.C. Lewis; C.P. O'Brien; and H.D. Kleber. (2000). Drug dependence, a chronic mental illness: Implications for treatment, insurance, and outcomes evaluation. JAMA, 284(13): 1689-1695. Retrieved July 8, 2008, from http://jama.ama-assn.org/cgi/content/abstract/284/13/1689 Manchikanti, L. (2006). Prescription drug abuse: What is being done to address this new drug epidemic Testimony before the Subcommittee on Criminal Justice, Drug Policy and Human Resources. Pain Physician, 9(4): 283-5. Retrieved July 8, 2008, from http://www.ncbi.nlm.nih.gov/pubmed/17066115 Michna, E.; E.L. Ross; W.L. Hynes; S.S. Nedeljkovic; et al. (2004). Predicting aberrant drug behavior in patients treated for chronic pain: Importance of abuse history. U.S. Cancer Pain Relief Committee. Retrieved July 8, 2008, from http://www.sciencedirect.com/science_ob=ArticleURL&_udi=B6T8R-4D5MW10-G&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=2f85ca14c59c0662d5b12034be4c29b1 O'Connor, P.G. and A. Spickard, Jr. (1997). Physician impairment by substance abuse. W.B. Saunders Company. Retrieved July 8, 2008, from http://www.sciencedirect.com/science_ob=ArticleURL&_udi=B75JC-4GDBWVT-H&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=0b602cd00aff1dfc20ffe74312251be5 Portenoy, R.K. (1996). Opioid therapy for chronic nonmalignant pain: A review of the critical issues. Elsevier Science Inc. Retrieved July 8, 2008, from http://www.sciencedirect.com/science_ob=ArticleURL&_udi=B6T8R-3VXJHDP-9&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=e7981dd3f18bd05bd16b1b13224635f3 Simoni-Wastila, L.and C. Tompkins. (2001). Balancing diversion control and medical necessity: The case of prescription drugs with abuse potential. Substance Use & Misuse, 36 (9-10): 1275-1296. Retrieved July 8, 2008, from http://www.informaworld.com/smpp/contentcontent=a713733559db=all Weaver, M. and S. Schnoll. (2002). Abuse liability in opioid therapy for pain treatment in patients with an addiction history. Clinical Journal of Pain, Addiction and Pain: Assessment and Treatment Issues, 18(4): S61-S69. Retrieved July 8, 2008, from http://www.clinicalpain.com/pt/re/clnjpain/abstract.00002508-200207001-00007.htm;jsessionid=LyVCgxvhGGrxl1nn39XTpmrcmFBv4bpwlHv28DpQV1LzszGtLYNQ!-607823098!181195629!8091!-1 Zacny, J.; G. Bigelow; P. Compton; K. Foley; et al. (2003). College on Problems of Drug Dependence task force on prescription opioid non-medical use and abuse: position statement. Elsevier Science Ireland Ltd. Retrieved July 7, 2008, from http://www.sciencedirect.com/science_ob=ArticleURL&_udi=B6T63-4806BM0-1&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=caa62acf652e4f880f59fa6b1ffb78e4 Read More