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Opioids

Frightening trends in use and abuse

 Do You Know somebody who takes prescription painkillers on a regular basis? And maybe they’ve been doing so for many weeks, or even months? Perhaps they have a serious illness or condition that causes relentless pain, or they’re recovering from surgery and need help getting past a rough patch. But you worry. How long can a person take strong medications such as hydrocodone or morphine and not become addicted? What are the meds doing to their system? And aren’t prescription pain medications what have caused the deaths of several celebrities we’ve heard about in the news?

“Opioids,” says Thomas Strandness, MD and Anesthesiologist at Memorial Hospital, “are a class of drug used to help decrease pain. They include prescribed medicines like morphine, codeine and hydrocodone, but also illicit substances like heroin. The body also produces various natural opioids like endorphins.”

Opioid usage has skyrocketed in the past few years, says Dr. Strandness. “The Centers for Disease Control states since 1999 the number of opioids sold has quadrupled, while there has been no change in the amount or frequency of pain Americans report.”

A frightening trend, to be sure. And, says Dr. Standness, “As for illicit opioids, heroin usage has also gone up around 60% in the same time frame. Interestingly, four out of five heroin users started abusing prescription medicines prior to their heroin usage.”

What, exactly, do opioids do in our systems?

Nick Piantanida, MD and Primary and Urgent Care Physician with Penrose St. Francis and South State Operating Group, says, “Opioids have multiple systemic effects in the human body. Cardiovascular effects include sudden death from cardiac failure related to a heart attack or irregular electrical rhythm. Gastrointestinal effects include constipation, stomach pain and even intestinal perforation. Behavioral health manifestations include aggravating depression and anxiety to include elevating suicide risk. Hormonal imbalances are seen with opioids lowering testosterone in males and even causing infertility complications.

“Addiction, misuse and dependence are all dose-response effects that complicate opioid use, such that the body expects to receive regular doses to function.”

Addiction can take hold, says Dr. Strandness, when, “over time, opioid receptors become less responsive, requiring larger amounts of the drug for the same effect, a process called tolerance. Then withdrawal symptoms start occurring in these patients where they must continue to use to avoid the negative effects. This leads to a vicious cycle of people seeking larger doses and not wanting to decrease their current usage.”

Bottom line, says Strandness, is “that opioids taken illegally or outside their prescribed dosages are incredibly dangerous… 78 Americans die every day from opioid overdose.”

So, we might ask, what is considered a safe use of opioids?

“Opioids in the acute and limited dosing setting defined as less than four weeks is considered ‘safe,’” says Dr. Piantanida. “Where opioids are used chronically—more than 4-6 weeks—every prescribing provider must take deliberate steps to mitigate risk. Risk mitigation includes several measures to educate patients in all areas of chronic opioid risks as mentioned above, with a huge emphasis on overdose, dependence and suppressed breathing that can result in sudden death.”

“Providers must screen for risks before prescribing, and proceed with caution with limited, small-dose duration of opioid use. If chronic use is essential, then a controlled substance agreement should be completed to define professional expectations on refill and treatment goals. I have older patients with severe debilitating arthritis in the back and major joints who, without opioids, would be bed-bound. This population is more mobile and contributing to society with a single or select dose of opioids every day. However, their care is under my direct observation with careful attention to side effects.”

Do we have alternatives to opioids when dealing with serious pain?

“The goal of pain management in the non-palliative/non cancer setting,” says Dr. Strandness, “should be to seek functional improvement for chronic pain or to facilitate recovery from acute injury. Drug free options such as physical therapy, exercise, cognitive behavioral therapy and other non-opioid based medications ought to be trialed prior to initiating opioids. When opioids are prescribed, they should be viewed as an adjunct to these other therapies and not the sole agent. It’s amazing to see how much benefit a patient receives from simple exercise compared to how little functional benefit a patient may get from longer-term opioids. In the acute postsurgical setting, anesthesiologists are performing more regional anesthesia techniques like nerve blocks or epidurals to limit patient exposure to opioids.”  

Did you Know

• Of the 21.5 million Americans 12 or older who had a substance use disorder in 2014, 1.9 million cases involved prescription pain relievers and 586,000 involved heroin.

• Drug overdose is the leading cause of accidental death in the US, with 47,055 lethal drug overdoses in 2014. Opioid addiction leads this epidemic, with 18,893 overdose deaths related to prescription pain relievers and 10,574 overdose deaths related to heroin.

• In 2012, 259 million prescriptions were written for opioids, more than enough to give every American adult a bottle of pills.

Source: American Society of Addiction Medicine 2016 Report