Behind the headlines about the US prescription opioid crisis lie complicated choices around pain.
By Sharon Reynolds
On either side of the story, the statistics are staggering. In 2013 healthcare providers in the United States wrote almost 250 million prescriptions for opioids to treat pain.1 Since 1999 the number of unintentional deaths from overdoses involving prescription opioids has quadrupled.2 Every day 78 people in the United States die from an opioid-related overdose, including prescription opioids.3
Pain remains a huge problem in the United States. Despite the spike in the use of prescription opioids, Americans overall still report the same amount of pain as they did a decade ago.4 In 2011 a report from the Institute of Medicine estimated that chronic pain—defined as pain lasting one to two months or more—affects approximately 100 million Americans and contributes extensively to suffering and disability in the country.5
“We don’t have more pain in the United States than in other countries in the world; we just treat it differently here,” says Beth Darnall, PhD, a pain psychologist and associate professor at Stanford University. Because women both report pain more frequently than men overall and are more likely to be affected by common chronic pain conditions,6 they are likely at some point in their lives to find themselves confronted with a prescription for opioids and the potential complications that can ensue.
The What and the Why of Opioid Prescriptions
Opioids work differently from other medications used to relieve pain. Drugs such as ibuprofen, naproxen, aspirin, and acetaminophen reduce the process of inflammation, the body’s natural response to injury, which leads to swelling and pain. Opioids bind directly to the neurons in the brain and elsewhere in the body that process pain signals. Through this binding they blunt those signals, reducing the perception of pain regardless of what is happening in the body.7 Because of their direct effects on the nervous system, opioids can also produce feelings of euphoria in some people and blunt emotions.7
Opioids can be very effective at reducing pain, but they also come with substantial side effects. For short-term use these may include constipation, nausea, feeling tired or confused, and respiratory depression.7 This latter effect—a reduction in breathing leading to a lack of oxygen in the blood—is especially dangerous for people taking other prescription medications. Some medications, such as benzodiazepines (including Xanax® and Valium®, which are prescribed for anxiety), some muscle relaxants, and some sleep aids, as well as any type of alcoholic drink, can also cause respiratory depression. When taken with an opioid, the combination can cause a person to stop breathing entirely: an overdose. Overdose can also be caused by too much of an opioid alone, and the risk of this grows with higher prescribed doses.
For long-term opioid use, these risks are joined by potential effects on hormones, sleep, libido, fertility, and the digestive system, among many others.8,9 For pregnant women opioid exposure poses risks to the fetus.8 People who take opioids for a long time will also experience tolerance and dependence, which are normal physical effects of the drugs. With tolerance, more and more of the same drug is needed over time to supply a consistent level of pain relief. With dependence, levels of certain chemicals in the body naturally change due to longterm exposure to an opioid. If the opioid is stopped suddenly instead of in a long, slow taper, one will experience the excruciating effects of withdrawal, which include muscle and bone pain, diarrhea and vomiting, and cold flashes, due to changes in these chemicals. Dependence is not the same as addiction (see sidebar “Numbing More Than Pain: A Path to Addiction”).
Because of the potential for these side effects, opioids had traditionally been reserved for cancer pain and palliative care. They also have a role in acute pain, explains Thelma Wright, MD, JD, a pain physician with the Pain Management Center at the University of Maryland Rehabilitation & Orthopaedic Institute. For pain following surgery “or trauma of any nature, opioids can be deemed necessary” for a few days afterward, she says.
“A Perfect Storm”
One problem, adds Dr. Wright, is that prescriptions meant to be temporary may not end up that way. This most often happens for patients receiving an opioid through their primary care physician and not a pain specialist: “It’s easy to write [a prescription] for an opioid and send the patient on their way. The problem comes when this pain does not go away, if it continues to persist,” she says. The patient may simply get the opioid prescriptions refilled without returning for a follow-up visit. The doctor also may not think to refer the patient to a pain physician or other specialist who might be able to determine the underlying cause of their now-chronic pain, she explains.
Dr. Darnall says that she has seen patients come into her clinic who have been taking opioids for 10 or more years without being reevaluated to determine whether the drugs were actually helping: “It was like the prescriptions just persisted forever. When starting an opioid, we need to always have an exit strategy.”
Another troublesome issue, says Dr. Darnall, is how, since the 1990s, opioids have become widely prescribed specifically for chronic pain. “We didn’t treat chronic pain with opioids historically,” she explains, because no long-term studies have been performed that show that they help.10
Nonetheless, she adds, “a perfect storm” of trends in the nineties led to the spike seen in opioid use, including heavy marketing— and even misinformation11— by pharmaceutical companies promoting it for chronic pain, and an increased focus on assessing and treating pain across medical specialties. Researchers estimate that in 2005, 3 to 4 percent of the entire US adult population was prescribed an opioid for long-term use.12
Broad Guidelines, Individual Pain
In the past few years, the nation has begun to address the epidemic of overuse, overdose, and addiction surrounding opioid prescriptions. Forty-nine states have implemented prescription drug monitoring programs, which help prevent multiple doctors from unwittingly writing opioid prescriptions for the same patient.13 The Comprehensive Addiction and Recovery Act, passed by the Senate and signed into law in July 2016, aims to expand access to overdose prevention and medications for the treatment of opioid abuse and to increase research into alternative strategies for managing pain, among other goals.
In March 2016 the Centers for Disease Control and Prevention released guidelines for prescribing opioids for chronic pain, which include an emphasis on trying all other medication options before considering an opioid, starting at the lowest effective dose, consistent reevaluation of benefits and harms, and exercising extreme caution at high dose levels.9
These guidelines, however, have stirred controversy and concern among a subset of patients with chronic pain who have found effective relief by incorporating an opioid into their pain management program.
Nancy,* an educator in her sixties living outside New York City, is one such patient. A former selfdescribed health nut who exercised five days a week, in 2002 she hurt her back in an accident that left her with one torn disk and several slipped ones. After corrective surgery made the pain worse—and resulted in nerve damage in one of her legs, as well—she spent three years unable to work because of the pain.
“I tried every single thing,” says Nancy. She consulted nine different doctors. She tried physical therapy, aquatic therapy, and therapeutic massage, which helped a bit. A doctor finally suggested she try opioids in tandem with a drug specifically for nerve pain.
“That’s the only way to help my intractable pain. It doesn’t even get rid of it, but it helps me to get through and to have a life. It enables me to be productive, to not just be stuck on the couch,” she explains. “Adding a long-acting, slow-release opioid patch probably saved my life since my cardiologist was concerned about the harmful effects on my cardiovascular system of the chronic stress from pain. And I was becoming depressed. This method of medication delivery avoids the ups and downs of pain every few hours when the medication wears off.”
She worries that the new guidelines could become regulations that limit physician discretion to try opioids in patients like her who might benefit or that restrict access to the medications even for patients like herself who are currently using them responsibly. “If the climate that we have right now was this way when I got hurt, would my doctor have done the same thing when he put me on the medication? I’m afraid that maybe he wouldn’t have,” she explains.
Though studies have not shown benefit in chronic pain patients overall, “our data speak in averages,” says Dr. Darnall, “and real-world patient care has individual variability. I see [chronic-pain] patients in clinic who do well on opioids. We have to give physicians the discretion to treat pain individually,” she adds.
Alternatives, with and without Pills
“The problem is that these medications were just thrown out to everyone, without optimizing other conservative approaches, such as self-management, psychology, and physical therapy,” says Dr. Darnall.
In Dr. Wright’s specialized pain clinic, opioids are never the first option for treatment, she explains. For nerve pain, they would first test seizure medications like Neurontin® (gabapentin) or Lyrica® (pregabalin), which often provide relief. For muscle pain or spasm, they would try a muscle relaxant. For minor trauma like a broken toe, they would first give an anti-inflammatory like Advil® (ibuprofen). Other options include injections and topical medications like Lidoderm® (lidocaine). “There are so many different medications you can use without going into the opioid toolbox,” she says.
Her clinic also employs pain psychologists like Dr. Darnall. These specialists can train patients with chronic pain in mind-body techniques, such as biofeedback and cognitive behavioral therapy. While such modalities don’t target pain at the physical source, they target pain where it’s processed—in the central nervous system. Mind-body skills calm the nervous system and help prevent pain from triggering other negative responses, like anxiety, which can set off a negative feedback loop that leads to greater pain.
“Anxiety and stress amplify pain processing in the brain and spinal cord, in the central nervous system,” says Dr. Darnall. “The true definition of pain is that it’s a negative sensory and emotional experience. How we think and feel, how we respond to stress, what’s going on in our environment—all of these factors have an impact on pain processing and how intensely we experience pain. We can learn very simple skills, so we can best control that and get our mind-body connection working to our advantage instead of working against us. And the great thing is you get to keep those skills—you don’t need a prescription; once you learn them, they’re yours, and you can use them for the rest of your life.”
Everyone Knows Someone
Even though the opioid prescription tide of the past 20 years is beginning to recede, the great need for pain treatment in the United States and the ubiquity of opioids as “pain relief” in the public consciousness mean that the pills remain commonly encountered in the health system. And with hundreds to thousands of prescriptions dispensed every day, likely every American knows someone who has struggled with misuse of these medications. Dr. Wright encourages everyone—doctors and patients— who encounters opioids to educate themselves about how to use them safely. “If you’re not educated in the management of pain with opioids, you could be unsafe,” she concludes.
*Names were changed on request due to privacy concerns.
Numbing More Than Pain: A Path to Addiction
Though physical dependence is unavoidable in long-term prescription opioid users, addiction is not. But addiction can and does happen in people initially prescribed opioids for pain. As defined by the National Institute on Drug Abuse, “Addiction is a chronic disease characterized by drug seeking and use that is compulsive, or difficult to control, despite harmful consequences.”14 The direct effects of opioids on the nervous system explain their allure to many people who end up abusing them.
“Opioids are highly reinforcing. They don’t just blunt pain processing and sensory perception; they also blunt emotional experience,” explains Dr. Darnall. “Imagine a person who’s very anxious or stressed out—going through a bad divorce, for example—and that person has surgery, after which they’re prescribed opioids, maybe a month’s worth or more. And they notice that they really like them. It’s subtle. It’s like, Wow, I’m feeling better; I want to refill this, and the next thing you know, you’re months in.” Katie* had this experience. As a 33-year-old primary school teacher, she was playing basketball with the kids during recess when she took a shot, doubled over, and couldn’t stand back up. A herniated disk led to three different surgeries and, eventually, degenerative disk disease and chronic pain.
Katie was given an opioid painkiller, and she ended up taking more than was prescribed, running out before the end of the month and having to suffer through withdrawal before going through it all over again. “I was trying to numb feelings,” she says, “but pain medicine can make you feel crazy.”
Five years later she got clean, but she has experienced several relapses, when she thought she could take the drugs as prescribed for pain but discovered that she could not. Now 60, she says, “I’m done. I’m not going to die from pain, but the pills could kill me. And that’s not the legacy I want to leave for my daughter.”
Information about treatments used for opioid addiction can be found on the website of the National Institute on Drug Abuse: drugabuse.gov/publications/research-reports/prescription-drugs/treating-prescriptiondrug-addiction/treating-addiction-to-prescription-opio.