Friday, April 12, 2013

Addiction Fears Trump Pain Relief in Poll

Pain SurveyA new national public opinion poll finds that Americans appear to be more concerned about pain-reliever abuse and addiction than chronic pain itself. In fact, slightly more than half of respondents think that healthcare providers should have set limits on the amount of pain medication they can prescribe. Yet, there are many contradictory and confusing aspects of this poll that need careful consideration.

The poll on “Chronic Pain and Drug Addiction” [PDF available here] was conducted online in March 2013 by Zogby Analytics for the Alexandria, VA-based advocacy coalition, Research!America. The survey had a total sample size of 1,016 respondents, with a theoretical sampling error of ±3.1%. According to background information in an accompanying news release [here], chronic pain conditions affect about 100 million U.S. adults at a cost of approximately $600 billion annually in direct medical treatment costs and lost productivity.

Although a majority of poll respondents (63%) said they knew of someone who experienced pain so severe that they sought prescription medicines to treat it, and another 60% believed chronic pain tends to be dismissed by healthcare providers and the public, only 18% said chronic pain is a major health problem. Even though chronic pain may affect more than a third of the adult U.S. population, it was ranked 8th in importance on a list of 9 less prevalent disorders; after cancer, heart disease, diabetes, drug addiction, depression, alcoholism, and Alzheimer’s disease (in descending order). A small proportion of respondents (16%) even expressed the view that pain is overstated as a health condition.

In contrast, according to poll results, Americans are greatly worried about the misuse and abuse of medication to treat chronic pain. More than 4 out of 5 respondents (82%) believed that taking prescription pain relievers long-term for chronic pain could end in addiction, which nearly half (47%) described as a major health problem. An overwhelming majority (85%) were very concerned or somewhat concerned that prescription pain medication can be abused or misused, and 40% said that prescription medication abuse and addiction is a major problem in their own community.

Two-thirds of those polled (66%) were unaware that tamper- and abuse-resistant formulations for some prescription pain medications are now available. At the same time, slightly over half (52%) agreed with the following statement: “Some states put limits on doctors when prescribing pain medication. Do you think doctors should have limits on the amount and dosage of pain medication they are allowed to prescribe?”

Other poll highlights include:

  • More than half of poll participants (54%) said healthcare providers are not discussing the possibility of developing dependence or addiction to pain medication enough with their patients.

  • Based on their own experience or what they have heard, respondents said that they would use the following treatments to try to relieve chronic pain: physical therapy (64%), over-the-counter pain medication (55%), diet or lifestyle change (54%), chiropractor (49%), prescription pain medication (47%), herbal remedies (38%), or acupuncture (36%).

  • About a quarter (28%) of respondents said that they have extra — ie, unused, unwanted, or expired — prescription pain meds in their homes. The most common disposal method for pain medication was putting it in the trash, selected by 30%; secondarily, 22% said they flushed it down the sink or toilet.

  • When it comes to addressing “the prescription drug abuse problem,” only 4% felt it is the responsibility of law enforcement, while 5% said state government and 12% said the federal government were responsible. The largest proportion of respondents (44% combined) believed that organizations, families, and individuals were responsible.

  • Roughly a third of participants (taking into account the margin of error) believed that chronic pain has garnered less attention than it deserves from mass media, elected officials, and researchers. However, about the same proportions of respondents also felt that drug addiction has received inadequate attention from those same 3 groups.

The news release suggests that, as drug addiction becomes more prevalent, most Americans are split on whether addiction and chronic pain are getting the attention they deserve. According to Research!America President and CEO, Mary Woolley, “We need to better understand addiction. We shouldn't shy away from research on new pain treatments based on fears of abuse. The suffering is simply too great. More robust investment in research and the engagement and support of policy makers and health care providers are essential to developing effective strategies to reduce the prevalence of addiction.”

COMMENTARY: The overall impression from poll results is that the American public is generally more concerned about abuse and addiction relating to pain medications than they are about the adequate treatment of persons with chronic pain. For example, only 18% of respondents ranked chronic pain as a major health problem, while 47% rated drug addiction as being a more important concern.

Furthermore, 85% were troubled that prescription pain medications could be abused or misused, and 82% said that taking those drugs for chronic pain could lead to addiction. And, at least half of respondents (52%) believed that healthcare providers should be limited in the amount and dosage of pain medication they can prescribe.

As typically happens, the poll was widely reported by news media without questioning of the validity or reliability of results. However, there are some important limitations of the poll to consider. A foremost question is, considering the diversity of the U.S. population numbering about 315 million persons, can responses from a little more than 1,000 poll participants be considered a valid representation of public opinion?

Upon our inquiry, Research!America informed us that Zobgy Analytics uses randomized recruitment and complex weighting techniques to select samples of participants best representing demographics of the entire population. For this poll, selected participants were ≥18 years of age, the largest proportion were ages 30 to 49 (36%), 51% were females, and a majority were married (54%), white (68%), and had no college degree (62%). Respondents also were balanced according to typical demographics across U.S. region, religion, and political party affiliation, among other factors.

However, despite such meticulous epidemiological sample construction, when extrapolating outcomes in a relatively miniscule sample to a much larger population there likely would be a high probability of an imbalance of important factors and/or unknown confounders that are uncontrolled. Small sample size also lacks statistical power for performing subgroup analyses that help to better understand responses according to demographic influences. Moreover, as is evident in all other types of research employing small samples, without verification of results in comparable studies the reliability and validity of outcomes is uncertain.

In the case of an opinion poll there also are difficulties of developing survey questions that are not so specific that they might bias responses, yet are not so general or vague that participants are uncertain as to what the questions are asking. Here are just several specific concerns about the “Chronic Pain and Drug Addiction” polling questions:

  • While 60% of participants said that they knew of someone with severe pain requiring prescription medication, it is unknown how many respondents, themselves, had experienced such pain — especially, chronic pain. In a representative sample, we might expect a third of respondents would have such pain, but this is not evidenced by the meager 18% in this poll ranking chronic pain as a major health problem.

  • The polling questions frequently refer to “prescription pain medications,” also mentioning “abuse-resistant formulations,” but there is no use anywhere of the terms “opioids,” “opiates,” or even “narcotics” to describe these medications more specifically. One might assume that respondents automatically had opioid analgesics in mind when answering questions, but this is not entirely certain.

  • There is an emphasis in many questions on pain-reliever abuse, dependence, and addiction; although, respondents’ perceptions of “addiction” or “dependence” are unknown, and the terms were not clearly defined. As we observed at length in a previous UPDATE [here], “addiction” and “dependence” are probably two of the most overused and misunderstood terms by healthcare professionals, and most certainly so by the public, and the absolute risk of true addiction newly emerging during analgesic therapy is still uncertain. Therefore, responses to these poll questions may only reflect the public’s confusion or misperceptions regarding these issues, which challenges the validity of drawing any conclusions.

  • When asked in separate questions what percentage of drug overdose deaths involve either (a) physician-prescribed pain medication or (b) prescription medication obtained illegally, responses varied widely. The poll authors indicate that the correct answer in each case was 75%, and the broad “51-75%” category was selected by 27% of participants on average for both questions. However, data behind that 75% estimate [also discussed in an UPDATE here] do not distinguish between prescribed versus illicit opioids, so there was essentially no correct answer to those two questions.

Research!America explained to us that their objectives in commissioning this poll were to help inform policymakers and the health care community about public perceptions relating to the burden of chronic pain, whether it receives the attention it deserves, and what perceptions are of prescription pain medication addiction and abuse. Yet, since the messages from this poll are in certain ways conflicting and somewhat confusing, do the outcomes clearly reflect public opinion on those issues?

In sum, nearly two-thirds of respondents said they knew of someone with pain requiring prescribed pain relievers and 6 out of 10 believed chronic pain is too readily dismissed by healthcare providers and the public. Another third said that chronic pain receives less attention than it should from news media, politicians, and researchers.

On the other hand, respondents did not rank chronic pain highly on a list of major health problems and an overwhelming majority strongly expressed apprehensions about the abuse, dependence, and addiction potential of pain medications. They believed that prescribers were not doing enough to warn patients about these problems, and at least half of respondents felt that healthcare providers should be limited in the amount and dosage of pain medication they are permitted to prescribe.

Of interest, 40% of respondents believed pain medication abuse and addiction are major problems in their communities; another 36% were uncertain. However, 44% said that it was up to community organizations, families, and individuals to address those problems; whereas, only 21% in total believed that state/federal government or law enforcement should be responsible, and only 15% felt that physicians are answerable. In this regard, public opinion seems to favor less regulation and legislative action when it comes to solving problems that ultimately require local initiatives and individual responsibility for successful resolution.

Proviso: The above critique addresses only the particular poll in question and is not intended to comment on the overall work of Research!America or Zogby Analytics. Research!America (www.researchamerica.org) is the USA’s largest nonprofit public education and advocacy alliance working to promote research that improves health. Founded in 1989, and commissioning polls since 1992, the organization is supported by member groups representing 125 million Americans. Zogby Analytics (www.zogbyanalytics.com) was founded in 1984 and is a leading research company providing advanced data collection and analysis.

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