Why long term use of opioids is not the answer

In 1804, Frederich Serturner experimented with opium and created something new—morphine—named after the Greek god of sleep and dreams, Morpheus. More than 200 years later, at least 8 million Americans fall asleep at night under the influence of an opioid. Every morning, 40 of them don’t wake up.

As described in a previous article on this subject, the United States is in the grip of a prescription opioid disaster: with 2 million people addicted, drug overdose is now, for the first time, responsible for more deaths than car accidents, and prescribed opioids are responsible for most of the fatalities. What can be done to control this epidemic?

In reality, there are two separate problems. First, what should be done for the millions already hooked on Oxycontin, Vicodin and other opioids? How can we prevent so many of them from becoming part of next year’s statistics?  Second, what can we do to prevent the next 2 million, people who are showing up in physicians’ offices now, seeking treatment for their chronic pain, those looking for relief but putting themselves at risk for addiction?

“It’s hard for physicians to say ‘no’ when patients demand opioids for pain because both patients and physicians have come to believe that opioids offer a solution.”

Members of both groups have at least one thing in common: they live in a country that assumes, whatever ails us, that there will be a quick, complete and external fix for it. According to Jane C. Ballantyne, MD, FRCA, Professor of Education and Research in the Department of Anesthesiology and Pain Medicine at the University of Washington, a pre-eminent authority in pain management, “We live in a culture in which the expectation is that we can ‘fix’ everything.” Unfortunately, because of now-suspect research, overzealous marketing by the pharmaceutical industry and a campaign that encouraged doctors to stop being “opioidophobic” about pain, Dr. Ballantyne notes that “it’s hard for physicians to say ‘no’ when patients demand opioids for pain because both patients and physicians have come to believe that opioids offer a solution.”

Physicians frequently prescribe opioids for use in the treatment of acute pain, in some cases without exploring the patient’s substance use history or assessing for the risk of addiction- a problem in and of itself. But with respect to longer term use, it really seems to require a master’s touch in order to use opioids safely and effectively. For example, Mark Willenbring, MD, former Director of the Treatment and Recovery Research Division at NIAAA/NIH Founder and CEO of Alltyr: Addiction Treatment for the 21st Century, believes that opioids can be “very helpful in restoring function in chronic pain”, but bemoans the fact that “there is no consensus about who should receive how much opioid and for how long” and notes that doctors need “much better education in pain management and opioids.”

While experts may disagree as to whether there should be any role for opioids in managing chronic pain, they agree that the long term use of opioids is not the answer. Put simply, they just don’t do a good job of  managing pain in the long run. According to Anna Lembke, MD, at Stanford University Medical Center, “it’s important to realize that opioids are not actually very effective for chronic pain, and can in some instances even make pain worse by causing a condition called ‘opioid-induced hyperalgesia’.”

So, unfortunately, there really is no single, simple “magic bullet” solution to chronic pain. Chronic pain is a long slog of a burden that needs to be met full-on by an actively engaged, motivated, psychologically resilient, hard-working patient if quality of life is to be maintained.Seen in this light, out of all the options available for chronic pain, opioids are in a class all by themselves in that they not only often fail to work, they cause addiction and death. According to Dr. Ballantyne, “We shouldn’t be using opioids at all for chronic pain, except in very unusual circumstances. Every medication that is used for pain tends lose its charm after a certain period of time.” Unfortunately, she notes, when the opioids stop working the patient is “unable to stop because of dependence and bad side effects.” Better never to start.

The two million

But it’s too late never to start for the two million Americans who are already living with the physical and psychological agonies that result from the multiple stressors of pain, opioid addiction and fear of overdose, not to mention the various severe side effects of chronic opioid use: sedation, tolerance, constipation, sexual dysfunction, etc. It’s a deep, dark hole to climb out of, but it can be done. According to Andrew Tatarsky, Ph.D. the Director of the Center for Optimal Living, an addiction treatment program in Manhattan, many patients come to treatment with a vast ambivalence towards their drug and their physician. “They love and crave their drug, the euphoria and the relief,” Tatarsky says. “But they also hate it because they know they’re both physically and psychologically addicted to a potentially dangerous medication, and suffering in a variety of ways. And they express a similar mix of emotions toward their physician, sometimes complaining that they weren’t properly advised about the risks, while at the same time experiencing a profound relief and gratitude every time they get a refill.”

Addiction treatment is a core ingredient in the recipe for working with people dependent on opioids for pain. According to Andrew Kolodny, MD, the Chief of Psychiatry at Maimonides Hospital in Brooklyn, “we have to make sure that patients addicted to opioids have access to effective addiction treatment. If we just close pill mills and make doctor shopping more difficult, without expanding access to treatment, people who are opioid addicted will turn to the black market for pills or heroin and overdose rates will remain high.”

The first step is getting patients who are addicted to acknowledge the addiction—that’s a huge part of the biopsychosocial trajectory towards recovery. Once that challenge is met, effectively managing the addiction is a goal that can be accomplished in several ways. Although nobody that I spoke with endorsed the idea of rapid detox fromopioids, many patients who are seeking treatment are admitted to inpatient detox, usually followed by a rehabilitation program. Others opt for Medication Assisted Therapy with a “partial opioid agonist” such as buprenorphine or methadone, which mimic some of the effects of traditional opioids but are less addicting. Dr. Lembke points out that “for people addicted to prescribed opioids, for whom abstinence has not worked, opioid substitution therapies such as methadone and buprenorphine are effective”.

Dr. Ballantyne notes that “these medications will also treat the pain, so you’re managing the addiction as well as the pain”. Adds Dr. Willenbring, “if everyopioid addict had access easily and cheaply to buprenorophine and methadone it would sharply reduce overdose deaths”. He also recommends “distributing naloxone injection kits to users/friends/families, which has been proven to reduce deaths.” Buprenorphine and methadone can be used to taper patients slowly from opioids to other forms of treatment for pain or used long term as maintenance therapy.

Experts are careful to point out that addiction is best treated in a comprehensive way. According to Susan Foster, V.P. and Director of Policy of Policy Research and Analysis at the National Center on Addiction and Substance Abuse at Columbia University (CASAColumbia), “a multi-pronged approach to addiction treatment that includes a combination of pharmaceutical and psychosocial therapies typically yields the best results.

How to prevent the next two million opioid addictions

What is the best approach for new patients? How can we prevent the next two million opioid addictions and the next 15,000 deaths? Only by changing the way we deal with addiction and chronic pain.

The solution must include, as an integral element, that prescribers develop a greater awareness of addiction. Frequently, little or no attention is given to a new patient’s historical relationship to alcohol and other drugs. Giving a prescription for Oxycontin or Vicodin to a patient without fully exploring past and current substance use is counterintuitive- but it happens all the time. “All physicians should routinely screen patients for risky substance use and addiction as an essential component of evidence-based medicine.  This is particularly true in patients with pain or other conditions which may require controlled prescription medications”, notes Jayaram Srinivasan, MD, MPH, CPH, Senior Medical Advisor at CASAColumbia.

Experts agree that a “multimodal” approach to pain management is best. Since there is no “magic bullet” for chronic pain that will eliminate pain long term without causing side effects (or death), the best approach is to have a quiver full of arrows in the battle against pain. And the conversation that happens in the early stages is critical, says Norman Wetterau, MD, FAAFP, FASAM,  President of the New York Society of Addiction Medicine. The language that is used to discuss these issues is critical, especially when patients walk in the physician’s office expecting that an opioid will be prescribed: “Rather than saying  ‘I cannot give you opioids,’ you can say, ‘I have something better for your pain.’” And again, the best approach is often multidimensional.

According to Dr. Ballantyne, “there are a variety of alternative approaches that are ultimately more effective including psychological treatments, acupuncture, yoga, Tai Chi, tricyclic antidepressants and anticonvulsants.” Others find great relief through chiropractic treatments, meditation or relaxation training. And there are many non-addicting options available from a prescription pad. According to Dr. Srinivasan, “Effective non-opioid pharmacological treatment of pain may include numerous options such as aspirin, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), selective NSAIDs, anticonvulsants, tricyclics, serotonin-norepinephrine reuptake inhibitors (SNRIs), antispasmodics, topical analgesic agents, and others.” But Dr. Ballantyne reminds us that the “the single most important approach focuses on the psychological aspects of pain because the patient needs to be engaged, activated and motivated in order to achieve the best outcomes”. Again, chronic pain is an ongoing challenge, and only those who personally engage will get the best results. Those who passively expect their doctors to relieve their pain wind up in trouble.

Dr. Kolodny is confident that the medical community will be able to turn things around. In his role of President of Physicians for Responsible Opioid Prescribing (PROP), Dr. Kolodny devotes much of his time to making sure that physicians have the tools they need to weigh the pros and cons of opioid prescribing: “Doctors who realize thatopioids are dangerous and addictive, and that they don’t seem to work well for most people with chronic pain, will prescribe more cautiously.”

Richard Juman is President, Insight BusinessWorks, Inc. and blogs at The Fix.

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  • http://twitter.com/frasputin Fat Rasputin

    It seems the thesis of this post is there is never a place for opiates, I must say that a multidimensional approach should not necessarily exclude opiates and it would be a shame to dismiss them out of hand out of prejudice.

  • Deb Stone

    The person using morphine for pain cannot determine point of their addiction, it is usually someone near them who must monitor these effects once it crosses a certain boundary and start detox. process., reason for numbers that do not recover.

  • Payne Hertz

    This piece is devoid of scientific validity and basic humanity. Where is the evidence that opiates do not work long term? The fact is there have been few studies done to answer this question one way or the other. Those that have been done, though of poor quality, have demonstrated the long term efficacy of opioids. Concluding from the lack of high quality evidence of their long term efficacy that they don’t work is unscientific. Absence of evidence is not evidence of absence is a basic principle of science. Most therapies for pain lack evidence of long-term efficacy.

    This is also the experience of many pain specialists who actually treat pain, contrary to your unscourced assertion that experts all agree that long term use of opiates in not the answer. It is also the experience of millions of pain patients who would long ago have parted ways with this therapy were it not effective, the same as they do any other useless therapy. Funny, but their opinion and experience is completely absent in this debate.

    According to Dr. Ballantyne, “there are a variety of alternative approaches that are ultimately more effective including psychological treatments, acupuncture, yoga, Tai Chi, tricyclic antidepressants and anticonvulsants.”

    Where’s the evidence for long-term safety and efficacy of any of this? NSAIDs kill far more Americans every year than opiates do, and there have been many studies suggesting that the cardio-vascular effects of many NSAIDs may be every bit as pronounced as those of Vioxx, which is credited with killing 150,000 people worldwide and may have killed hundreds of thousands more.

    http://www.counterpunch.org/2012/06/05/vioxx-and-the-morality-paradox/

    “Chronic pain is a long slog of a burden that needs to be met full-on by an actively engaged, motivated, psychologically resilient, hard-working patient if quality of life is to be maintained.”

    Sure, why provide prompt and effective relief for pain when you can make “psychologically resilient” patients endure a “long slog” of torture while they work towards what, exactly, learning how to “cope” through mind over matter mumbo-jumbo? How utterly and shamelessly barbaric.

    What other class of illness is treated by withholding treatment in favor of allowing the devastating effects of the illness to take their toll? Perhaps we should limit insulin to patients who have demonstrated psychological resilience by surviving an amputation or two. There is a growing body of evidence that chronic pain is a neurological disease in its own right, and failure to aggressively treat pain at the get go may be a primary cause of chronic pain due to central sensitization of the nervous system and alterations by pain of neural pathways.

    In the end I suspect this debate is all about money. Why treat pain with drugs that by natural right should be cheap as dirt when you can exploit people for tens of thousands of dollars with useless surgeries, injections, behavioral pain clinics, psychotherapy and quack, new-Agey interventions while treating their “addictions” in rehab centers which themselves have little evidence of efficacy.

    The development of an addictive disorder should not necessarily be a bar to treatment of pain with opiates. After all, it is not a bar to treatment of addiction itself with opiates, and studies in Europe have been pretty consistent in demonstrating the effectiveness of heroin maintenance in treating even the most hard-core addicts, let alone chronic pain patients with comparatively mild addictive propensities.

    • Jenness

      Don’t confuse them with actual facts, it’s like the mainstream authors don’t want to hear it because the “sound bite” isn’t catchy enough and no one will pay for their article or they’ll get less pats on the back from others that also have no experience in the issue.

      The reality I see every day is this: Patient comes into office. General Prac/Family Doc no longer will prescribe them Vicodin because they’ve upped them to the point they feel uncomfortable. Patient is addicted, in pain, hasn’t slept in months or years, has developed hygiene issues, seems mentally impaired, catastrophizing every situation that is discussed, is depressed, asks all sorts of “can I get (insert drug name)” questions and has been denied care all around town due to above issues.

      This patient would (excuse my frankness) slit their wrists or go out and get heroin if they were told to do yoga.

      What they need is a “scary” long acting opioid so they can sleep and be out of pain enough to get some sanity. Then, after they are able to cope enough they need their medications adjusted and adjusted. They simply cannot handle “instant change” because they’ve been traumatized by poor prescribing methods (which aren’t considered poor prescribing by the establishment UNTIL they go to a pain medicine doctor and then suddenly it is THAT doctor’s fault).

      *rolls eyes*

      The patients I see every day never asked for cancer, for genetic or debilitating spinal conditions, to be injured at work in a way that has fused their back and they aren’t even 40 or to have survived an automobile accident that murdered the ones they loved or left them with a life long condition that they suddenly have to manage. They never asked to be addicted to vicodin. Or to take so much tylenol their livers give out. But hey, at least they aren’t on morphine and don’t get shunned for taking hydromorphone, exalgo, or suboxone. Give me a freaking break!

      I am not the doctor so I can state my disgust for this type of article that offers nothing at all of value, only useless questions for which there ARE answers.

      Patients need to be counseled MUCH sooner and put into true pain management programs. They need to be stabilized on medications in the BEGINNING that work and not forced to go through medieval survival of the fittest torture until they are finally so broken and addicted to Class III’s that they are begrudgingly sent to the right specialist. No one does this with diabetics or heart disease patients, the fact they do it with chronic pain is insanity.

      It’s all about telling the patient the TRUTH. They need to be told the truth about their conditions. They need to be told specifically that there are ways to end their pain (if there are) or the truth if they never will have a reasonable chance of ending it due to technology, their finances or insurance. The truth makes a big difference. It fosters acceptance, innovation, and people get really creative when they feel they know what to expect. I have NEVER seen a chronic pain patient that was addicted come into this office and say “They told me I’d always be in pain and that I needed to come into pain management and find a way to deal with the pain, management my weight, get on the right medications or I could lose my life and be an addict or develop emotional problems.” The addicts all say “They told me it was just a…..(sprain, break, bulged disk…..)” and then made to feel like it could get better or minimized the condition but gave them Norco, and not a little bit of Narco either – but yet those same doctors act amazed when the patient comes back, condition has progressed and wants the same prescription or more and the patient is having a tough time understanding why they can’t “get over it”.

      We have a patient that flies from Amarillo here to Orange to get stem cell injections. No medicine…just that…insurance won’t pay but guess what..it works and now so can he. He literally has cut back on basics in all other areas to be able to do this – but that is how important not hurting and being able to work is for him & his family. But it’s considered “experimental”.

      We also have patients that due to fusions will never be able to live without some form of opioid. Ever. They will take scary doses for the rest of their life because their pain is really that bad but with the right mix, even they can have a quality of life that is livable. Some people really will live with a Fentanyl patch until the day they die and not die from that.

      Best practices and cookie-cutter solutions are the WORST THING to EVER happen to American medicine. Everyone is so vastly different and reacts so vastly different that there simply can not be any system of any true value – other than to give every physician the best schooling possible and let them care for their patients and get paid a living wage to do so. Having non-Physicians or Physicians in other specialties regulate who gets what drug/care/surgery has thrown this so many patients into crisis from chronic pain to pediatrics. I hate articles like this. Hate them. They only serve to perpetuate the ignorance on what is now such a “trendy” topic.

    • MeredithKendall

      The psychologically-resilient patient is the one who doesn’t commit suicide. And I’m not knocking people who commit suicide – living without a quality of life is not living.

      Note on yoga: I do it and I like it. However, plunk “yoga injuries” into Google and articles on yoga injuries will come up. Important to have a good teacher and actually know what is causing the pain otherwise it will make things worse.

  • poisonalice

    Our society is SO obsessed with addiction that even doctors can no longer tell the difference between a natural physical dependence, that happens in many drugs other than opioids and other controlled substances (I have a physical dependence on gabapentin, if I even miss one dose I can start withdrawing, would you say I’m addicted to it? No.), and real, true addiction. And I would throw out a guess and say that the majority of doctors have never even heard of pseudo-addiction, when a patient shows “addictive-like” behaviors because their pain isn’t being properly controlled and their pain leads them to become emotional. I have been on opioids for close to a decade now and even though I HAVE increased my dose, it’s not entirely due to tolerance but also to progression in my disabilities. I went through everything. Before I went on the opioids, I was put on a whole slew of prescription NSAIDs, which has led to my current NSAID allergy (I go into mild anaphylaxis if I even take 200mg of ibuprofen, I can’t imagine what a full dose would do to me), I tried Lyrica (was RXed it for fibromyalgia when it was still in clinical trials for that) at the highest dose and nothing (though I’m now on gabapentin, but mainly to control nerve sensitivity), did PT (when I did it for my back, it inflamed my fibromyalgia, if I did it for my fibromyalgia, it made my back worse, not including the fact that both made my knee worse) to no avail, topical treatments I can only use rarely, because of my psoriasis, and I gone through all that psychotherapy stuff and while it felt good getting out my emotions, it did nothing to help me cope with the pain. I also tried those horrid anti-depressants marketed for pain, which gave me severe panic attacks and actually INCREASED my pain. There are a lot of chronic pain patients out there on long-term opioids because they’ve ALREADY TRIED everything else and NOTHING ELSE WORKED. I do believe that people are too freely prescribed these medications, and that other treatments need to be tried before being given opioids, such as like in my case, but it’s just insulting and inhumane to think that pain patients such as myself shouldn’t be given them for long term use and we just need to “deal with it”. My pain is so intense without the medication that I would literally kill myself if I wasn’t able to stay on my opioids, rather than live the rest of my life in that severe pain 24/7. I would just LOVE for all doctors who are anti-opioid to go a year in the kind of chronic pain that their pain patients go through, and see whether or not they would change their minds. I bet they would change it within the first week, if not the first 24 hours.

    • MeredithKendall

      Completely agree on the lack of understanding in the difference between drug-seeking and abuse and the patient trying to get pain relief. The two can overlap, but I’m not sure how much that occurs.

      • poisonalice

        I take my medications exactly as prescribed, but I have panic disorder and anxiety disorder, which can be aggravated if I can’t get my prescription before I run out (the very idea of the severe pain I’ll go through without my pain medications cause me panic attacks), or if I have a large increase in pain that my pain medications aren’t covering and it’s lasting more than a few days, that will give me panic attacks too. These panic attacks often look like “drug-seeking” behavior to people who don’t know me and my medical history very well. I’m sure there are some people that work in my doctor’s office who have labeled me an addict, and I’m sure some at the ER have labeled me as such, as my doctor told me that if I have a sharp increase in pain that lasts more than a day and my medications aren’t covering it and I can’t get in to see him immediately, go to the ER for immediate treatment until I can see him. Thing is, when I do that, the ER staff tells me that I shouldn’t have gone to the ER, that they’re there to treat stuff like car accidents and broken bones, not the average back ache. They don’t understand though, even the few hours of respite given to me in the ER helps me tremendously until I can see my doctor, as the pain that leads me to the ER is always severe enough that I’d rather kill myself than experience the pain any longer. I know that when I start thinking about killing myself because of my pain level, it’s time to go to the ER, so it’s not like I’m going every time my back hurts a little more than usual. I’ve also had to go for migraines that make me suicidal, too. I was actually admitted to the hospital for testing for 2 days for one. They never got around to the spinal tap, though, because my migraine started going away by the time they came up with that idea.

  • MeredithKendall

    I cannot recount the number of times I have said to a doctor, “I don’t want pain medication, I just want this fixed.”

    First
    doctor: “Don’t know what to tell you.” Second doctor: “It’s
    osteoarthritis.” Third doctor: “Wait, what?!” Psychiatrist: “No, this is
    not in your head, and the pain is still real even if that were the
    case.”

    Drugs typically used for psychiatric-related diagnoses are
    The Crazy People Drugs. NSAIDS are They Sell Those At Walgreens, They
    Must Not Work For Much Outside Of Headaches. Steroids are Wait, You Mean
    What Body Builders Use?/Oh, They Gave That To Me When I Had Poison Ivy.

    Opiates are The Pain Drugs, and getting them is validation for many
    that pain is real and not “in my head.” The side effects aren’t nearly
    as uncomfortable as that of antidepressants/anticonvulsants, and scary
    as NSAIDS or steroids (at least for those of us who have taken NSAIDS
    and steroids and had serious esophageal problems and mood dysregulation
    as the result). Suboxone, methadone, and tramadol have some of the most
    horrendous withdrawal symptoms, and the abuse potential is still alive
    and well even if it isn’t as pronounced or advertised (I say this as
    knowing people personally and professionally that have ended up in rehab
    as the result of one of the trifecta of magical opiods that supposedly
    don’t cause Problems Like That).

    Few know how to recognize and
    treat addiction, and I say this as someone who works in the mental
    health field. I was required to take two classes on addiction, which is
    more than people in some other disciplines (and nothing on chronic pain -
    good look finding a therapist who knows how to treat it). We don’t
    actually know what mechanism causes people to abuse drugs. There are
    correlations, some of which are strongly positive. People with regular
    exposure to a substance with known abuse potential are more likely to
    abuse that substance than people who do not have regular exposure to
    that substance. We do know that people with chronic pain can have
    problems in the addiction arena, but we also know that there is a
    correlation between inadequately treated pain and addiction – hence the
    call for not witholding opiates simply because they have abuse
    potential. And we do know that daily exposure to opiates will result in
    horrid withdrawal symptoms when they are discontinued. And we do know
    that people don’t like discomfort (especially opiate withdrawal) and
    will do what they can to avoid that discomfort.

    There are barriers to effective pain treatment, including for those of
    us who have the money and specialists a ten minute drive away. For me,
    it was finding someone who didn’t dismiss half of what came out of my
    mouth to make a referral and then finding another specialist who
    operated on current evidenced-based practices as opposed to dismissing
    half of what was coming out of my mouth. For others, there is a lack of
    time, money, and programming as mentioned in another blog post. Yes,
    there is the “lazy patient who brings it all on herself” (using “her” as
    us chronic pain womenfolk get some of the nastier labels), but I have
    trouble blaming a person for lack of exercising as I had to limp the
    five minute walk to the pool this summer and the only reason for not
    crying was my kid being with me. And yes, we are a “pill-popping
    culture,” but I think we have conditioned ourselves to assume a normal
    life is devoid of all emotional and physical pain in the same way we
    assume that tomatoes are perfectly round and bread takes weeks to get
    stale
    or spoil – technology has allowed us to avoid things that were once
    avoidable. We don’t know how to tolerate pain, and we use tools for
    conditions that are problematic regardless of whether or not our pain
    is truly pathological.