Until the mid 1990s, prescribing opioids to relieve pain was largely limited to critical conditions such as cancer, severe trauma, or post-surgical pain. Many physicians were reluctant to prescribe opioids for chronic use because of concern for addiction, physical withdrawal and tolerance (the need for greater doses to achieve the same effect). Over the past 20 years, as these restrictive practices were loosened, consumption of opioid painkillers escalated from two to five times the rate of use prior to this turning point. At the same time opioid-related deaths quadrupled. The Centers for Disease Control and Prevention (CDC) has stated that this unprecedented increase in consumption of opioid painkillers has led to the worst drug overdose epidemic in United States’ history. Preventing opioid-related deaths is now on the CDC’s list of the top five public health challenges. It has recommended that preventing opioid-related deaths should focus on the 10% of patients prescribed high doses of medication from a single health professional and the 10% of patients who receive high doses from multiple physicians. The CDC report also encourages more education for physicians on prescription of opioids, pain management, and addiction, and specifically encourages physicians to consult state-run prescription databases and to discontinue opioid therapy for patients not receiving benefit.
The intense escalation in use of opioid painkillers began around 1995. A campaign by pain advocacy groups and pain specialists were driven to convince physicians to identify and treat pain with the same fervor they do other vital signs. “Pain as the fifth vital sign” was the rallying cry to aggressively address non-life threatening chronic pain with opioids. Caution in their use was eclipsed by claims that the risk of addiction was low, the risk of respiratory depression was fleeting, and drug diversion and abuse were less important than pain management. This movement led physicians to overestimate the benefits of opioid medications for chronic pain and underestimate the potential for addiction and other adverse consequences. A recent survey conducted in the Boston area shows encouraging signs of increasing physician awareness emerging in this domain. Of 56 primary care physicians surveyed, a majority expressed feeling reluctance and stress in managing patients with chronic pain, and many were concerned with patients’ misuse of, or addiction to, opioid medications.
Remarkably, the effectiveness and safety of long-term use of opioids for non-cancer pain has never been demonstrated, even though patient surveys suggest that most patients prescribed opioids still report pain and functional impairment. There have been no reported studies that evaluate opioid therapy compared with no opioid therapy for longer than one year. We do not know whether pain, function, quality of life, opioid abuse, or addiction occur after long-term use. Some observational studies have reported that opioid therapy for chronic pain is associated with increased risk for overdose, opioid abuse, fractures, heart attacks, and sexual dysfunction. Higher doses are associated with higher risks.
Patients Using Prescription Opioids for Pain Should Be Aware of Potential Consequences
The short-term benefits of opioids frequently are justified by claiming that they provide pain relief sufficient to restore normal life activities. But the overprescribing of opioids has led to a sharp increase in opioid addiction, and progression to heroin addiction, a sharp rise in emergency department visits and overdose deaths, increase in the number of infants born addicted to opioids and in withdrawal, fractures from falls, reduced gonadal size, increased pain sensitivity, chronic constipation, and chronic dry mouth. These unintended consequences to health and even increasing deaths are more disturbing when considering the uncertainty of whether opioids are even effective in the long-term.
Misuse, abuse, addiction
Opioid seeking patients have a number of motives. Pain relief is the obvious, but patients with pain may also hunt for relief from depression, anxiety, depression, or stress. Others may seek opioids solely for their psychoactive effects. Misuse is defined as opioid use contrary to the directed or prescribed pattern of use, regardless of whether harm or adverse effects occur. Misuse may be characterized by underuse, erratic or disorganized use, inappropriate or excessive use; examples of misuse include using to manage symptoms of anxiety or other distress, using with alcohol or marijuana, and overusing. Abuse is defined as intentional use of an opioid for a nonmedical purpose, such as achieving euphoria or altering one’s state of consciousness. Addiction is described as a pattern of continued uncontrollable use (e.g., “impaired control over drug use, compulsive use, continued use despite harm, and craving”), with experiences of, or potential for, harm. Opioid addiction can result from repeated use, either for pain relief or for psychoactive purposes. Opioids are very addictive for two reasons: they produce euphoria when used and profound dysphoria when drug use is terminated. Across most studies, the rates of misuse average between 21% and 29% and rates of addiction average between 8% and 12%. These rates may be underestimated.
Progression to heroin addiction
The epidemic of addiction to opioids medications has created another worrisome trend. Prescription opioid users may be inclined to switch to heroin use, as heroin is less expensive and easier to obtain than medical opioids, which are under greater scrutiny and more restrictive prescribing practices. A recent federal survey showed that 4 out of 5 current heroin users report that their opioid use began with prescription opioid misuse. The rising prevalence of addiction to opioids has paralleled a rising tide of heroin overdose deaths and heroin addiction treatment admission.
Infants born to mothers addicted to opioids
Opioid withdrawal symptoms in newborns increased three-fold recently. These symptoms are associated with many health problems in newborns, including low birth weight, poor feeding, and breathing problems. In a recent study done in Tennessee, 63% of infants suffering opioid withdrawal were born of mothers using at least one opioid prescribed by a healthcare provider (opioid pain relievers or opioid maintenance medication for addiction). Far fewer cases were found among mothers of illicit drugs such as heroin or diverted medications.
Nonmedical Users Are Not the Only Ones Harmed
Efforts at curtailing this public health epidemic have focused on those people who use diverted opioid medications (without prescriptions for themselves) for non-medical, psychoactive effects. It is a myth to assume they are the only ones at risk or are harmed. Addiction or overdose deaths due to opioid medications also occur in patients with legitimate pain complaints and legitimate prescriptions. Even though new nonmedical users have declined in the past decade, pain patient overdose deaths, addiction treatment, and other adverse public health outcomes have increased dramatically in age groups more likely to report pain. Nonmedical use of opioids may be common among teenagers and young adults (15 to 24 years of age), but overdose deaths are highest in the 45-to-54 age bracket, with adults age 55 to 64 experiencing the highest increases. In fact, accidental overdose deaths are more common among middle-age medical users addicted to opioids and with a history of a substance use disorder, than young nonmedical users. It is essential to recognize that addiction to opioids, not use or abuse, is a key driver of this crisis.
Response to This Public Health Threat: Preventing and Treating Addiction
Medical professionals and patients must be aware of the risks associated with opioids medications. Opioids should be prescribed and used cautiously for both acute and chronic pain, after detailed screening for patient risks. Non-opioid pain-killers should be considered by both patient and physician in pain management. Reducing use among non-medical users is also essential, especially among adolescents and young adults. Not only are they at high risk for progressing to addiction, but they perceive medical prescriptions as less risky than street drugs like heroin.
Screening of people who may be at higher risk for abusing prescription opioids is becoming more common. The advantages of screening are obvious: it may prevent addiction, progression to using street heroin, and to injecting opioids. The risks escalate with drug injections, as infections, tissue degeneration, and overdose crises are common. Providing trained emergency first responders (police, EMTs) access to an opioid antagonist (naloxone) to block breathing suppression is another public health strategy. It is also essential to provide treatment for opioid addiction, including access to medications, residential treatment, and mutual-help treatment programs.
Summary and Conclusions
The adaptations of the brain and body to long-term frequent opioid use can lead to addiction, physical dependence, diminished pain-killing effects, and overdose deaths. Many people who misuse, abuse, or are addicted to opioid painkillers are likely to benefit from interventions, mentoring, education, and treatment. With increased scrutiny of patients at risk prior to prescribing, and increased vigilance of patients prescribed opioids, this epidemic may diminish. In the meanwhile, it is likely that millions of Americans using opioids for a variety of reasons are in need of professional help.