Opioid Epidemic

We, as clinicians, are uniquely positioned to turn the tide on the opioid epidemic - U.S. Surgeon General Vivek Murthy

Opioid Epidemic

image by: Robert Weinstein

BEGINNING in the late 1990s, pharmaceutical companies selling high-dose opioids seized upon a notion, based on flimsy scientific evidence, that regardless of the length of treatment, patients would not become addicted to opioids.

It has proved to be one of the biggest mistakes in modern medicine...

How did we get this so wrong?

The so-called proof that patients would not become addicted was based on a limited number of patients. This was coupled with the idea that opioids should be used for a broad range of indications — including all types of moderate to severe pain when, in fact, they don’t work against all forms of chronic pain.

In turn, the Food and Drug Administration relied too heavily on doctors to figure out how to appropriately prescribe these medicines. For many of them, a pill was an expedient way to try to help their patients. Figures published by the Centers for Disease Control and Prevention for the period 2008 to 2011 show that among those who were at the highest risk of overdose, 27 percent used their own prescriptions and another 49 percent either got or bought opioids from friends and relatives. Only 15 percent bought them from a drug dealer.

Doctors, regulators and drug makers also mistakenly divided the world up into those patients who had legitimate pain and who they believed would not become addicted, and drug addicts. Moreover, they missed one fundamental: The more opioids prescribed, the more opioid abuse there will be.

One thing that all experts agree on is that opioids have a role in cancer pain, end-of-life palliation and some forms of acute pain. The question is whether we make people with chronic pain better by treating them with opioids.

No doubt they sometimes work in the short term. And some pain experts believe that there are patients who function well on moderate doses of opioids and do not require more. But over time, the biology of opioids makes tolerance — and thus the need for higher and higher doses — a reality for a considerable number of patients who stay on the drug.

Continued opioids are needed to keep the physical withdrawal symptoms at bay. Those withdrawal symptoms are associated with their own pain. Thus, whatever pain that occurred at the beginning of treatment is replaced by the pain that is generated by the drug’s withdrawal symptoms.

Some patients will make heart-rending pleas that they cannot live without their opioids. But we have failed to see this for what it is, the signature of addiction: “I need it. I can’t get better or normal without it.”

Some experts believe that lower doses taken over a long period may be appropriate in certain instances. But that requires careful monitoring on the part of both the patient and the doctor. We need to recognize that there are many forms of pain, and not all respond to opioids. All are real. Some are caused by tissue injury, others by nerve injury. In a number of conditions, we can become hypervigilant to signals in our body that keep us trapped in a vicious cycle of pain. Certainly in those where we become keenly alert to the pain, treatment strategies including cognitive behavioral therapy are more effective than opioids.

What we have learned with addictive substances is that how society perceives them will predict how widely they will be used. For decades, cigarettes were made out to be something that we wanted and would give us pleasure. Then that perception changed as people came to understand that cigarettes actually were deadly addictive products that had no place in a healthy life. Opioids are trickier because they have some value in certain conditions. But we need to view them for what they are: addictive and potentially deadly drugs.

Source: David A Kessler, The Opioid Epidemic We Failed to Foresee, The New York Times, May 9, 2016.

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Last Updated : Sunday, July 7, 2019