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Opioid Abuse in America

Chris Davlantes, MD (A Second Opinion)

We were all recently saddened by the news that Prince had died in his suburban Minneapolis home, and it sheds some light on the fact that we are in the midst of an epidemic much worse than the much-publicized Zika Virus you may have heard about recently:  Prescription opioid overdose.   Prince’s death – if truly caused by a painkiller overdose as is suspected but not yet confirmed – was tragic, but it would be just one of the estimated 1,000 ER visits per day and 40 overdose deaths per day which occur from prescription painkillers, devastating many American lives, families, and communities.  Many celebrities have sadly ended their lives prematurely due to this devastating problem:  Whitney Houston, Michael Jackson, Heath Ledger, Anna Nicole Smith…and we are just seeing the tip of the iceberg.  The amount of opioids (narcotics) prescribed and sold in the U.S. has quadrupled since 1999 and has accounted for over 165,000 deaths since then due to overdoses.  Close to 260 million painkiller prescriptions are written every year, half of which are prescribed by primary care providers, and up to 25% of the patients getting those prescriptions from their PCP struggle with addiction (whether they are willing to admit it or not.)  In 2014, nearly 2 million Americans 12 years or older either abused or were dependent on prescription painkillers.

“No pain, no gain” was an exercise motto which was popularized in the 80s by Jane Fonda’s aerobic workout videos, which encouraged us to “feel the burn”.  It is estimated that 11% of adults experience chronic daily pain, which limits their daily function to some degree, and I’m not referring to that temporary “good pain” you feel during or after a hard workout.  Many who suffer from chronic severe pain deserve safe and effective pain management, but it is important for them to know that the risk of prescription opioids – especially in high dosages and with long-term use – probably far outweighs the benefits.  Benefits of long-term opioid painkillers for chronic pain are not well supported by medical evidence, particularly for chronic low back pain, headaches, and fibromyalgia.  Long-term therapy with opioid painkillers can cause side effects ranging from something seemingly benign such as chronic constipation and/or nausea, to more serious problems such as dependency/addiction, abuse, and death due to overdosing (which is often unintentional). 

The U.S. Centers for Disease Control and Prevention (CDC) is encouraging clinicians to assess the risks and benefits of opioid therapy with their patients, particularly when the short-term goal is clinically meaningful improvements in pain and function (e.g. returning to work and usual recreational activities.)  The CDC recommends reducing the dose of painkillers or tapering and discontinuing them altogether, if there is not at least a 30% improvement in pain and function.  This does NOT apply to people who are using painkillers in the context of active cancer treatment, palliative care, and end-of-life care.

Risk factors which your doctor should assess and which can increase the risk of harm from opioid painkillers include:

  • Personal or family history of substance abuse
  • Anxiety, depression, or PTSD
  • Pregnancy
  • Age 65 or older
  • Sleep-disordered breathing (e.g. obstructive sleep apnea)
  • COPD/emphysema or other underlying lung problems
  • Kidney or liver disease
  • Interactions with other prescription drugs (e.g. benzodiazepines such as Xanax, Ativan, etc.)

Alternative therapies should be considered and discussed with your doctor for certain chronic conditions, including:

Low back pain:  Use of (either alone or in combination with opioid painkillers) non-narcotic medications such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen, as well as certain types of antidepressants (e.g. SNRIs)

Migraine headaches:  Beta blockers, trycyclic antidepressants (TCAs), anti-seizure medications, calcium channel blockers, cognitive behavioral therapy, relaxation, or biofeedback

Neuropathic pain:  Topical lidocaine, topical capsaicin, TCAs, SNRIs, gabapentin/pregabalin, or interventional procedures such as local or regional nerve blocks.

Osteoarthritis:  Physical therapy, exercise, weight loss, acetaminophen, NSAIDs, topical NSAIDs, or local injections of the affected joint(s) with steroids or hyaluronic acid

Fibromyalgia:  Low-impact aerobic exercise (e.g. swimming, water aerobics, cycling), cognitive behavioral therapy, biofeedback, pregabalin, duloxetine, milnacipran, TCAs, or gabapentin

Pain Clinics are another option for people who deal with chronic pain, where you can see a doctor (usually an anesthesiologist) who specializes in pain management and who will try to offer alternative treatments, which can provide the greatest benefit with the least amount of risk.

Seek help if you think you may be developing a dependence upon painkillers.  With good management and no prior history of addiction, most people can find temporary relief from pain with appropriate use of prescription painkillers and will never go on to developing an addiction.  We may never know for a while (if ever) whether or not Prince was addicted to painkillers and if that is what contributed to his death, but – if he was – it may have been because he did not seek help.  Many people suffering from addiction are afraid of the stigma associated with addiction and the repercussions on their jobs and/or friends and family.  Warning signs or concerns that there may be adverse effects of prescription opioid painkillers include:

  • Chronic nausea or constipation
  • Frequent sedation or confusion
  • Slurred speech or abnormal gait
  • Breathing interruptions during sleep
  • Taking or craving more medications than prescribed or difficulty controlling use

Tapering and discontinuing opioid painkillers should be done slowly (i.e. don’t quit “cold turkey”) and in coordination with the PCP or medication prescriber.  In general, to minimize the symptoms of withdrawal (which include drug craving, anxiety, insomnia, abdominal pain, vomiting, diarrhea, and tremors), the dose should be decreased by only 10% of the original dose per week.  The PCP may also make a referral for psychosocial support from a mental health provider.

Opioid painkillers are not the first-line therapy for chronic pain outside of active cancer treatment, palliative care/hospice, and end-of-life care.  Evidence suggests that non-opioid treatments, including non-opioid medications and non-pharmacological therapies, can provide relief to those suffering from chronic pain, and are much safer.

So, BE FIT, BE WELL, and BEWARE of the risks of prescription painkillers