Am I Addicted? Making Sense of the Opioid Crisis in America
Opioids: Am I Addicted?
Opioid Crisis in America: Opioid medications offer an important tool in the treatment of some chronic pain issues, but one doesn’t need to look far into the news to realize that these medications are being abused and are responsible for an ever increasing number of adverse consequences, including death. It is important to understand that this article addresses opioid use in chronic, non-terminal, non-cancer pain. Patients with pain from terminal diseases including cancer are not the focus of this article.
Opioids are drugs that act within the central nervous system on cells to block the sensation of pain. Unfortunately, they also bind to other receptors in our central nervous system that account for their bad side effects, like decreasing our drive to take a breath and stimulating centers in our brain that are associated with addictive behaviors.
Examples of opioids include morphine, hydrocodone (Vicodin), codeine, oxycodone (Percocet, OxyContin), oxymorphone (Opana), suboxone, Butrans and methadone. Illicit opioids include heroin and illegally produced fentanyl.
The United States has seen a staggering increase in the number of opioid related deaths over the last 35 years. In 1980, the number of drug overdose deaths per year was about 7000. In 2016, an estimated 60,000 people died from drug overdoses, with most of those involving some type of opioid. In a bit of good news, opioid prescriptions in the United States have started to level off, reversing a steady upward trend over the last 30 years.
Why has this happened? You can go back to the early 1980s when a number of medical articles started to promote the use of opioid medications for non-cancer pain. Long-standing fears among doctors on prescribing pain medications began to be relaxed. This was not unnoticed by pharmaceutical companies who began aggressive marketing campaigns to encourage doctors to treat their patients’ pain with opioids. The result was a steady increase in prescriptions for opioid pain medications, putting people who are prone to addiction at risk.
People who previously had no history of addiction found themselves losing control of their pain medications and suffering devastating consequences including loss of their job, divorce, homelessness and isolation. Recently, the pendulum has started to swing the other way, with physicians being reluctant to prescribe opioid pain medications. This sometimes Draconian approach to conservative prescribing has made it difficult for some patients who truly benefit from these medications to find appropriate care.
The other consequence with more conservative prescribing habits is the decreased supply of prescription medications on the streets with a population of addicts looking for an alternative. With a decrease in prices of heroin and the alarming increase in illegally made fentanyl, a very potent opioid, many people are turning to these dangerous alternatives to fuel their addiction. The CDC, state medical boards and medical societies are launching educational initiatives to help provide guidance to physicians on responsible prescribing of these medications.
If you are on pain medications like these, what should you know? First you should understand that these types of medications are just one tool that can be used to treat chronic pain, and they may not be the best tool at that. Studies show that long term use of opioid medications at best can give about 30% improvement in pain (about the same as placebo) and improvement in function is not clear.
Also, be aware that most people who are on these types of medications for a long time will likely become tolerant to them meaning that the medication tends to lose effectiveness over time. This can sometimes be addressed by changing to a different medication in the same class, but sometimes it requires taking a holiday from using the medication. Increasing the medication to account for tolerance is generally going to be unsuccessful because it just leads to further worsening of the tolerance.
Addiction, while a risk on these medications, is generally low for most people. If you have a history of addictive behavior to any substance, a family history of the same, significant psychological disorders, or are young, your risk is going to be much higher. Your healthcare provider is going to be more cautious using these medications for someone with this history and will likely require you to have closer follow up.
Opioid medications can be an important tool in the fight against chronic pain. Even though they have been used for pain for literally thousands of years, we still are learning how to effectively use these powerful medications. Responsible prescribing by physicians and responsible stewardship by our patients is key to successful use of this class of pain medications.
Having realistic expectations of how much relief these types of medications can give for chronic pain is an important step towards successful pain care. There are other treatments including non-opioid medications, interventional pain management, physical treatments, cognitive behavioral therapy, and spiritual practices that have been shown to be successful. If your healthcare provider suggests these types of treatments as part of your chronic pain management plan, be open to them.
by Dr. Magnuson, Board Certified Anesthesiologist
Dr. Magnuson is a Board Certified Anesthesiologist with Added Qualifications in Pain Management. He is a graduate of Creighton University School of Medicine, University of Missouri Kansas City Anesthesiology Residency and completed his fellowship in Pain Management at the University of California San Diego.