Each individual who uses chronic opioids was at some point started for the first time on a prescription opioid. Often the problem was an episode of acute pain, such as a twisted ankle. Opioids may also have been newly started for a chronic pain problem, such as arthritis or chronic headaches, which was not well controlled with non-opioid approaches. (This post will not address those who began their chronic opioid use recreationally by obtaining their first pills from a “friend.”)
A recent study performed by Express Scripts, a large pharmaceutical company, raises red flags about the likelihood that someone newly beginning on opioids will end up using them chronically. The study looked at close to 7 million people who filled a prescription for an opioid for the first time. Half of all people who used opioids for over 30 days were still on opioids three years later.
This statistic is very concerning. It suggests that once opioids are started and continued for over one month, there is a 50-50 chance that person will be on opioids chronically. While this class of medication can help with acute pain, its use in chronic pain is fraught with problems. Opioids have a tendency to actually heighten the sensation of pain by down-regulating areas in the CNS and peripheral nervous system which dampen the experience of pain. Individual susceptibility to this phenomenon is variable, but there is nonetheless a strong prospect that continued use of opioids for more than several weeks will increase a person’s pain sensitivity, leading to a need for more opioids. Once this vicious cycle starts, it can be difficult to break out of it.
Other concerning information from the Express Scripts study is that about one third of all people on chronic opioids are also taking benzos, which increases the risk of overdose. Over one-quarter of chronic opioid users are taking at least two different short-acting opioids, though the therapeutic need for such a combination is manifestly obscure.
Implausibly but revealingly, opioid consumption was higher among young adults (defined as ages 20-44). This one factoid speaks volumes. Even non-scientifically-minded observers can rationally presume that older people have more biological and physical reasons to have chronic pain. Yet they use less opioids than younger folks. Though not referred to in the study, I feel it is important to note that the population segment with the highest opioid use is precisely those who were entering adulthood during the period when physicians were being repeatedly advised that our concerns about opioids were ill-founded. So-called experts on opioid use told us to stop worrying so much about addiction. They said there is “no upper limit” when prescribing opioids. Pain should be treated as a vital sign (of course, it was the only” vital sign” which did not bear on whether a person’s life or vitality was in question). Physicians who did not escalate opioid doses sufficiently were being disciplined by state medical boards.
The fruits of two decades of such unscientific exhortations are becoming increasingly apparent. Deaths from opioid overdoses increased 400% in one decade from 1999 to 2010. Prescription opioids have in many cases become gateway drugs to use of heroin. And no one seems to be of the opinion that chronic pain is better controlled now than it was 30 years ago, when physicians used to be very cautious about prescribing opioids.
Fortunately, the pendulum is swinging back towards safety. Information is starting to come out about how the movement to encourage greater opioid prescribing was developed and financed by big pharma. The “opioids are great” campaign did not arise on a foundation of medical studies indicating how safe and efficacious they were. The campaign was a house of cards supported by money and by the sad reality that too many physician leaders were unwilling to question big pharma’s mirage. Now, thank goodness, clinicians are returning to a more rational and scientific approach to managing acute and chronic pain in the context of the risks and benefits of opioids and other treatment options.
What are the quick take-home messages?
For individual physicians and clinicians, be careful and give extra thought before writing out that first opioid prescription for a patient, especially those with a chronic pain condition. For acute pain, some discussion with the patient ahead of time to create appropriate expectations that the medication is only for short-term use can help. When the request comes in for the first refill, it is time to step on the brakes and consider denying the request or making the next script for only two weeks. This is especially true in a setting where the inciting reason for the pain should be resolving, even though the patient is strongly requesting “just a few more weeks” of opioids. That few more weeks could turn in to a lifetime of pain. As far as newly starting opioids for chronic pain, be aware that once started, it will be extremely difficult to ever stop. There is an excellent chance the patient’s pain will actually get worse than if they had never started opioids. Patients with chronic pain do not like to hear that, but it is important they learn about the biological problems created by opioids.
And the take-home lesson for medicine as a whole? We need to be much more cautious about allowing outside forces, especially those with dicey financial incentives, to influence our standards of practice. Especially when the science supporting such changes is painfully flaky.
Richard Fleming, MD