Every day, more than 115 people in the US die after overdosing on opioids. And the efforts now being made to curtail addiction and stem the shockingly high death and overdose rates are all over the news.
Under-recognized problem: While there’s no question that opioid addiction is a serious problem in this country, there are some circumstances where patients need these drugs.
To learn more, Bottom Line Health spoke with Jane C. Ballantyne, MD, FRCA, a leading pain specialist.
THE TREATMENT CHALLENGE
Chronic pain (usually defined as lasting three to six months or longer) is widespread, affecting about 100 million American adults.
Yet there’s always a balancing act when it comes to treating pain with opioids. About 10% to 20% of the population has risk factors (such as a risk-taking personality) for addiction, even with first use—especially if they have a personal or family history of drug abuse.
And the longer you take these drugs, the more likely you are to become dependent. Drug dependence, which can be a precursor to addiction, compulsive drug use and other harmful behaviors, can occur within 30 days…and even within five days in some patients.
PAIN SPECIALISTS ARE WARY
The majority of doctors, including primary care physicians, receive little training in the best ways to treat pain. Many of these doctors are now nervous about prescribing opioid medications due to increased government oversight (including voluntary opioid-prescribing guidelines issued by the CDC in 2016)…uncertainty, in general, about optimal dosing…and worries about the risk for addiction.
In a survey published in 2017 in Practical Pain Management that included more than 3,000 chronic pain patients, nearly 85% reported being in more pain than they were before stricter oversight recommendations were instituted.
Undertreated pain is a real concern when it prevents patients from engaging in normal activities and enjoying a good quality of life. This doesn’t mean that doctors should dispense drugs more freely. Many people do better overall when they rely on drug-free methods of pain relief, including things like physical therapy, counseling or support groups. To find such a support group near you, ask your doctor.
SAFER OPIOID USE
Opioids are powerful drugs that need to be monitored. They aren’t likely to cause problems when they’re taken for a few days for acute pain (after surgery, for example), but long-term use can cause serious side effects, including osteoporosis, digestive problems (such as constipation) and opioid-induced endocrinopathy—decreases in testosterone and other hormones.
I provide long-term opioid prescriptions only for select groups of patients (discussed below). Patients with acute pain—after a back injury, for example—might need opioids, but should take them for as short a time as possible…and only if they can’t get adequate pain relief from safer approaches, such as exercise, physical therapy and/or over-the-counter (OTC) acetaminophen (Tylenol) or a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen (Motrin) or naproxen (Aleve). Prescription antidepressants or anticonvulsants also can reduce pain regardless of its cause.
With some exceptions, I advise patients never to start treatment with hydrocodone and acetaminophen (Vicodin), oxycodone (OxyContin) or other opioids and to try other pain-relief methods first.
Exceptions: Patients who are terminally ill can have a much higher quality of life when they take high doses of opioids—and not just because of pain relief. Someone with a terminal cancer, for example, might feel more at peace when taking the drugs. Similarly, patients with intractable diseases that impair their ability to function—such as spinal cord injuries, severe multiple sclerosis, etc.—might do better when they take the drugs.
But for those who can do without an opioid, lifestyle approaches, including cognitive behavioral therapy or physical activity, can sometimes relieve pain more than prescription or OTC drugs. Only take an opioid when other approaches don’t work…and only take a dose that’s high enough to relieve pain but low enough to allow you to function normally. Also important…
• Set limits. Some doctors continue to write opioid prescriptions too casually.
My advice: Don’t take an opioid for short-term pain unless you have a very clear injury—after a car accident, for example. Even then, take the drug for a few days at most. Also: The safest way to take opioid medications—both for acute and chronic pain—is to use them only as needed to control severe or sudden pain…not around the clock, unless it’s absolutely necessary.
• Attend a pain clinic. Patients with complex pain do better when they work with pain specialists at an interdisciplinary clinic (available at most major medical centers), where the medical team typically includes doctors, nurses, psychologists and physical therapists. Opioid medications may be prescribed carefully in these settings, but the emphasis is on other safer, longer-lasting methods of pain relief.
• Talk to your doctor about dosing. It’s common for patients taking opioids to develop tolerance—they gradually require more medication to get the same relief. This is not the same as addiction. However, the higher doses will increase the risk for side effects, including addiction. Do not change your medication or dose on your own. Get your doctor’s advice.
• Ask about longer-acting drugs. Patients with acute pain after surgery or an injury often need a fast-acting drug, such as nasal or sublingual (under-the-tongue) fentanyl. But patients with chronic pain usually do better with longer-acting drugs, such as extended-release oxymorphone (Opana ER) or a buprenorphine patch (Butrans).
Long-acting drugs provide a steady level of medication to stabilize their effectiveness—with fewer “letdowns” that can lead some patients into inappropriate drug-seeking behavior. They’re not a perfect solution because patients who take them may be given an additional prescription for a fast-acting drug to control “breakthrough” pain.
Addiction isn’t likely to be a problem if you use these powerful medications only when needed and with the caveats described above.