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Health Advice
by Dr. Weiss

Jul 11, 2016
The Opioid Epidemic - Management of chronic pain is an art and science. For most patients, the serious and too-often-fatal risks of opioids outweigh the benefits.
  • Deaths from prescription-opioid overdoses have quadrupled over the past 15 years.
  • An estimated 19,000 are dying yearly from narcotic painkillers including hydrocodone, oxycodone, morphine, and fentanyl.
  • Deaths occur across all age groups, socio-economic status and ethnicities.

Sadly, opioid abuse is not a new or novel problem. Opioid use for pain management has swung back and forth several times over the past 100 years, with many famous physicians becoming “hooked” or seduced by the addictive properties.

There is no other class of medications routinely used for nonfatal conditions that has the potential to kill patients so frequently. One of every 550 patients started on an opioid therapy dies of an opioid-related cause a median of 2.6 years later. The statistics are dose-related and worsen with higher doses.

The prevalence of opioid dependence may be as high as 26% among patients in primary care receiving opioids for chronic non-cancer-related pain, according to a recent New England Journal of Medicine Perspective. Mental illness patients are at higher risk, but otherwise risk is not predictable.

The effect of opioid abuse on the brain and body depends on specific receptors in the brain, spine, and other organs in the body. The opioids attach to these receptors and reduce the perception of pain and create a false sense of well-being known as euphoria. However, this class of medications also produces drowsiness, mental confusion, nausea, constipation and other undesirable side effects.

The euphoric effects combined with the addictive properties, which mean larger and larger doses to obtain the same results, exacerbates the opioid epidemic we are now experiencing. Patients who are already on opioids are less likely to have good pain control in general. Studies of postmenopausal women with recurrent pain conditions who are on opioids are less likely to have an improvement in pain and have worsening function, presumably due to potentiated pain perception.

The Centers for Disease Control and Prevention (CDC) has shared three key principles which underline 12 recommendations for using opioids for chronic pain.  http://www.cdc.gov/media/dpk/2016/dpk-opioid-prescription-guidelines.html

First and foremost, physicians should avoid prescribing narcotics whenever possible except for palliative or end of life care. Non-opioid therapy for acute or chronic pain—such as exercise therapy, weight loss, psychological therapies such as cognitive behavioral therapy, nonsteroidal anti-inflammatory drugs, and antidepressants—can all be effective and are much safer.

Second, when opioids are used, the lowest possible dose for the shortest time with limited number of pills prescribed is best for all concerned. “Start low and go slow” will avoid problems and save lives.

Third, what should be foremost on the minds of both physicians and patients is very close monitoring of patients with a plan to withdraw or at least lower the dose of narcotics while substituting non-addictive therapies.

Management of chronic pain is an art and science. For most patients, the serious and too-often-fatal risks of opioids outweigh the benefits.