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Opioids for Severe Pain
Vol. 21 No. 1 January 2001
Opioids for Severe Pain: Little Change Over 15 Years To the Editor: In a recent article in the New England Journal of Medicine, Morrison et al. 1 highlighted the difficulty that patients (particularly those who live in nonwhite neighborhoods) experience when trying to fill prescriptions for opioid analgesics, and prompted us to review our experience over the last 15 years. In the mid-1980’s, we conducted surveys to determine the availability of opioid analgesics in New York City 2 and nationally. 3 A telephone survey of 33 randomly selected pharmacies in the Bronx, New York (response rate, 66%) found that 17 stocked no Class II opioids (drugs requiring triplicate prescriptions in New York State). Only three pharmacies routinely stocked hydromorphone, oral morphine or methadone, the drugs most appropriately used for the treatment of severe cancer pain. We then contacted 94 randomly selected pharmacies in all five boroughs of New York (response rate 84%); 27 (29%) stocked no Class II opioids and fewer than 15% stocked any of the opioids preferred for cancer pain. Fear of robbery and lack of demand were the most commonly cited reasons for not stocking the drugs. We subsequently conducted a survey of 1,121 pharmacies nationally, in collaboration with the National Association of Retail Druggists. Nearly all kept an oxycodone preparation in stock, but only 38.5% carried an oral morphine preparation and only 56% said they stocked methadone. Problems of access to opioid analgesics have a long history. Although Morrison et al.’s finding that 49% of pharmacies had “complete” or “nearly complete” stocks of opioids seems a small step in the right direction, the numbers are still troubling and disparities across neighborhoods add a new concern about the medically under-
Letters
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served. Even if a pharmacist is willing to order an opioid, the failure to maintain a stock can burden those with new prescriptions or changing doses, and those who need emergency supplies. Unfortunately, these scenarios are common and the lack of immediate access becomes one more problem, contributing to the undertreatment of pain. The failure to stock opioid drugs because of “lack of demand” is an enduring problem reflecting a broader reluctance to use opioids. 4,5 Inadequate physician training, problematic attitudes and fears on the part of physicians, nurses and patients, and regulatory barriers all compound the problem. The continuing lack of access to opioid drugs in pharmacies, particularly those in disadvantaged or minority neighborhoods, is a small but important element in a decades long tragedy of undertreated pain in this country. Ronald M. Kanner, MD Department of Neurology Long Island Jewish Medical Center New Hyde Park, New York, USA PII S0885-3924(00)00237-2
References 1. Morrison RS, Wallenstein S, Natale DK, Senzel RS, Huang LL. “We don’t carry that.” Failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics. N Engl J Med 2000;342(14):1023–1026. 2. Kanner RM, Portenoy RK. Unavailability of narcotic analgesics for ambulatory cancer patients in New York City. J Pain Symptom Manage 1986;1:187–189. 3. Kanner RM, Cooper ES, Portenoy RK. Unpublished data. 4. Breitbart W, Rosenfeld BD, Passik SD, et al. The undertreatment of pain in ambulatory AIDS patients. Pain 1996;65(203):243–249. 5. Grossman SA. Undertreatment of cancer pain: the barriers and remedies. Support Care Cancer 1993;1(2):74–78.
Opioids for Severe Pain: Little Change Over 15 Years To the Editor: In a recent article in the New England Journal of Medicine, Morrison et al. 1 highlighted the difficulty that patients (particularly those who live in nonwhite neighborhoods) experience when trying to fill prescriptions for opioid analgesics, and prompted us to review our experience over the last 15 years. In the mid-1980’s, we conducted surveys to determine the availability of opioid analgesics in New York City 2 and nationally. 3 A telephone survey of 33 randomly selected pharmacies in the Bronx, New York (response rate, 66%) found that 17 stocked no Class II opioids (drugs requiring triplicate prescriptions in New York State). Only three pharmacies routinely stocked hydromorphone, oral morphine or methadone, the drugs most appropriately used for the treatment of severe cancer pain. We then contacted 94 randomly selected pharmacies in all five boroughs of New York (response rate 84%); 27 (29%) stocked no Class II opioids and fewer than 15% stocked any of the opioids preferred for cancer pain. Fear of robbery and lack of demand were the most commonly cited reasons for not stocking the drugs. We subsequently conducted a survey of 1,121 pharmacies nationally, in collaboration with the National Association of Retail Druggists. Nearly all kept an oxycodone preparation in stock, but only 38.5% carried an oral morphine preparation and only 56% said they stocked methadone. Problems of access to opioid analgesics have a long history. Although Morrison et al.’s finding that 49% of pharmacies had “complete” or “nearly complete” stocks of opioids seems a small step in the right direction, the numbers are still troubling and disparities across neighborhoods add a new concern about the medically under-
Letters
3
served. Even if a pharmacist is willing to order an opioid, the failure to maintain a stock can burden those with new prescriptions or changing doses, and those who need emergency supplies. Unfortunately, these scenarios are common and the lack of immediate access becomes one more problem, contributing to the undertreatment of pain. The failure to stock opioid drugs because of “lack of demand” is an enduring problem reflecting a broader reluctance to use opioids. 4,5 Inadequate physician training, problematic attitudes and fears on the part of physicians, nurses and patients, and regulatory barriers all compound the problem. The continuing lack of access to opioid drugs in pharmacies, particularly those in disadvantaged or minority neighborhoods, is a small but important element in a decades long tragedy of undertreated pain in this country. Ronald M. Kanner, MD Department of Neurology Long Island Jewish Medical Center New Hyde Park, New York, USA PII S0885-3924(00)00237-2
References 1. Morrison RS, Wallenstein S, Natale DK, Senzel RS, Huang LL. “We don’t carry that.” Failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics. N Engl J Med 2000;342(14):1023–1026. 2. Kanner RM, Portenoy RK. Unavailability of narcotic analgesics for ambulatory cancer patients in New York City. J Pain Symptom Manage 1986;1:187–189. 3. Kanner RM, Cooper ES, Portenoy RK. Unpublished data. 4. Breitbart W, Rosenfeld BD, Passik SD, et al. The undertreatment of pain in ambulatory AIDS patients. Pain 1996;65(203):243–249. 5. Grossman SA. Undertreatment of cancer pain: the barriers and remedies. Support Care Cancer 1993;1(2):74–78.