Overprescription of Opioids Would be a Problem Even if Addiction and Overdose Did Not Exist

A number of commentators have unhelpfully framed debate about the astonishing rate of opioid prescriptions in the U.S. (more annual prescriptions than adults in the entire population at this point) as a “war” between those who care about preventing addiction/overdose and those care about reducing pain for patients in need. From this vantage point, any attempt to reduce or even question the number of opioid prescriptions is an attack on people in pain, another front in the heartless drug war, evil cops interfering with angelic docs etc.

This framing is medically and scientifically wrong, as New York Times reporter Barry Meier points out in this interview. Prescription opioid overdose and addiction are currently huge problems in the U.S., but even if they weren’t, the indiscriminate prescription of opioids would be dangerous to public health. Opioids typically have a miraculous effect on acute pain, but this does not necessarily translate into chronic pain relief, particularly as tolerance sets in over time. Even more disturbing, my colleague Dr. Jodie Trafton and I are among many researchers who have found that a portion of long-term opioid users became hyperalgesic, i.e., they experience more rather than less pain.

This is not the only line of scientific findings that flies in the face of the assumption that if opioids are used less often, more pain will be the inevitable result. In a study my colleagues and I conducted with surgery patients (first author Dr. Ian Carroll; publication here), the amount of time individuals stayed on opioids after surgery, surprisingly, bore no relationship to their level of pain. People stay on opioids for a range of reasons not necessarily linked to pain; in our study taking them for long periods was well-predicted by pre-existing depression, for example. Many people who are on these medications would be in better health and equal or less pain if they were weaned off them.

A further dangerous side-effect of long-term opioids is hormonal, as Meier explains:

These drugs have a very powerful impact on our production of sexual hormones — testosterone in men and estrogen in women. Lower hormone production is not just about growing hair or sexual performance; it’s about your entire energy level. These drugs are depleting people of energy. There are even data showing that the more powerful opioids, the long-acting OxyContin, methadone, fentanyl, which is sold as Duragesic, have an even more powerful effect on depressing hormone production than short-acting opioids.

What Meier is saying will come as a shock to those who foment over-simplified policy debate about opioids, but will not be surprising to pain medicine specialists. Although that field has a few extreme voices regarding opioids, for the most part pain management experts are already doing what the rest of the country needs to do: Trying to find the right balance between the benefits and costs of these drugs rather than declaring them horrible or flawless.

Comments

  1. Bruce Ross says

    Interesting what he says about use of opioid painkillers and delayed return to work after back injuries, but you’ve got to wonder about cause and effect there.

  2. says

    the assumption that if opioids are used less often, more pain will be the inevitable result.

    The surgery study addresses the length of opioid use within a patient’s (acute) drug career, not the prevalence of pain within a population, where legal & convenient access to opioids is the study variable in the first place.

    From the paper:
    No patient reported taking opioid medications after pain had resolved, and most postsurgical patients stopped opioid use before their pain had resolved (Fig. 1). Thus, the variance in opioid use duration occurred only in the setting of persistent pain. In other words, if 2 patients both had pain for 90 days after knee surgery, one may have stopped opioids on day 10 whereas the other continued opioids until day 80. This variance is explained by our multivariate model, suggesting that the variance between these 2 patients is best explained by their preoperative differences in opioid use, self-perceived risk of addiction, and depressive symptoms

    The study doesn’t address how the pain differed & was resolved after opioid use was ceased i.e. what was the evolution of pain in patients who used opioids and then stopped vs those who didn’t?

    • Barbara says

      Sometimes a certain level of pain is better than the alternative. I was in much more pain after my second c-section than I was after the first (and this is typical, but there were some additional reasons why the difference was even bigger for me). After two weeks, I stopped taking opioids and got by with Ibuprofen alone because not only was I feeling zonked all the time, but it was clearly contributing to feeding issues with my newborn. So I learned to deal with a higher level of pain, that, thankfully, went away nearly completely after a year. (Don’t believe doctors who tell you that the kind of surgical pain associated with c-section is no worse than the kind of pain you get from a natural delivery. I had both and they are not the same. I needed no pain relief beyond hot soaks after my vaginal delivery and recovered within two weeks.)

  3. Jakob Kotter says

    I have been taking opiates for chronic severe pain for three years. of course I am addicted you cannot take opiates for over a week without developing some level of addiction and experience withdrawal as the dose metabolizes away. I have taken morphine, time release morphine, fentanyl via patch, and dilaudid. I now take dilaudid and prefer it as it provides the best control with the least narcotizing effects. Without pain medicine I cannot walk and my spine becomes a rigid non functional rod. Hyperalgesia is a major, major problem, I have to raise and lower my daily dosage constantly in order for the drug to remain effective and for the pain and additional pains not to become overwhelming. For example although I have severe arthritis in both knees and structural genetic issues in both knees my right knee is normally well within tolerance for me without pain medicine, where as the left knee, which has no meniscus remaining is always feeling on fire. After two weeks of Dilaudid at a set dose the pain in may back and both knees and my other various orthopedic injuries becomes overwhelming and no longer responds. By backing of for 48 hours to a minimal dose the pain subsides and I can take a normal dose and be pain free for another week and a half. This is to say it is a lot of work, requires intense personal control, and not a hint of addictive personality or it would be totally ineffective therapy.

    • Barbara says

      First, let me say that I am very sorry for how much pain you must be in. You raise a really interesting point, because when I started reading Barry Meier’s book, one thing I had not understood is that a lot of doctors respond to the loss of analgesic benefit of pain patients using opioids by raising the dose — almost ad infinitum, under the theory that there is no unsafe dose. This seems inherently counterintuitive to me (that there is no unsafe level of opioid medication), but your experience, of constantly adjusting the drugs must be very tedious and would probably strike many doctors as just too much work to oversee in the average patient and perhaps very risky to try in others.

      • NCG says

        I second Barbara. It sounds to me like you’re the one who should be getting the free massages (from O’Hare’s linked piece). I hope you find a treatment that works better.

  4. Josh G. says

    Sure, there’s a reasonable conversation to be had about when opiates should be prescribed for pain and in what amounts. But I’m not at all convinced that the DEA is a productive participant in that conversation…

    • NCG says

      I have the same worries as you in regard to the political side of this, but I don’t think it’s fair to blame Humphreys for our idiotic media discourse. Plus, heaven forbid anything happens to me, at least now I’ve been warned about this stuff. I had no idea that you were supposed to monkey with your opioid levels the way Kotter has to. (And I imagine, it’s probably beyond the average patient.) So, I think it’s well worth the discussion. It’s not his fault if his ideas get misused. That is the fault of the misuser.

    • Brett Bellmore says

      I’m quite sure that some people with a legitimate need for opiates are going to have some fun, too: When my (now deceased) mother was in the hospital with acute gall bladder infection, and certainly an appropriate recipient of opiates, I visited her, to find her staring at the ceiling. Asking her what had her attention, she told me she was just watching the clouds go by, very peaceful.

      I pointed out she was indoors, and she remarked, “Oh, so this is why people take drugs.”

      But just because he had a bit of fun, too, was no reason she should have been forced to suffer.

    • dave says

      No such thing as medical freedom in the U.S.- outside of refusing treatment. The health care industry dictates who has what access to what diagnosis and treatments. Their beliefs are not based on what is true per se, but rather serves their occupational interests. Opioids- a case in point. The pain specialists lied about the addictive potential of opioids so they could get money from pharmaceutical companies. They admitted that there was a lack of long term studies on opioids. Were all free to believe in lies and fraudulent activity of medicine- after all were sheep dumb before the shearers. Freedom in medicine- is a fiction just like patient oriented care and empty rhetoric about quality care or evidence based medicine.

  5. NY-Paul says

    You are exactly right.

    Due to my own situation I have studied this issue more than most other topics that affect me. If you follow this story at all you will find that that the overwhelming percentage of coverage concerns doctors who may over prescribe, patients who might feign their pain problems, hard working DEA agents, together with State & Local Police forces, publicity grubbing politicians, and the ever growing number of investigations our overworked “forces against evil” are compelled to concentrate on due to this “Alarming, Growing Epidemic.“

    Somewhere in the narrative you might find a throw-a-way reference to legitimate, suffering patients.

    • dave says

      I didnt know there was no other effective treatment for pain- i guess hypnosis, manaka acupuncture, toyohari meridian therapy, microwave resonance therapy, low intensisty pulsed ultrasound,schweitzers formula, dry needling, primal reflex release technique, Domincic method,- to name a few. Its regrettable medicine has brainwashed people into beliving there are few alternatives for people in pain. But i blame the moral and mental laziness of medicine- after all, as Dr Volkow indicated Veterinarians receive much more education in treating pain then do regular doctors. And so what does the average doctors know about pain- almost nothing.

      • NY-Paul says

        From both personal, and anecdotal, knowledge doctors know, “no one ever died from a ’little’ pain.”

  6. Mark A.R. Kleiman says

    Right! Add to all of that the deaths from methadone overdose, many of which relate to the incapacity of the non-specialist physicians who write most of the pain prescriptions to get it through their heads that methadone’s long metabolic half-life means that it builds up in the body, so that continuing for a week the dose that works the first day may lead to respiratory arrest. It’s a shame that the people who make a living being in a panic about “drug abuse” have picked up on the prescription opioid problem and run it through their standard response repertoire, rather than confronting the actual issues.

    Relatedly: There’s apparently good reason to think that (1) providing a bit of amphetamine-type stimulant along with the opioid not only counteracts the drowsiness but also potentiates the pain relief, allowing patients to get by with smaller opioid doses; and (2) providing a bit of naloxone (an mu-opioid-receptor antagonist) doesn’t interfere with pain relief but does retard tolerance formation. But there’s apparently no reason to think that our insane patent-based system of financing pharmaceutical research will ever make either of those important clinical advances practically available.

    • Barbara says

      It’s true, for a variety of professional reasons I have to think about prescription drug business day in and day out and it took me a while to realize that pharmacologic innovation is basically dependent on how and whether the drug “molecule” intersects with patentability. This means that virtually no new drug innovation exists without being insanely expensive, and even existing drugs that are currently cheap will only be “validated” by linking them to some other mechanism that allows the manufacturer to extrapolate monopoly rents (e.g., orphan drug status and 17P/Makena).

      Devising a parallel path to validate the expanded efficacy of off-patent drugs that does not require the private investment of millions or even billions of dollars would be a worthwhile project.

    • Brett Bellmore says

      Mark, it’s not just opiates. My wife and I have both, in the past year, had respiratory infections, and both been prescribed “Z packs” for them. What struck me as beyond peculiar was the fact that we both received the same dose. (I’m close to 3 times her weight!) This probably had something to do with the fact that I relapsed, and she had awful stomach upset while taking the antibiotic.

      This prompted me to do some research into the recommended dose for Azithromycin. Imagine my surprise when I found out the recommended dose really did NOT depend on the patient’s weight, only age. Biologically, that’s insane. No drug actually behaves that way.

      I’ve come to realize that, even as the totality of medical knowledge advances, the fraction of it that’s actually being used in most cases has been shrinking. Maybe that’s because that totality is just beyond the capacity of a single mind to encompass, but I have suspicions that the practice of medicine is being degraded in the interest of cost savings, too. Having only one size of “Z pack” sure simplifies inventory, even if it hurts patient outcomes.

      So, doubtless, there’s a lot of stupidity in the prescription of opiates. But they’re hardly a special case.

    • dave says

      Theres more to proper pain care then pills. Use of pills makes people feel they are helpless to control their pain. Moreover pills are just Cnidian antipathic remeidation and dont address causes. Remarkably medicine despite frequent boasting of how much they know about pain mechanisms still dont know what causes low back pain in 85% of cases. The causes of fibromyalgia, migraine, osteoarthritis etc- remain unknown, prognostic biomarkers for pain conditions-unknown-modern medicine has failed people in pain.

      • Barbara says

        “Modern medicine has failed people in pain.”

        Modern medicine in the U.S. fails anyone whose needs cannot be monetized. My husband had surgery for kidney stones that lodged in his urethra — the result of that surgery is a constant, nagging pain (not the doctor’s fault, I hasten to add, just the predictable outcome of this kind of procedure in a certain percentage of patients). Doctor shrugs his shoulders and tells him to look up prostatitis on the Internet. Patient care and surgery are not the same thing and doctor is paid only for the latter. And this can be seen as a microcosm for our entire medical enterprise: drugs are paid for, so drugs are used to treat pain. So infuriating on so many levels.

        • dave says

          Barbara- I agree with you. As U.S. doctors are paid twice as much as European doctors and provide worse care and are less patient oriented, clearly doctors in the U.S. are too greedy and too unqualified to treat people in pain.

          • Barbara says

            Most doctors are at the mercy of the same forces that are beyond the control of patients as well, beginning most starkly with the Medicare physician reimbursement insanity, which basically bypasses judgment (if you can’t figure out how to value something perfectly that doesn’t mean you should assign it a value of next to zero) and grossly overvalues “doing stuff” (because it is easier to value) regardless of whether it is done well, adds value, comports with an actual diagnosis, or actually betters people’s outcome. Literally, doctors are being paid to do stuff to us regardless of our actual need. Most people truly do not understand the incentives under which doctors (and hospitals by extension) operate.

          • NY-Paul says

            Barbara says:

            “Most people truly do not understand the incentives under which doctors (and hospitals by extension) operate.”

            Lol. I was getting some exercise walking the halls of a hospital during post-op after a procedure had been performed on me recently when Dr. ABC, my urologist, and not involved in the current treatment, noticed me and yelled out, “hi Paul, how are you?” “I responded, “fine, I’ll be going home tomorrow.” We said our good byes, and that was that.

            The following month, as I was perusing the paid bill from by my insurance company, I noticed a line indicating a charge of $80 by Dr. ABC for “follow up.”

            This doctor surely understands the “incentives.”

          • david says

            Doctors know well how to follow the money. Doctors are not the innocent victims of poor pain care. They are the morally and mentally lazy generators of poor pain care. My how they gang up on legislators when the govt. wants them to have education in pain care. And despite some of their colleagues concerns-doctors have yet to develop a vision or plan for improving pain care.

          • Barbara says

            Paul: You should have written a letter to the doctor with a copy to the insurer that this was obviously a mistake and that you did not receive any follow up care. That is just an outrageous thing for a doctor to do, and the fact that it was only $80 or that you weren’t paying isn’t the point. The point is that it is probably a pattern or practice of this doctor that, if audited, would amount to thousands of dollars every year for such “follow up” visits.

  7. Ed Whitney says

    Over at the Incidental Economist http://theincidentaleconomist.com/wordpress/some-kidney-stones-related-facts/ , Austin Frakt has some reflections on kidney stones and cites a Cochrane review comparing NSAIDs to opiates for acute renal colic (mostly with confirmed stones). The NSAIDs were about as effective as the opiates even in this rather classic setting where opiates are considered the most appropriate pain relief treatment. Of the 20 studies in the Cochrane review, only 3 were done here in the US; the other 17 were in other countries. Most of the studies were head-to-head comparisons of NSAID vs. opiate, but a few drug combinations were also allowed in the review. Both NSAIDs and opiates administered as a bolus were effective. The most startling thing the authors conclude is “… patients receiving NSAIDs achieve greater reduction in pain scores and are less likely to require further analgesia in the short term.”

    This is a surprising result. It is not clear why so few of the clinical trials were done in this country.

    • Keith Humphreys says

      Thanks Ed, for this great link and information. The US and Canada consume a spectacular level of opioids that has no parallel anywhere else in the developed world. It’s a recent phenomenon, really a creation of the past 15 years.

  8. dave says

    Its doctors-especially pain specialists who are addicted to using opioids. Opioids are a quick way for doctors to mistreat pain and there is no theoretical basis for opioid use either in the gate theory or the energy crises theory of pain. There is no such thing as hypoopioidemia. Its regrettable the problem has lasted so long- especially given the frequent bragging of doctors about how much they understand about pain mechanisms. The pain specialists despite being under federal investigation continue to promote the use of opioids- after all they still receive lots of money from pharmaceutical companies. There will be a 25% increase in opioid use from now until 2018. The Opioid economy is flourishing-thanks to the moral and mental laziness of medicine toward people in pain.

  9. James Wimberley says

    The real scandal here continues to be the unavailability of morphine and other opioids for pain relief for cancer and other patients in the Third World. Raising their use across the world to British or American levels (with their manageable and comparatively minor problems of dependency) should be a policy objective, not a worry.

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