After sad experiences and “near-misses” with patients, relatives, and acquaintances, I am passionate about increasing awareness to help halt a dangerous situation in the U.S. We are experiencing a devastating man-made epidemic of overdose deaths from opioid pain relievers (OPRs).
According to the Centers for Disease Control and Prevention, 46 people die every day from an overdose of prescription OPRs. The number of overdose deaths attributable to these painkillers has risen 3-fold since 2001, to over 16,000 in 2013, double the 8,200 deaths from heroin. Even more unsettling, 60% of these deaths are in patients who receive their prescriptions from one doctor, which means they are not “doctor shopping” to obtain the drugs, or taking or buying them from others.
Many of these deaths are in patients with chronic pain, who are often treated with high doses of these potent oral medications for extended periods of time. Some patients inadvertently or purposely misuse them, and experience respiratory depression ending in death. Some of the medications end up in the hands of people who abuse them, leading them to progress to outright addiction, which we now call opioid abuse disorder. Many patients become physiologically dependent on OPR’s, and suffer from distressing withdrawal symptoms if they are late with a dose, run out of pills, or try to stop them.
What went wrong with our attempts to care for patients with chronic pain, so that we began to rely on OPRs for treatment? Since most opioids that are misused and abused originate directly or indirectly from doctor’s prescriptions, how did we medical professionals let this tragic epidemic develop? I often ask myself these questions, and find the answers to be complex. Over the past 20 years, OPRs have been the main response of the medical system, and the pharmaceutical industry, to the huge problem of chronic pain.
We did not question the pharmaceutical industry’s involvement in our practices, and their marketing of these medications, which expanded their use from acute to chronic pain, without research to show effectiveness in this setting. We began to hold dear the attitude that pain in our patients needed to be treated at all costs, and even considered pain level to be a vital sign, like pulse and blood pressure. We got into the habit of prescribing one or two week’s supply of pills routinely, even if the need was only for 2-3 days after surgery. This in effect stocked family medicine cabinets with leftover OPRs that could easily fall into the hands of teens and young adults likely to abuse them.
An underlying part of the answers to these questions is that we doctors are products of modern U.S. society, which places high value on ‘magic pills’ and quick fixes, even for complex problems. We hoped to please our patients holding these same values, and who often expect to be handed a prescription at every doctor’s visit, as opposed to considering therapies needing more time and self-motivation. We neglected the importance of continuing to look for underlying root causes or contributing factors for chronic pain in our patients, and we seemed to forget entirely that our bodies have amazing natural self-healing abilities that can be optimized without the use of drugs geared to covering up symptoms.
As a gynecologist focusing my practice on women with chronic pain, I became alarmed at the rapidly rising use of OPRs in women, and their increasing rate of overdose deaths. There has been a 4-fold increase in opioid overdose death rates in women since 1999, and now these overdoses kill more women than motor vehicle accidents. More women suffer from chronic pain than men, leading to them being more likely to receive OPR prescriptions. Although the reason is still unclear, it is some researchers and clinicians' experience that women may also become physically dependent on opioids more quickly than men. In my practice, I was distressed to see new patients coming in for consultation already on OPRs, sometimes having been given little information on what the medications were and the risks involved.
Perhaps the risks of death and other adverse effects from taking OPRs would be worth it for some chronic pain patients, if they were actually helped by them. But unfortunately I found little benefit for my patients. My clinical experiences called into question much of what we believed over the years about benefits of treating pain with OPRs. I was glad that a systematic review of all the published studies of opioids in chronic pain was recently performed; the researchers also found no evidence of long-term benefit, but did expose the risk of serious harm.
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Why so many medical professionals continue to write these prescriptions, despite the evidence, is difficult to understand, but may be related to what they perceive as a lack of other options. Effective safe integrative approaches for chronic pain are often not in their clinical toolboxes. Increasing the awareness, of both doctors and patients, of the benefit of mind-body therapies that enhance self-healing and self-care is crucial. In my practice, once we determined together that a patient’s OPRs are not helping, and, because of adverse effects such as constipation and hormonal imbalance, may actually be increasing her pain, most patients want to stop them. With education, support, and the practice of mind-body therapies such as those in Body and Brain Yoga, most are successful in gradually tapering off OPRs.
What can we each do to halt this epidemic of death and injury from OPRs? Primary prevention, which means discouraging new use of opioids in almost all clinical settings, is key. “Start at the beginning and keep opioid-naive patients opioid-naive” is what Dr. Lewis Nelson and co-authors recently urged medical professionals in the Journal of the AMA.
2 This will require education to retrain clinicians, patients, and society at large, so that opioids are no longer the easy go-to element of the doctor’s toolbox, and expectations about preventing, experiencing, and treating pain become realistic. We all have a role to play in curbing this epidemic, by declining OPRs ourselves, by advising and supporting our family and friends to use integrative approaches for pain relief, and by sharing our practice of Body and Brain Yoga with other people with chronic pain.
On a personal note, I am relieved to hear good news about a young relative of mine, who became physiologically dependent on OPRs inadvertently, by taking them frequently when partying with his circle of college friends. He has entered a 90-day residential rehab program after unsuccessfully trying to stop them on his own and now has hope he will get back on track to a useful fulfilling life.
Next month I will return to the bright side and discuss safe and natural strategies to help live well with chronic pain.
Stay tuned and be well,
Deborah
Common opioid pain relievers (OPRs): generic and brand names. Most people who have had surgery or a dental extraction have been prescribed one of them.
OPIOID PAIN RELIEVERS:
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GENERIC NAMES
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EXAMPLE BRAND NAMES |
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codeine
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Tylenol#3 |
| fentanyl |
Duragesic patch |
| hydrocodone |
Vicodin |
| morphine |
MS Contin |
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oxycodone
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Oxycontin, Percocet
|
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oxymorphone
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Opana
|
|
tapentadol
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Nucynta
|
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tramadol
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Ultram
|
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David B. Reuben, Anika A. H. Alvanzo, Takamaru Ashikaga, et al. National Institutes of Health Pathways to Prevention Workshop: The Role of Opioids in the Treatment of Chronic Pain. Annals of Internal Medicine, 2015; DOI:10.7326/M14-2775.
- Lewis S. Nelson, MD; David N. Juurlink, MD, PhD; Jeanmarie Perrone, MD. Addressing the Opioid Epidemic. JAMA October 13, 2015 Volume 314, Number 14:1453-54.