Opioids are a powerful class of painkillers derived from opium that come from the poppy plant. These drugs, which come in pill or liquid form, are available by prescription and can help relieve your worst pain. The pills may be prescribed after surgery, and sometimes to chronic pain sufferers. But, what are opioids and why do so many people caution against their use?
What are opioids?
Opioids are a class of drugs that act on pain receptors in the central nervous system. You may also hear them called opiates or prescription painkillers.
Commonly prescribed opioids include the following list along with related brand name versions of the substance:
- Morphine (Astramorph or Kadian)
- Oxycodone (OxyContin or Roxicodone)
- Fetanyl (Actiq or Duragesic)
- Hydrocodone (Vicodin or Lortab)
- Methadone (Dolophine or Methadose)
The street drug heroin also falls into the opioid category.
These painkillers bind to opioid receptors located in your brain, spinal cord, digestive system, and other organs. Once the drug latches onto the opioid receptor, it sends the message to the rest of your body that you’re not in pain. These drugs effectively diminish your pain by changing the way you perceive it.
What are opioids most common side effects?
Opioid side effects may include:
- Slowed or troubled breathing
- Opioid induced constipation
Other risks of opioid use include tolerance, withdrawal, addiction, and abuse. When too much is taken or it’s taken incorrectly, opioid medications can also lead to overdose and death.
For those who take opioids for long periods of time, they can also build up a tolerance to the drug which requires that they take more of it to find pain relief. This happens as your body becomes used to taking the medication, and becomes less reactive to it.
As patients develop a tolerance for a medication, they must take ever-higher doses of drugs to relieve their pain. This shouldn’t be confused with addiction or abuse, but it does require more active management by these patients in coordination with their doctors.
The following video reports on why opioid tolerance may occur.
Opioid withdrawal symptoms
Users of opioids may become physically dependent, which means the body needs more of the drug for normal functioning. When a person is physically dependent on an opioid, he or she may experience withdrawal symptoms upon stopping use.
Withdrawal symptoms may include:
Patients stopping long-term opioid use under a doctor’s care can gradually taper the amount of drug taken to avoid symptoms of withdrawal.
Risks of opioid abuse and addiction
When hydrocodone, the world’s most widely prescribed opioid, hit the market in 1920s, it seemed like the answer to many people’s prayers. At the time, there was a growing addiction to the opiates found in a popular cough medicine at the time, and hydrocodone seemed to offer a safe, predictable way to end the addiction to cough syrup.
The euphoric effect that hydrocodone had was noted, but the benefit seemed to outweigh the risk. Fast forward 90 years to 2010. While the number of doctor visits for pain has stayed the same in the years between 2000 and 2010, the number of opioid prescriptions for management of non-cancer pain has almost doubled, going from 11% in 2000 to 20% in 2010.
Why is addiction such a concern?
Opioids trigger euphoric feelings by activating the portion of your brain connected to rewards.
The powerful drug’s ability to make people feel happy has led to rampant drug abuse, and a significant public health threat has emerged over the last few decades. Painkiller overdose death rates have more than tripled in the United States since 1990, according to the Centers for Disease Control and Prevention (CDC). In 2008 alone, more people died from opioid overdoses than heroine and cocaine combined.
Worse, as we’ll discuss shortly, current research is showing time and again that opioids actually have little effect on treating long-term, chronic pain.
Are we living through an opioid epidemic?
As doctors wrote in a literature review in the The Journal of the American Academy of Orthopaedic Surgeons, the answer is clearly “yes.” The impacts of this epidemic are sending shock waves through all areas of medicine.
The United States consumes 80% of the world’s prescription opioids (and 99% of the world’s hydrocodone) yet makes up only 5% of the world’s population. Physicians seem to be writing more opioid prescriptions for orthopedic pain that could be managed in other ways. That finding is particularly alarming to study co-author Brent J. Morris, MD, a shoulder and elbow surgeon with the Lexington Clinic Orthopedics — Sports Medicine Center.
What does the research say?
Dr. Morris believes there are other ways to evaluate whether or not opioids are necessary. He notes:
“Physicians should aim to control pain and improve patient satisfaction while avoiding overprescribing opioids. A comprehensive strategy of risk assessment is needed to identify patients who may be at risk for opioid abuse. Objective measures including patient history, recognition of aberrant behavior, urine drug testing, state prescription drug–monitoring programs, and opioid risk-assessment screening tools may be necessary in select cases.”
This assessment of benefits to the condition and risks to patient is especially important when it comes to prescribing opioids for chronic pain. Dr. David Steffens, chair of the psychiatry department at University of Connecticut Health and one of the authors of the study noted that:
“[T]here’s no research-based evidence that these medicines are helpful [when treating long-term pain]…and [due to the high prescription rates in the U.S. and high rates of dependence], this is a peculiarly American problem.”
National Institutes of Health study
Further, a white paper from the National Institutes of Health (NIH) found that there was little or no evidence that opioids were effective for long-term care of chronic pain.
A seven-member panel at NIH listened to evidence presented by an outside research group that had been charged with analyzing all available research on the efficacy of opioids as a treatment for chronic pain. This group found that not only were opioids ineffective long-term, but they were also detrimental to the patients.
Pain journal study
This is backed up by a study in PAIN®, the journal of the International Association for the Study of Pain.
Kevin E. Vowles, PhD, of University of New Mexico (UNM), Albuquerque and his colleagues found that 20-30% of opioid prescriptions were misused by patients, and the dependence rate is approximately 10%. Vowles notes that:
“On average, misuse was documented in approximately one out of four or five patients and addiction in approximately one out of ten or eleven patients.”
This means that from a high of 207 million opioid prescriptions in 2013, 40 to 60 million of those may be completely unnecessary to manage pain, and another 20 million of those are filled by patients who would be classified as dependent.
The high human and financial cost of opioid misuse and abuse don’t seem to be worth any benefit that a single patient may derive. Dr. Vowles and his colleagues write in their conclusion that:
“[They] are not certain that the benefits derived from opioids, which are rather unclear…compensate for this additional burden to patients and health-care systems.”
Guidelines and recommendations for safer opioid use
As researchers continue to look at what are opioids and how successful they are at treating pain, it’s up to current practitioners, patients, and lawmakers to create sustainable guidelines for safe use. These guidelines should help reduce the risks of opioid abuse. But, they should also make these medications available to those chronic pain patients who do find relief because of them.
To curtail problems of abuse and misuse, the Food and Drug Administration (FDA), in late 2013, ordered opioid manufacturers to study the impacts for patients taking these drugs long-term. The FDA also increased labeling requirements for extended-release and long-acting opioids in an effort to raise awareness of the risks associated with taking them.
In 2016, the CDC took this a step further and provided more comprehensive recommendations to primary care clinicians for opioid prescriptions and use for managing chronic pain. Their guidelines addressed:
- When to initiate or continue opioids for chronic pain
- Opioid selection, dosage, duration, follow-up, and discontinuation
- Assessing risk and addressing harms of opioid use
- Methods to improve communication between clinicians and patients about the risks and benefits of opioid therapy for chronic pain
For more information about state prescription drug monitoring programs, visit the U.S. Department of Justice/Drug Enforcement Administration’s Diversion Control website.
But what if there are cases in which long-term opioid use were indicated as a safe and effective pain management technique? Is there a way that opioid use can be monitored and supported for the safety and health of the patient?
Indeed, careful screening before prescription and diligent monitoring after are two very effective ways to minimize the risk of dependence. Pain Doctor recognizes that there is a need for caution in opioid prescribing and utilizes a 12-step compliance checklist before beginning long-term opioid therapy. These steps include:
- Assessment of pain (0-10 scale)
- Clear documentation of rationale for opioid use (i.e., chronic lower back pain, degenerative disc disease)
- Clear documentation of beneficial clinical response to opioid use (i.e., decrease pain or increase function)
- Establish goals of opioid treatment and review of goals (i.e., patient has an increased ability to function)
- Current and updated medication list
- Documentation of substance abuse and social history
- Physical examination of painful area
- Documentation of risks and benefits (i.e., risks explained to patient)
- Appropriate referral for additional evaluation and treatment (i.e., psychiatric referral for depression)
- Updated Pharmacy Board review
- Current and consistent UDS within last 30 days
- Sign an Opioid Agreement within last six months
It is important to note that patients are screened for a history of substance abuse, including any family history that might indicate a genetic predisposition. States that have prescription drug monitoring programs in place can also help support doctors in their monitoring by reporting suspicious activity in refills or any unusual patterns. While it is clear that current research indicates more restraint in opioid prescriptions is necessary, with proper monitoring and a comprehensive treatment plan, there may be benefits of use for some patients with chronic pain.
What are my other options?
First, if you are concerned that you or someone you love may be at risk of addiction, take action and get more information.
Next, you have options to reduce your or stop your use of opioids. While medications do have a place in pain management, they are not the only tool in a pain specialist’s arsenal. A highly-skilled pain specialist will also use complementary therapies to help a patient reduce their pain as much as possible. These include physical therapy, chiropractic, and exercise.
Next, they’ll also use interventional pain management approaches, like epidural steroid injections, that are highly-targeted and minimally-invasive to treat a patient’s pain. With the right approach and a dedicated pain management team, you can reduce or completely stop how many opioids you’re taking to manage pain. To learn more about a comprehensive pain management approach, click here.
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