Solving the prescription opioid problem

English: Drug overdose
English: Drug overdose (Photo credit: Wikipedia)

I’ve posted several times recently on the problem of opioid over-prescription and overdose.

Some might assume that I want some regulatory or statutory intervention to address the issue. Truth is, I’ve got more questions than answers and I would not support a response that forces us to choose between treating pain and preventing addiction and overdose.

It appears that opioids are a great solution to acute pain but a lousy treatment option for chronic pain. (Though,  they may be the least bad option.)

I’m not an expert on policy in this area, just an observer. But, my first thought is that The Joint Commission played a huge role in shifting pain treatment and that they may be a good way to change the behavior of prescribers and health systems.

The big difference this time is that PHARMA provided some wind at the back of those system changes. Other than medical cannabis, it would seem that the wind would be working against us this time. (Though, there is research being done on different delivery strategies for cannabis and its relative effectiveness.)

The current state of pain management is especially bad for addicts. It leads to bad care, neglect and stigma. Even addicts who really want non-opioid, but effective, pain management get brushed off as drug-seeking.

This feels like I’m stating the obvious, but it would seem that we need more education research on non-opioid treatment options, better access to the ones that already exist and better engagement strategies for the existing behavioral strategies.

Overprescription of opioids is bad medicine

Artist: Ashley Mackenzie Via: High Fructose
Artist: Ashley Mackenzie
Via: High Fructose

Keith Humphreys points out that the problem with the explosion of prescriptions for opioids isn’t just addiction and overdose. They are often just not good medicine.

Opioids typically have a miraculous effect on acute pain, but this does not necessarily translate to chronic pain relief, particularly as tolerance sets in over time. Even more disturbing, my colleague Dr. Jodie Trafton and I are among many researchers who have found that a portion of long-term opioid users became hyperalgesic, i.e., they experience more rather than less pain.

This is not the only line of scientific findings that flies in the face of the assumption that if opioids are used less often, more pain will be the inevitable result. In a study my colleagues and I conducted with surgery patients (first author Dr. Ian Carroll; publication here), the amount of time individuals stayed on opioids after surgery, surprisingly, bore no relationship to their level of pain. People stay on opioids for a range of reasons not necessarily linked to pain; in our study taking them for long periods was well-predicted by pre-existing depression, for example. Many people who are on these medications would be in better health and equal or less pain if they were weaned off them.

A further dangerous side-effect of long-term opioids is hormonal, as Meier explains:

These drugs have a very powerful impact on our production of sexual hormones — testosterone in men and estrogen in women. Lower hormone production is not just about growing hair or sexual performance; it’s about your entire energy level. These drugs are depleting people of energy. There are even data showing that the more powerful opioids, the long-acting OxyContin, methadone, fentanyl, which is sold as Duragesic, have an even more powerful effect on depressing hormone production than short-acting opioids.