It’s no secret that the United States is in the midst of an opioid abuse epidemic. An estimated 2 million Americans have prescription opioid use disorders—a medical condition that involves opioid abuse—according to an August 2017 study in the Annals of Internal Medicine. Another 12 million people have misused opioids, such as taking an opioid prescribed to someone else or using the drug in ways other than as prescribed by a doctor.
Commonly prescribed opioid medications include oxycodone (OxyContin, Percocet), hydrocodone (Vicodin), hydromorphone (Dilaudid), morphine, and fentanyl. Some adults depend on them to relieve chronic pain (pain that lasts three months or longer) that might otherwise leave them homebound and unable to maintain their independence. Yet the trend of frowning upon opioid use is growing, leaving many patients to wonder whether they’re being led down a path to addiction or if they’re destined to a life of pain, immobility, and loss of independence if their doctor decides their narcotic pain relievers are too risky to continue taking.
Still, the statistics don’t lie: Opioids are dangerous. Forty-six Americans die from an overdose of prescription opioids every day, says the CDC. And nearly one in four patients prescribed opioids for chronic pain develop an opioid use disorder. A person diagnosed with an opioid use disorder continues to use opioids despite being significantly impaired or distressed by their opioid cravings, failure to control drug use, inability to fulfill personal or work obligations, and other lifestyle problems.
If you regularly, or even occasionally, use an opioid to relieve chronic pain, ask yourself whether you need such a strong drug. Is it worth the serious risks, such as addiction or an accidental overdose? To help you answer those questions, we debunk some common myths about opioids.
Opioid pain relievers should never be used by older adults.
Fact: Opioid pain relievers may be used short-term (usually three to seven days) for acute pain that someone might experience after surgery or an injury such as a broken bone. Doctors also prescribe opioids for relief from cancer pain or for palliative care (treatments that relieve pain and enhance comfort) or end-of-life care.
Most people can safely take small doses of a prescription opioid for a short time. However, older adults who use opioids long-term to ease chronic pain from conditions like osteoarthritis, back ailments, nerve damage, migraines, or fibromyalgia are more vulnerable to adverse effects. But for some people with debilitating chronic pain, opioids may be their only choice if all other pain management options have failed.
Nearly all patients experience one or more of the drug’s side effects, but the severity of the effects varies from person to person. Some side effects, such as dizziness, itching, nausea, and vomiting, may last only a few days after starting an opioid or after a dosage is increased. Others, including sedation or sleepiness, falling, memory impairment, and constipation, may last longer.
What’s more, many older adults take other drugs, such as muscle relaxants like carisoprodol (Soma) and cyclobenzaprine (Flexeril) and hypnotics like zolpidem (Ambien) and eszopiclone (Lunesta), that can interact with opioids. Combining opioids with benzodiazepines—anti-anxiety drugs such as alprazolam (Xanax), diazepam (Valium), clonazepam (Klonopin), and lorazepam (Ativan)—is particularly dangerous, as is mixing alcohol with narcotics.
Mistakenly thinking you forgot to take a pill and then taking another can be fatal. High doses of opioids can cause slow breathing, also referred to as respiratory depression, which can lead to death. For those reasons—as well as the risk for developing an opioid use disorder—many primary care doctors avoid prescribing opioids for most types of chronic pain.
The CDC prohibits doctors from prescribing opioids for chronic pain.
Fact: In 2016, the CDC released a clinical practice guideline aimed at primary care physicians who prescribe opioids for chronic pain. The guideline contains recommendations, not mandatory rules, meant to help reduce the risk of misuse. However, some states have placed certain restrictions on opioid prescribing, such as limiting prescriptions to a seven-day supply of pills, to stem the tide of narcotic pain relievers being misused.
The CDC’s goal in drafting the recommendations was to improve the way opioids are prescribed for chronic pain, aside from cancer pain and palliative and end-of-life care. The guideline emphasizes providing access to safer, more effective chronic pain treatment. Among the CDC's recommendations for doctors:
- Use non-opioid medications or nondrug therapy as the first treatment choice to manage chronic pain.
- Consider opioid therapy only if the benefits for both pain and function are expected to outweigh the harms.
- When prescribing opioids, prescribe the lowest effective dosage and combine opioids with other therapies.
- Prescribe immediate-release opioids instead of extended-release opioids, including methadone and fentanyl (available as a skin patch), which are associated with a higher risk of overdose.
- Regularly monitor patients using opioid pain relievers, which may include urine drug testing.
Chronic Pain: Work with Your Doctor
There’s a fine line between the benefits and harms of using opioids to control chronic pain. Here's how to work with your doctor to set realistic treatment goals and minimize your risks.
Taking a prescription opioid puts people at high risk for eventual heroin abuse.
Fact: While it’s true that nearly 80 percent of heroin users start by misusing prescription opioids, according to the U.S. National Institute on Drug Abuse, only about 4 percent of people who misuse opioids go on to use heroin. When people addicted to opioids can no longer obtain a legal prescription, they may turn to heroin, an illegal—and cheaper—opioid.
Prescription opioids act on the same parts of the brain and have a method of action similar to that of heroin. Both drugs bind to receptors in the brain that regulate feelings of pain and pleasure. Taking opioids can reduce sensations of pain and enhance sensations of pleasure, which contributes to cravings for the drugs. As a result, there’s a risk that people can abuse them or become addicted, especially if they take opioids in a higher dose, more frequently, or for a longer duration than prescribed.
Opioid tolerance, dependence, and addiction are the same things.
Fact: All three are the result of repeatedly using a drug, but each affects the brain and body in different ways, and they have some important distinctions:
- Tolerance—Over time, the body may build up a tolerance to the drug, requiring a higher dose to achieve the same effect once felt with a lower dose.
- Dependence—It’s common for the body to adapt to the presence of opioids, which can lead to physical dependency and withdrawal symptoms, such as anxiety, insomnia, and flulike symptoms, if the drug is stopped abruptly. Physical dependence alone doesn’t constitute addiction, but it can accompany addiction.
- Addiction—Addiction is a disease that changes brain circuitry. It’s characterized in part by cravings and compulsive use of the drug to experience euphoric effects.
Most people taking opioids will not become addicted to the drugs. But according to a study published in 2016 in The New England Journal of Medicine, the risk for opioid overdose or addiction rises among people who are:
- Older than 65
- Taking a daily opioid dose of greater than 100 morphine milligram equivalents
- Using a long-acting or extended-release formulation
- Using opioids for longer than three months
- Combining opioids with benzodiazepines
- Suffering from sleep-disordered breathing, such as sleep apnea
- Diagnosed with impaired kidney or liver function
- Depressed or have a mental disorder
- Known to have a history of alcohol or other substance abuse
- Have overdosed in the past
People who live in rural areas and have a low income are also more vulnerable to abuse and overdose than those in the general population, the CDC says.
Pain Relief, Without Opioids
Opioids aren’t always the best way to treat chronic pain. Here are 12 alternatives, from over-the-counter medications to complementary approaches. Their effectiveness will vary depending on the patient and the pain’s location, among other factors.
This article first appeared in the February 2018 issue ofUC Berkeley Health After 50.
Published March 30, 2018