Positive Health Online

Nor shall any man's entreaty prevail upon me to administer poison to anyone; neither will I counsel any man to do so. -  Hippocratic Oath

In the US we have about 4.6% of the world’s population and consume about 80% of the opioid medication produced in the world. Over 50 million people suffer with severe chronic pain and another 38 million people suffer with depression, generalized anxiety disorder and PTSD in the United States.  The use of pain killer in the form of opioid medication such as, morphine, codeine and Percocet, to alleviate the pain is not only a serious issue but has serious negative consequences with extended use.

“The military has a massive narcotic/pain management over prescription and abuse problem,” says Dr Gary Kaplan.  Dr Kaplan attended a small conference focused on trying to create a new model of care for the military pain management program held recently at the Samueli Institute. Together, the prevalence of chronic pain and the increasing use of opioids have created a ‘silent epidemic’ of distress, disability, and danger to a large percentage of Americans. The overriding question is: Are we, as a nation, approaching management of chronic pain in the best possible manner that maximizes effectiveness and minimizes harm? - NIH P2P Workshop, The Role of Opioids in the Treatment of Chronic Pain.

A recent  report by the NIH suggests that when it comes to the treatment of chronic pain the medical profession may be very much in violation of what can be regarded as the first medical ethic, “first do no harm”.  Acute pain, if you will, is a bit of a no-brainer. Pain is a message that damage is occurring to our body and we need to take action. From a medical perspective the physiology of acute pain is well understood, it is associated with tissue damage and resolution of the pain is associated with healing of the injury. Over the years, the medical profession has accumulated a vast array of therapeutic tools to combat chronic pain, though a cure still very much eludes us. One of those ‘tools’ is opioid medication. Opioids include such medications as morphine, codeine, and oxycodone. 

In 1997 the American Academy of Pain Medicine, in an acknowledgement of the severity of the suffering of patients with chronic pain as well as our inability to provide many of these patients with acceptable solutions to their pain, issued a consensus paper endorsing the use of opioid medications for the treatment of chronic noncancerous pain. The Academy acknowledged that one of the problems with long-term use of opioids was addiction. In response, the medical profession began making the distinction between addiction and dependence. Addiction was defined as a craving for opioids with the intension of getting ‘high’ as associated with drug-seeking behaviour. Dependence occurred when an opioid medication was prescribed for medical reasons; a dosage was established where the pain was controlled and the patient realized a significant improvement in the quality of their life. While the intention was noble the consequences have been unacceptable.

Since then, the sales of prescription opioid medications measured in grams skyrocketed from 1997-2007 by 866% for oxycodone, 525% for fentanyl, 280% for Hydrocodone and 222% for morphine. As reported in Pain Physician in July 2012, “Gram for gram, people in the United States now consumes more narcotic medication than any other nation worldwide.” The report goes on to document that over 90% of patients taking opioid pain medications were prescribed these medications for the treatment of chronic pain.

The consequences of this explosion in the use of prescription narcotic medication for chronic pain have been horrific. In 2011 approximately 17,000 drug overdose deaths involved prescription opioid medications, and according to the CDC, “In 2007 there were more opioid analgesic deaths than overdoses involving heroin and cocaine combined.” While a significant number of these drug overdose deaths are associated with diversion of the medication to people who were not originally prescribed the medication, 60% of the deaths occurred in patients when they were given prescriptions based on the prescription guidelines by medical boards. In addition to addiction, side effects from opioid medications include constipation, increased risk of birth defects, falls and fractures, heart attacks and a decrease in the production of testosterone. One other significant counter intuitive side effect: in some people opioids can cause hyperalgesia, a worsening of the pain.

While the NIH report offers a number of important policy and institutional changes to address this ‘silent epidemic’, I would suggest that the basis of our problem comes from a lack of understanding of what we are treating. Acute pain and chronic pain (not associated with ongoing tissue damage such as in cancer) are two very different phenomena in the body. Unquestionably the evidence supporting the use of long-term opioids in the treatment of chronic pain is insufficient. What else needs to be done?

1. We need better studies to help us understand when the use of long-term opioid medications can be useful;
2. Physicians need to be better educated about the diagnosis and treatment of patients suffering with chronic pain;
3. Ultimately the use of long-term opioid medications is an admission of failure. Our failure to be able to offer a cure or find other means of pain relief for an individual. These are medications of last resort;
4. Chronic pain is not a ‘thing’ but one manifestation of a complex physiologic process that frequently impacts many body systems including gastrointestinal, psychological, endocrine, and sleep. Treatment of individuals requires that we take a whole person perspective in our diagnosis and treatment, which requires a multidisciplinary approach.

In sum, as a pain specialist, I believe there is an important role for opioid medication, but that role should be limited. It should be prescribed only to selected individuals for the purpose of relieving pain and improving their quality of life when all other medical approaches have been exhausted, and then it should be very closely monitored by the diagnosing physician. Ultimately, the long-term use opioid medications is an admission of failure - it means we have failed to offer patients a cure or identify a less risky way providing pain relief to an individual. First, do no harm. Opioids should be medications of last resort.