Around 100 million Americans are living with chronic pain. For some, the pain is so severe that it interferes with everyday life and can even lead to mental health problems, such as anxiety and depression. With this in mind, it is no wonder patients want quick, effective pain relief, and to achieve this, many turn to opioids. But are the drugs be causing more harm than good?
According to the Centers for Disease Control and Prevention (CDC), around 78 Americans die from an opioid overdose every day, and between 2000-2014, the drugs were responsible for almost half a million deaths in the US.
While many of these deaths are down to use of illegal opioids – such as heroin – more than half of opioid overdose deaths involve a prescription opioid; since 1999, deaths from prescription opioids have quadrupled in the US.
Health care professionals have put the significant rise in opioid deaths down to the dramatic increase in prescriptions of these drugs; more than 259 million opioid prescriptions were written in the US in 2012 – the equivalent to a bottle of pills for every adult in the country.
Such figures have led the use of prescription opioids to be labeled as a “silent epidemic,” and last week, the CDC issued new prescription guidelines in a bid to tackle the problem.
Furthermore, the Food and Drug Administration (FDA) recently announced that new warnings would be added to all prescription opioid medications to inform doctors and patients of the risks associated with their use.
But are such changes likely to prove effective? Are they enough to significantly reduce the number of overdose deaths caused by prescription opioids? Or will they – as suggested by some individuals – prevent patients with chronic pain from getting the treatment then need? We investigate.
Opioids are drugs that bind to proteins in the brain, spinal cord and gastrointestinal tract called opioid receptors. In doing so, the drugs block pain signaling to the brain, reducing the perception of pain.
The drugs are prescribed for patients with moderate to severe pain who do not respond well to other pain-relieving medications. This often includes patients who experience severe pain after surgery or as a result of advanced cancer.
Commonly prescribed opioids include oxycodone, hydrocodone, codeine, morphine and fentanyl.
When taken for a short time and under a doctor’s instructions, opioids can be very effective for alleviating pain and are generally safe.
However, many individuals use the drugs long term – generally defined as 3 months or longer – despite many health care professionals claiming there is a lack of evidence to suggest that such treatment is effective.
Last February, for example, a systematic review of randomized trials and observational studies of long-term opioid use for chronic pain – published in the Annals of Internal Medicine – concluded that “evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function.”
Needless to say, there are major concerns regarding long-term opioid use. The drugs can become addictive. They act on the same brain reward system as the illegal opioid heroin, producing a sense of euphoria.
According to the CDC, around 1 in 4 people in the US who receive opioid prescriptions long term in a primary care setting have problems with addiction.
Additionally, opioid users are at an increased risk of unintentional overdose. Between 1999-2014, around 165,000 Americans died from prescription opioid-related overdose.
In part, this risk is driven by increased tolerance to the drug when taken for long periods; users may need to take more of the medication in order to feel any pain relief.
A recent study reported by Medical News Today suggests that the risk of opioid overdose may also be influenced by the dosage patients are prescribed, with researchers finding that patients who died of unintentional overdose were prescribed opioids at double the dose of those who did not overdose.
Other side effects of opioid use include physical dependence – where a user experiences withdrawal symptoms after opioid cessation – increased pain sensitivity, nausea, vomiting, constipation, sleep problems, confusion, reduced energy and depression.
While there is no doubt that opioids can be effective for short-term pain relief, health care professionals across the globe are in agreement that their use has spun out of control.
The CDC note that the sales of opioid prescriptions in the US quadrupled between 1999-2014, but the rate of chronic pain among Americans remained stable over the same period.
As mentioned previously, in 2012, doctors wrote enough opioid prescriptions to provide a bottle of pills for every adult in the US – a snapshot of the nation’s reliance on the drugs, and an indicator that opioids are seen as a first-line treatment for chronic pain.
As such, federal health agencies in the US believe that imposing stricter guidelines for the prescription of opioids for chronic pain is key to reducing the number of deaths due to the drugs.
“More than 40 Americans die each day from prescription opioid overdoses, we must act now,” said CDC Director Dr. Tom Frieden last week. “Overprescribing opioids – largely for chronic pain – is a key driver of America’s drug-overdose epidemic.”
In response to the epidemic, the CDC have released a guideline that includes 12 recommendations doctors may refer to when deciding whether to prescribe opioids for a patient with chronic pain.
Within the guidelines, there are three key recommendations:
- The use of non-drug and non-opioid therapy as a first-line treatment for chronic pain patients. “Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient,” the CDC state
- If opioids are used, doctors should prescribe the lowest effective dosage in order to lower the risk of misuse and overdose. “Benefits of high-dose opioids for chronic pain are not established,” state the guidelines
- Doctors should always be cautious when prescribing opioids and closely monitor all patients. “Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation,” say the CDC. “Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently.”
Commenting on the new recommendations, Dr. Debra Houry, director of the CDC’s National Center for Injury and Prevention Control, says:
“Doctors want to help patients in pain and are worried about opioid misuse and addiction. This guideline will help equip them with the knowledge and guidance needed to talk with their patients about how to manage pain in the safest, most effective manner.”
In general, the CDC’s new guideline has been met with much positivity, with one health care professional citing it as a “game-changer.”
“It’s the first time that the federal government is clearly communicating to the medical community that opioids are not appropriate for long-term use, that the risks outweigh the benefits,” Dr. Andrew Kolodny, director of Physicians for Responsible Opioid Prescribing and the chief medical officer of Phoenix House, a non-profit drug rehabilitation organization, told The Guardian.
There is evidence to suggest the recommendations may work. Earlier this year, a study published in the Journal of Emergency Medicine revealed how an opioid prescribing guideline put in place in the emergency department at Temple University Hospital in Philadelphia, PA, instantly reduced prescribing rates of the drug.
However, not everyone is welcoming the CDC’s recommendations with open arms. In a blog, Bob Twillman, PhD, executive director of The American Academy of Pain Management, raises concerns that the guideline could potentially stop many patients with chronic pain from receiving much-needed treatment.
“Simply put, the one statement that best summarizes the goal of the CDC guideline is, ‘Take all steps possible to minimize exposure to opioids when treating chronic pain,'” he comments.
“While CDC undoubtedly is well-intentioned, achieving this goal must be done in a way that does not harm the vast majority of people using opioids to manage their chronic pain – who have a positive risk/benefit ratio and who do not misuse or abuse their vital medications.”
Furthermore, the new guideline has received criticism from the American Cancer Society Cancer Action Network (ACS CAN), which claims the guideline may have “unintended consequences for cancer survivors living with chronic pain.”
“Pain does not end when an individual completes treatment,” says ACS CAN President Chris Hansen. “Most often, cancer patients deal with lasting effects from their disease or treatment including pain for a significant period of time or indefinitely.”
“We remain concerned that without a balanced approach that accounts for the full continuum of care for cancer survivors, the emphasis on reducing inappropriate use of pain medications will impede access to necessary pain relief for individuals fighting pain from cancer,” he continues.
“ACS CAN urges the CDC to closely monitor implementation of this guideline and its impact on cancer patients and survivors experiencing pain.”
While the new opioid prescribing recommendations have attracted a clearly mixed reaction, there is no doubt that the opioid epidemic is a major public health issue that needs to be addressed; encouraging doctors to be more cautious when treating patients with chronic pain is a step in the right direction.
And it is not only the CDC that are addressing this important issue; yesterday, the FDA announced they are adding new safety warnings to all prescription opioid drugs.
These will include a boxed warning about the risks of misuse, abuse, addiction, overdose and death, as well as warnings about the risk of opioid use in combination with other drugs and the risks associated with opioid use in pregnancy.
Additionally, the labeling on prescription opioid drugs will include clearer dosing information and instructions related to drug administration and patient monitoring.
The FDA say their “actions are one of the largest undertakings for informing prescribers of risks across opioid products, and one of many steps the FDA intends to take this year as part of our comprehensive action plan to reverse this epidemic.”
While federal health agencies in the US are evidently taking the opioid epidemic seriously, only time will tell whether their approaches will work. But with more than 40 Americans dying from a prescription opioid overdose every day, any method that stands a chance of success is worth a try.