Opioid addiction is a disease that can steal our siblings, children, parents, and sometimes our beloved music and movie stars. It knows no age, racial or ethnic barriers. According to the Centers for Disease Control and Prevention, prescription opioid misuse is an urgent public health problem, with drug poisoning deaths involving opioid analgesics, which includes both prescription and illicit opioids, quadrupling between 1999 and 2014.
Some are calling opioid abuse the deadliest drug epidemic in US history. Politicians, health organizations, and insurance companies are calling for limits on the number and strength of opioid prescriptions, but the American Medical Association and many pain organizations caution this could make it difficult for chronic pain sufferers to get the pills they need.
Dr. Lynn Webster
The CDC’s 2016 Guideline for Prescribing Opioids for Chronic Pain draft proposal, urges primary care doctors to try drug-free methods to relieve chronic pain, such as exercise, weight loss and physical therapy, as well as non-opioid pain relievers such as acetaminophen and ibuprofen, before resorting to powerful opioid pills. If opioids are needed, the guidelines recommend starting with the smallest effective dose of immediate-release opioids, avoiding more dangerous time-release formulations except when needed.
“Opioid abuse is a much more complicated issue than the CDC and lawmakers would have us believe,” says Lynn Webster, MD, Vice President Scientific Affairs, PRA Health Sciences. “While it’s true we are seeing a continual increase in opioid-related overdose deaths, this coincides with a significant drop in opioids prescribed. Reducing the supply side does not address the demand for opioids, nor does it help address the needs of people with addictions. Reducing the amount of prescribed opioids may in fact force many of those denied opioids for pain to seek illegal opioids such as heroin and synthetic fentanyl, which are for more dangerous. The unintended consequence could be even more fatal overdoses.”
Opioid abuse is a much more complicated issue than the CDC and lawmakers would have us believe.
The current options to treat opioid addiction include methadone, buprenorphine, and naltrexone. By binding to opioid receptors they curb drug cravings and block the effects of drugs like heroin. There are also studies underway to develop opioid drugs that would safely and irreversibly lose their potency over a specified period of time beyond the prescribed use period, rendering them devoid of their euphoric effects.
History of Opioids
Opium-derived painkillers have been around for thousands of years. The Sumerians referred to the opium poppy as “Hul Gil”, the “Joy Plant”. The earliest known reference to opium growth dates back to 3400 BCE in lower Mesopotamia. Hippocrates, the “father of medicine”, noted opium’s usefulness as a narcotic in treating internal disease. In 330 BCE Alexander the Great introduced opium to India.
By the 1800’s morphine was isolated from opium. The German chemist Friedrich Wilhelm Adam Sertuner named it after the god of dreams, Morpheus. It was commonly used as a pain killer during the Civil War. In 1898, heroin was synthesized as a derivative of morphine and by the early 20th century was sold as a cough suppressant. When heroin addiction skyrocketed, Congress passed the Heroin Act in 1924 which made the importation, manufacture and possession of heroin illegal, even for medicinal use.
The prescription opioid landscape changed in the 1990’s as new options on how to treat pain came to market, particularly extended release technology. New standards for pain management were introduced in 2000 and pain was recognized as the “fifth vital sign”. By 2002, 6.2 million Americans were abusing prescription drugs. The misuse and abuse of prescription painkillers contributed to more than 730,000 emergency room visits in 2009, a number that doubled in just five years.
In February 2016, President Barack Obama said he would seek $1.1 billion in new funding for opioid-addiction treatment and Congress followed by passing 18 opioid-related bills in May.
The misuse and abuse of prescription painkillers contributed to more than 730,000 emergency room visits in 2009, a number that doubled in just five years.
Chronic pain affects more Americans than cancer, heart disease and diabetes combined. The Institute of Medicine estimates that 100 million US adults suffer from pain that never ends, often the result of injury, disease, or dysfunction of the nervous system. These facts seem to be subsumed by growing concern of opioid abuse and misuse, a problem that is real and getting worse, but there is fear as the pendulum swings toward greater opioid restrictions, it may prevent many patients from getting adequate pain treatment.
“Opioids are both over-prescribed and under-prescribed depending on the population,” says Dr. Webster. “The fact is there are many more people who suffer from chronic pain than opioid addiction, but because of the scrutiny of opioid prescriptions, and new federal and state guidelines, many doctors are fearful of regulatory sanctions, DEA investigations, or even incarceration if one of their patients has an adverse outcome while using opioids. As a result, some patients with pain are under-treated or not treated at all.”
Opioid painkillers stimulate receptors in the brain and elsewhere to produce a powerful pain-numbing effect. They also lessen anxiety and depression—two common side-effects of intense pain. Inadequately managed pain can lead to adverse physical and psychological outcomesfor individual patients and their families. It can sometimes suppress the immune system and result in postsurgical infection and poor wound healing. The inability to escape from pain may also create a sense of helplessness and even hopelessness causing patients to become depressed and want to end their lives.
While America may face an overuse problem, in some parts of the world opioids are far too scarce. The British medical journal Lancet reported that in a single year 40 Russians committed suicide because of unbearable pain. In many countries, people suffering from cancer and other terminal illnesses often are provided no pain relief. In Columbia, which produces its own opioid painkillers, some regional governments cannot afford to buy them or consider them a low priority.
“Reducing death’s related to opioid misuse must be a priority,” says Dr. Webster. “But if we want to reduce the amount of opioids prescribed for people in pain, then concurrently we must provide them safer alternatives to handle their pain.”