The societal problem of opioid addiction

Opioids are a family of pain medications chemically related to opium and heroin. They include morphine, fentanyl, codeine, hydromorphone and others. Opioids have unique properties that make them both indispensable for pain management and extremely dangerous.

Unlike virtually any other family of medications, opioids have no maximum effective dose. If any dose, no matter how high, is ineffective at controlling pain, a higher dose can give more pain relief. Most other medications don’t work this way. For example, if 800mg of ibuprofen doesn’t bring relief, it’s very unlikely that any higher dose will. This property makes opioids a mainstay for treating severe acute pain, such as from fractures or after surgery.

But the risks and side-effects are substantial. Tolerance (diminished effectiveness with repeated use) is a common problem requiring dose escalation to maintain the same pain relief. Withdrawal symptoms are miserable (but not dangerous) and addiction is very common. The most serious risk is that opioids decrease the drive to breathe. In patients who are dying and short of breath, this is a welcome benefit, not a side effect. Opioids are essential in hospice care because of their ability to eliminate the sense of shortness of breath. But that same effect in an overdose can stop breathing entirely. Philip Seymour Hoffman is only the most recent well-known victim of this property of opioids.

When I did my residency in the mid-90s the philosophy I was taught about opioids was simple. Opioids were for acute pain. If you broke a bone or had a documented kidney stone you could have a prescription that would last a week or so. Patient requests for more prolonged treatment were met with suspicion. The exception was for dying patients. If you had chronic pain form a disease that was going to kill you, you could have all the opioids you wanted. But if you had chronic pain from arthritis, or chronic back pain, or anything else non-fatal, then opioids were simply off the table. You had to make due with other medicines.

Sometime thereafter, we went through a revolution in our attitude. I’m not a pain specialist, so I don’t know if the revolution was supported by any scientific evidence or was simply a change in philosophy. The new teaching was that pain should be treated seriously, and that doctors had been negligent in providing their patients adequate pain relief. Since pain is an entirely subjective experience, there is no test or objective measurement for pain, and the patient’s report of pain should be accepted at face value. The use of opioid analgesics for chronic conditions became acceptable when other options failed.

What followed was an explosion of opioid prescriptions, opioid addiction, and overdose deaths. In 1999 in the U.S. 4,030 people died from overdoses of opioid prescription medications. In 2010 that number had more than quadrupled to 16,651. Since 2003, more people have died from overdoses due to prescription opioids than due to heroin and cocaine combined.

The American College of Physicians recently issued a policy position paper about prescription drug abuse. It was much more of a description of the current dilemma and a recommendation for future research than a guideline for prescribing physicians. The latter is what is desperately needed.

Adding fuel to this fire is the FDA’s decision this week to approve Zohydro, a new extended release formulation of hydrocodone. This decision has received much criticism from physician groups (see links to news articles below) who warn that the potential for abuse and overdose is enormous and that the need for another opioid analgesic is nonexistent.

Has our new more lax prescribing philosophy allowed some chronic pain patients to achieve adequate relief? Is the epidemic of addiction and overdose deaths simply a terrible but acceptable price to pay for the benefit of a far greater number of people who use opiates responsibly? I honestly don’t know. I would love to hear from a pain specialist if any rigorous studies exist on the topic. The societal problem of opioid addiction may have no solutions, only tradeoffs. It would be nice if those tradeoffs were informed by data.

Albert Fuchs is an internal medicine physician who blogs at his self-titled site, Albert Fuchs, MD.

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  • NormRx

    Let me see, over 16,000 prescription opioid deaths a year. About 11,000 gun murders a year, and guns are the problem?

    • Lisa

      There may be 11,000 homicides in which guns were used, but guns took the lives of 31,706 Americans in in homicides, suidides and accidents. So yes, I think guns are a problem. And personally I am less concerned about drug overdoses than gun violence. No one has ever threatened to shove opioids down my throat, but I have had threaten to shoot me.

      This doesn’t mean drug overdoses aren’t a problem.

      • NormRx

        After I clicked on the link in the above article, the updated figures for 2007 is 27,000 unintentional deaths. I don’t count suicides since all of the data shows even with the most stringent gun control laws it doesn’t affect suicides. Yes, suicides from guns might go down, but overall suicides do not. Opioid use does not save lives, yes they control pain but their use results in deaths. Guns are used defensively over two million times a year and the fast majority of times a shot is never fired. Go to the website “Guns saves lives” and you can sign up for a daily email showing defensive uses of guns. If you have been threatened by a gun perhaps it is time for you to take some training in the safe use of a gun, get a CC permit. Or the alternative is to carry a bag of opioid s with you can give them to the next junkie that threatens you with a gun.

        • Patient Kit

          I need a daily email from “Guns Save Lives” like I need a hole in the head.

          • NormRx

            You talk like you already have one, so I suppose you are correct you don’t need another one.

          • Patient Kit

            I have never owned a gun and never will. I don’t see how I talk like someone who already owns a gun. Perhaps the Brooklyn in me comes across when I communicate? >:-/

          • NormRx

            No problem, if you don’t want one, don’t have one. I realize everyone is brought up differently and depending where and when we have different views. I remember in 1961 I went to Japan as a young 18 year old and I became friends with two guys from Brooklyn and neither one knew how to drive. I found this inconceivable since I was driving since my feet could reach the pedals. They told me, with the expense, parking problems and good mass transit they never needed a car. Have a good day. Norm

    • goonerdoc

      Stop with the gun control remarks. Completely off the subject of the article, and doesn’t belong in this specific discussion.

    • querywoman

      Would they OD on something like alcohol if no opiods around? Or suicide from the pain?

  • southerndoc1

    Joint Commission and Press-Ganey have blood on their hands.

    • Chip Lohmiller

      Agreed about JCAHO. The idea that pain is the 5th vital sign fuels this fire. This notion that we should be free from pain has been perpetuated by this type of foolishness. Many providers understand the paradox of “patient satisfaction” as it relates to the responsible prescription of narcotics.

      • Kristy Sokoloski

        Chip, what suggestions do you have for those with chronic pain as to what they should be trying to control their chronic pain? The reason I ask this is because for many with chronic pain non-medication measures such as surgery, physical therapy, massage therapy, and others that are too long to list here does not work for them. So medications are their only option. But even with that said they may have tried other kinds of medications such as antidepressants in low doses to try and help control this pain before going on to the narcotic painkillers.

        I remember when it was announced that monitoring pain as a 5th vital sign and that was back in 2001. One of the reasons that this was done is because people who are in chronic pain and stay in pain consistently causes physical damage to the body. Especially when it comes to raising their blood pressure which of course makes the heart have to work much harder than it should.

        • buzzkillerjsmith

          Tricyclics, anti-seizure drugs, NSAIDs, spinal injections, SSRIs or SNRIs for coexisting depression/anxiety, muscle relaxants, peripheral nerve ablations, counseling, biofeedback, PT, OT.

          These measures, when appropriate, should come before chronic lifelong opiates for most pts.

          Pain medicine is a field in itself. As a family doc, I would definitely get a consult with a pain doc before committing a pt to long-term opiates for benign pain. Opiates are nasty drugs in many cases. Not to mention the societal impacts. A vicodin goes for 10 bucks on the street.

          • querywoman

            I don’t think opium is all that bad, but it’s not always appropriate. Historically, making it illegal in the US was a way to surpress Chinese immigrants.
            I used to talk about this a lot wtih a friend who died from ALS./Lou Gehrig’s. He used to be arunner adn he had used Vioxx.
            Opiates don’t work for all kinds of pain.
            Some antidepressants, like Elavil, are used for pain. My father had serious curvature of the spine, a degenerative disease, that was visible. He kept complaining of pain while the VA just didled around with his heart, etc.
            I could see that he was depressed as well as in pain. He said he saw an article on depression in Reader’s Digest that fit him perfetcly and asked the VA to put him in nut wing.
            Whatever antidepressant they put him on worked perfectly for his visitble spine curvature.
            It really doesn’t matter what the real cause of his pain was. What matters is the antidepressant worked.
            My mother hobbled out of an emergency room one night, tired of waiting, for severe back pain. The next morning, she took a couple fo Tylenol and was amazingly better.
            My mother lated tried acupunture for back pain, when medicine, chirorpactic and osteopahtic manipulatioon had not helped. It worked great for her.

            I know that I can alternate Tylenol and ibuprofen, and that’s what I did when I had my last teeth pulled. I had tried hydrocodone to supress the feeling so I could get used to my dentures, but I didn’t like it.
            I have written about how I fill a hydrocodone prescription maybe every year and a half for skin pain. I do need it when I need it, but I get tired of it fast.
            I used to have neck and shoulder spasms, which doctors dismissed as “stress.” It was computer related which they never explored. Doctors told me to use moist heat. A chriropractor told me to use ice, not heat. Ice packs were great, and I did not go further with the chiropractor.
            Do tens units help computer repetitive stress syndrome much?
            Yoga is my preferred treatment.

            Pain should not be dismissed outright with the assumption the patients want narcotics. There are so many options.

          • Suzi Q 38

            I have two RX bottles (#30 each) of Vicodin left over from my two surgeries last year.
            I think I used less than 10 from each bottle.
            I learned from this website how dangerous these drugs were, so I weaned myself off of them fairly early. I would just substitute Advil or Tylenol after a few days.
            A friend (whose 23 year old son died from an overdose recently) once saw my stash on the kitchen table and told me that it was worth a lot of money. “To WHO??” I retorted.
            I realized then and there that I should not leave these drugs in view.
            I started hiding them in a sock drawer instead, LOL.

            I decided to keep it for emergency pain, as I have done well with Nsaids alone or tricyclic antidepressants.

          • querywoman

            It just blows my mind that people will pay TEN DOLLARS for one hydrocodone.
            If you are not an addictive type, ti’s good to keep a little narcotic. You might wake up with a terrible headache and need one or two.
            FYI, my mother used to take Fiorinal for migraine headaches and occasionally gave me one. Years later, she discovered she could stop a migraine with OTC ibuprofen.

  • maggiebea

    I wish the statistic were reported as ‘deaths from abuse of prescription opiods,’ separate from ‘deaths from prescribed use of opioids.’ In my community there’s a lot of talk about the risk of grandkids selling grandma’s pills at school, and a bit less talk about adults becoming accidentally addicted during some major bone injury. I’ve never personally heard of a patient dying from unintentional overdose of a prescribed opioid they were taking for a pain they were having.

    • Kristy Sokoloski

      A number of the deaths from accidental overdose as a result of taking a prescribed opioid medication are unintentional. But you are correct that compared to the majority who die from the accidental overdoses the number is small. There was an article that just came out in the Washington Post that asked how come it is that the patients who are in chronic pain are not asked to give input on the issue surrounding this kind of medication. I haven’t read it yet, but I have heard some others say the article was pretty interesting.

  • querywoman

    Opiods never worked for my arthritis. Had to be NSAID’s, and I had to try a few. Yoga helped.

    • Kristy Sokoloski

      Querywoman,

      You are correct that for arthritis opioids don’t always work because of the fact that it’s an inflammatory condition. Unfortunately some with arthritis can’t take anti-inflammatories. As for the yoga, glad that it has helped you. My PCP tried to suggest that I do yoga to try and help with some of my pain issues. But I won’t do it for several reasons, the biggest one being because of the religious connection tied in with it. I know others may not agree about this aspect and that’s fine. We must find what works for us to help deal with our pain.

      • Lisa

        Try pilates – no ‘religious’ connection and many of the movements are based on yoga. Swimming may help too.

        I will say that most yoga classes offered in the US have absolutely no religious connection. Rather they are stretching and calisthenic classes.

        • querywoman

          I’m not familiar with, “pilates.” Will research. Swimming has the water to float us and cushion us. My mother, who was afraid of water, couldn’t walk far because of bone problems in her feet. She did some water aerobics.l She had trouble climbing in and it out, so she found a pool with good concrete steps built in.

        • Kristy Sokoloski

          The fact that many of the pilates movements are based on yoga makes them out too for me. And I don’t know how to swim. Tried to learn when I was a kid and never succeeded so I gave up trying. But my PCP did mention that or biking as a way to help me exercise. Too bad I can’t do either one of them. In the case of these two at least I tried but said “nope, can’t do this so never tried again”. As for most yoga classes in the U.S. having no absolute connection religiously. Interesting, but my research in to it showed otherwise. Like Querywoman said we are what we are.

          • Lisa

            I don’t understand why pilates would be out if some of the movements are based on yoga, but oh well…

            What do you do for exercise?

          • Kristy Sokoloski

            I try to do as much gentle stretching as I can, and try to walk through the house several times. Even going to the furthest point of the house at times to do some of my daily tasks. It works out in the end.

            Also, when we go shopping if we are in a parking lot that is pretty good sized then depending on how far away the car is parked I will walk a bit more instead of being close to the store. And then I get plenty of walking in the store. Right now almost everything is like extra exercise since I am still recovering from the surgery that I had to my left foot in Dec.

          • Lisa

            Foot surgery really complicates things. I hope you continue to recover.

          • Suzi Q 38

            I hope you feel better and the recovery from your foot surgery improves.

      • querywoman

        Nobody ever suggested yoga to me, whcih was a suggested I wouldn’t hvae minded. It was related to overwork on computers.
        A tad off topic: the fundamentalists Christians, some of them, say yoga opens a chakra and can cause a person to see demons.
        It’s never happened to me.
        Yes, I’m Christian. I’m big and tall and physically lazy, but I have a very flexible body. Always have. My arms are crooked, “double jointed,” – misnomer! I used to sit as a child with my head down and my rear in the air. When I started seriously doing yoga, my parents remembered it. We are what we are.

        • Kristy Sokoloski

          Interesting thought about the idea of that yoga could cause a person to see demons. But that wasn’t the idea of the religious aspect I had in mind. It was another aspect that related to the thing of spiritism. And it was also interesting some of what I heard about the history of yoga when I saw a piece on one of the morning news programs that said some leaders like certain ones from India thought that it gave them supernatural powers.

          I wish I had a very flexible body. lol But my body is not flexible and even if I was ok with the idea of doing yoga my body would not be able to handle the poses.

          Yep, it is so true that we are what we are. That’s the beauty of knowing our bodies well.

          • querywoman

            Religion is a complicated issue. Yes, you can see that yoga is appropriate for me. No, I can’t do some of the really extreme yoga poses nor can I stand on my head.
            But I can do lots o stuff and am fortunate to have my flexible, stretchy body.
            I chose yoga for myself over something like acupuncture, because I control my body myself with yoga. Acupunture is controversial, and needs another person, and it sure worked for my mother’s pain.

          • Suzi Q 38

            I am considering acupuncture for my pain, since I don’t like gaining weight with my tricyclic.
            At first my husband said “no way.”
            Now he is getting more understanding when he hears me moan from pain as I move about.

          • querywoman

            Many American studies say acupuncture is worthless. It worked for my mother. A non X-ray hound chiropractor, an osteopathic and his meds, had all failed to help her.
            She also went to the acupunturist to help her stop smoking. She couldn’t take Wellbutrin. He gave her some treatment and some natural med. She stopped smoking, but accredited it to prayer.
            No one knows.
            Prayer doesn’t cure a lot of people.
            I mentioned it to the psychiatrist I was using at the time, and she asked me if I would try it for my diabetes. I thought about, but didn’t get around to it.
            Mama’s acupuncturist also moved away from down the street from me.
            I’m not opposed to acupuncture. I think it’s something you just have to try and see.
            Sometimes you need help from another person. If you can’t motivate yourself or are too down physically to try water aerobics, Tai Chi, or yoga you can certainly give acupuncture a shot.

          • Deceased MD

            2010 study showed superiority of acupuncture for back pain compared to sham. It doses work but it is very dependent on the skill of the acupuncturist which is highly varied.

          • querywoman

            It’s hard to believe that this ancient practice doesn’t help. Betty Ford spoke of getting acupuncture treatments after rehab.
            I’m pretty sure Mama had back pain. Her FP was out, and he had a sub who was more concerned with the drastic task of getting her to quit smoking than her pain.
            Her own FP would treat her anyway.”
            She’d gone to a chiropractor also who was inexpensive and not a big X-ray freak.
            In paid, she’d seen a TV program about acupuncture.
            So she went to an acupuncturist near her home who advertised himself as, “MD of China.” She said she though his cute young daughter set off a bell timer that went off at the end of the treatment and she felt so much better,
            It’s possible his treatment helped he stop smoking.
            Maybe I can remember his name and find him.
            In California, perhaps Suzi Q could find a really good acupuncturist from the other side of the Pacific. She says she’s part Asian, so maybe acupuncture is in her “genetic memory” – hee! hee!

    • Patient Kit

      I took Percocet for about a month after each of my 4 major surgeries (pathologic femur fracture, ruptured Achilles tendon, torn meniscus and hysterectomy for ovarian cancer). I was happy to have that level of pain control during the most acute phase of my post-surgery pain because it helped me get good healing sleep and get mobile and active more quickly. I was always happy to transition off the narcotics though because (a) a cloud really did lift and I was my sharp old self again and (b) I’m a fan of pooping regularly. For chronic and residual pain, I take ibuprofen daily. And I worry about the effect that could have on my liver and/or kidneys. But I need it to function. But, by far, one of my best pain management tools is swimming. I swim a mile at least 5x a week. It would be fair to say that I am addicted to swimming. My sister is a yoga addict. I might start trying yoga too.

      • Suzi Q 38

        I too, love swimming.
        I try to swim at least 45 minutes 3 times a week.

  • buzzkillerjsmith

    I had a discussion recently with one of the pain docs from Univ. of WA about a 20 year-old with a history of finger fractures and chronic pain. He is to get another surgery and his ortho is prescribing him one hydrocodone with acetaminophen every 4 to 6 hours. He has been taking 8 per day. He is supposed to get surgery in 3 months, so he was hoping that I would prescribe 8x30x3=720 tabs for him over the next few months. He said he would be willing to see me monthly to make sure everything was going ok.

    The pain doc concurred with my assessment that this clinical plan would be suboptimal.

    I would submit that the change in philosophy back in the 90s has not done this young gentleman much good.

  • querywoman

    Yes, they do. Sadly, the current American medical establishments criticizes what people want: antibiotics, pain meds, tranquilizers, etc.
    But they want us to participate in preventive medical testing and treatment for symptomless purported diseases at every turn.
    I felt better about medicine when Valium was the best selling drug, not a statin.

  • NormRx

    You must be responding to someone else, I never suggested NSAID’s, I really don’t care if someone uses opioids, and you are right, I have never experienced chronic pain. My whole point in my comment is there are doctors that want to severely restrict gun access because there are about 11,000 murders a year and about half of these murders are drug related, and yet all I hear are crickets regarding the 27,000 deaths a year from opioid use. And this is something that doctors have total control over. A pharmacy was recently closed in Key West, they were selling over one million dollars a year of Oxycontin to customers that had a prescription. Yes, maybe some may have been forged, but they didn’t care.

  • Suzi Q 38

    I am sorry that your pain is so intense.
    Did your severe pain start before or after your artificial disc and C6-7 fusion surgery?

  • T H

    I don’t see anything changing unless there is a sea change in the way people in the US see chronic disease: nearly all of them require lifestyle changes, not just taking pills.

  • Rita W

    Some of Dr. Fuch’s comments highlight the lack of scientific data and education of physicians, nurses, and pharmacists about opioids for pain management. It is interesting that 16,651 people dies of prescription opioid overdoses: this represents 0.67% of annual deaths in the US (http://www.cdc.gov/nchs/fastats/deaths.htm). This does not negate the potential problems of opioid (and other prescription drug) abuse, and is certainly an issue that we should be concerned about). I do not know where the information about prescription opioids causing more deaths than street drugs, but it probably is easier for someone in a rural area to get a prescription drug than to get heroin. Other authors have raised the concern about the lack of scientific data upon which to base assessments to identify potential drug abusers (Saitz R. Am J Med. 2013, 126:e17). And why so little concern about over-prescription of acetaminophen in combination opioid analgesics or the abuse of prescription and other steroids? Furthermore, tolerance is thought to be relatively uncommon – even in cancer patients who may need larger doses secondary to increasing tumor-related pain rather than tolerance. Dependence and addiction are not the same thing, and it is not possible to fund accurate stats regarding the incidence of addiction, which have ranged from about 3% to as high as 50% – in rather small uncontrolled samples. Hydrocodone is an excellent opioid analgesic that is, mg per mg, about as potent as morphine. As a palliative care APN who has cared for individuals who have cancer-related pain or severe non-life threatening pain related to other chronic conditions, I think the larger problem is the proposal that this drug be moved from schedule III to II. Now, even fewer people will be able to get analgesics they legitimately need and are not abusing – because more physicians will not prescribe them. Knowledge and attitudes just don’t seem to change, even with a problem that can negatively affect QOL and ADLs for pain sufferers and their families. And the problem of over- or misplaced-concern extends to them. I’ve certainly encountered patients who refused to take (relatively small doses of) opioids for painful life-limiting conditions after their primary physician told them that taking ANY doses would make them an addict! Add iatrogenic depression and despair.

  • sparklingsoul

    I have a unique background and perspective here: I’m a psychotherapist, pharmaceutical rep who sells pain meds, and former sufferer of severe pain. Therapists know that chronic-pain sufferers have a high rate of suicidal ideation and increased risk of suicide attempts, therefore, it is crucial that doctors work with patients to provide the best pain control possible. Even small decreases in pain have been shown to dramatically improve patients’ quality of life. Drug reps know that the best doctor to treat chronic pain is a pain specialist, because they have the time to do an extensive evaluation and treatment plan and can follow the patient closely. They are experts on the full armamentarium of pain medications, including NSAIDs, anti-seizure medications, and antidepressants. They create customized treatments for their patients’ pain, and they are comfortable assessing for potential opioid abuse. As a former sufferer of chronic pain (severe back pain for more than six months), I was indebted to my doctor for treating me with opiates during this time, because my pain didn’t respond to anything else (and I can’t tolerate anti-seizure medications). As the pain began to eventually decrease, I weaned myself off the opiates in just two weeks. I found it interesting that I had no interest in taking them once the pain diminished. I realize that other people may have gotten hooked on opioids in this situation, but I had an excellent pain specialist treating and monitoring me the whole time, which I believe greatly reduced my risk of addiction.