Editor’s note: Steven Findlay is an independent medical and health policy journalist and a contributing editor/writer for Consumer Reports. He begins blogging for MedShadow with this post. He’ll be deriving some of his posts and insights from Consumer Reports Best Buy Drugs, a grant-funded public information and education program that evaluates prescription drugs based on authoritative, peer-reviewed research.
In 2014, Americans filled 129.2 million prescriptions for one opioid — generic hydrocodone/acetaminophen — making that drug the most prescribed medicine in the US. Indeed, opioid painkillers are powerful medicines and highly effective for acute pain. If you’ve just had major surgery, a bad injury or sprain, or find yourself with a kidney stone, an opioid is a Godsend. That’s one reason drugs like Oxycontin (oxycodone), Vicodin and Percocet are also among the most prescribed medicines in the country.
On the other hand, these powerful painkillers are highly addictive and become particularly problematic when prescribed for chronic conditions or taken for longer than recommended by a doctor. Patients with a history of addiction need to be particularly careful when taking opioids, and their use of these medicines should be monitored carefully.
Short-Term Use Can Be Managed
Taken for several days, a week, or even a couple weeks after surgery or an acute injury, opioids pose little risk and have predictable and manageable side effects, studies show. One troubling side effect is constipation. You can take a stool softener for that problem. Dry mouth is also almost universal when taking an opioid, but water and ice chips can make it tolerable. Sedation is also common and annoying to many. It’s unavoidable, limits normal activity and is the price you pay for the pain relief — which is, by the way, highly effective. You can count on 50% to 90% relief with an opioid, depending on the severity of your pain.
Recent research indicates that physical dependency (see definitions below) does occur even with short-term use — and earlier than previously believed. Use of an opioid for just a week can result in physical dependency. But the unpleasant “withdrawal” symptoms that occur when you stop an opioid — sweating, body aches, restlessness, feeling jittery and irritable, insomnia and diarrhea — are sharply eased if you reduce the dose gradually over a few days before stopping completely.
So, all is pretty much OK with short-term use of an opioid drug when you really need something stronger than aspirin, acetaminophen (Tylenol), ibuprofen (Advil) or naproxen (Aleve).
But the use of opioids by people who have long-term chronic pain is much more questionable, as a new Consumer Reports Best Buy Drugs report explains.
CR’s new report — based on a systematic review of the medical research and reviewed by 3 pain experts — reaches the following conclusions:
- There’s no good evidence for or against the effectiveness of opioids in the treatment of long-term chronic pain. More precisely, the drugs may reduce the pain, but it’s not clear that the benefits of opioids outweigh the harms the drugs do to your body and life.
- The majority of people who take opioids for pain have side effects from the drugs. Some side effects ease over time but others don’t. In particular, constipation does not let up and must be treated. Sedation also continues; while it can be accommodated, it often undermines a productive life. Dizziness and nausea can be troubling initially but these reactions generally subside over time.
- The more serious side effects and risks associated with opioids are exacerbated when the drugs are taken long-term to treat chronic pain. In particular, studies now show that overdoses (accidental and intentional) are more common when people take opioids long-term. Likewise, the risk of physical dependence, tolerance, addiction and increased pain sensitivity are more common when people take an opioid for a few weeks or longer. (See definitions below.)
Opioid Side Effects and Risks
- Accidental overdose
- Decreased testosterone, sex drive, and impaired sexual function
- Drowsiness, sedation
- Increased pain sensitivity
- Irregular menstruation
- Memory impairment
- Nausea and vomiting
- Slowed breathing
- Suppressed immune system function
Dependence, Tolerance, Addiction – What Are They?
Physical dependence is when the body becomes accustomed to a drug. It does not mean you are “addicted.” In practical terms, it means when you stop taking the drug you will likely have “withdrawal” symptoms. How intense those symptoms are depends on the dose you have been taking and for how long.
Tolerance describes the fact that many drugs have decreasing effects over time. With opioids, that’s both good and bad. Good because you may have fewer side effects as your body adjusts to the drug, bad because the pain relief declines. Thus, to sustain the pain relief a higher dose is often needed, raising the risk of physical dependence and addiction.
Addiction is when you become psychologically dependent on a drug. It encompasses physical dependence but goes beyond that. You lose the ability to control the amount of the drug you take and make judgments about that. For example, you might take the drug independent of your level of your pain. In short, you crave the drug and seek it out even though you may know it’s doing you harm. Experts believe some people are genetically susceptible to becoming addicted to opioids. Having a family history of alcohol and drug abuse is also a risk factor for addiction.
Increasing use of opioids to treat people with chronic pain is one part of the “opioid epidemic” that in recent years has become a public health crisis in the US. Growing recreational use of opioids and street sales of the drugs to healthy people is another dimension of that crisis.
- In 2013, almost 17,000 people in the US died of an opioid overdose; in roughly half those cases people had received an initial prescription from their doctor, according to the Centers for Disease Control and Prevention. That’s an increase in opioid overdose deaths of 400 percent from 1999.
- Nearly 500,000 people are admitted each year to an emergency room because of opioid overdoses or adverse events.
- The US comprises 5 percent of the world’s population but consumes 80 percent of the prescription opioids supply.
The crisis, combined with recent research clarifying the risks of long-term opioid use, has led physician organizations to change their policies. Citing studies showing that 50 percent of patients taking opioids for at least three months are still taking them 5 years later, the American Academy of Neurology (AAN) in December 2014 recommended more judicious use of opioids in treating non-cancer related chronic pain.
Opioids provide “no substantial evidence for maintenance of pain relief or improved function over long periods of time (over 3 months) without incurring serious risk of overdose, dependence, or addiction,” the group said. The AAN did not issue specific guidelines for opioid use, however — a nod to pressure from pain specialists who said there’s just not enough evidence to know when they should and should not be used.
The American College of Physicians and American Pain Society have also recommended that opioids be prescribed more carefully to treat chronic pain.
The Consumer Reports Best Buy Drugs report goes a step further. It advises people who have chronic pain (and their doctors) to try less risky pain relievers — such as acetaminophen, ibuprofen or naproxen — first. Solid research shows that many people with moderate to severe chronic pain get meaningful pain relief with these less expensive over-the-counter (OTC) medicines, the report says.
Higher doses of OTC drugs are usually required to ease severe pain than those you’d take for a headache or muscle ache, and all these drugs have higher risks when taken at higher doses.
Unfortunately, almost no studies have compared non-opioid drugs with opioids in treating moderate to severe chronic pain over long periods. That’s a shameful lapse in medical research in my opinion, given the wide use of both. Another gap: there’s little hard evidence on how the opioids compare to each other in terms of safety and side effects when used to treat people with chronic pain, either for short or long periods. (The exception is methadone, which is not recommended for pain.)
The report recommends talking with your doctor about non-drug treatments for pain, too. These include cognitive behavioral therapy, exercise, spinal manipulation, and physical rehab programs. While more and more doctors recommend these interventions as a supplement to drug treatment, there’s a paucity of good-quality research on whether they do any good.
Short-Acting vs. Long-Acting Opioids
The debate over opioids flared anew in 2014 with the approval by the FDA of a drug called Zohydro ER, an extended-release form of widely prescribed hydrocodone. An FDA advisory committee recommended overwhelmingly against approval of the drug but the FDA gave it the go-ahead anyway, arguing that it represented “a new treatment option for the management of pain severe enough to require daily, around-the-clock, long-term treatment and for which alternative treatment options are inadequate.”
Both the FDA expert advisory committee and other medical groups argued that the drug had “no clear advantage” over other opioids and noted that adding another opioid to the market at a time when state and federal health officials were struggling to reduce opioid misuse and abuse was ill-advised. The attorneys general of 28 states formally asked the FDA to reconsider its approval of Zohydro. Consumer Reports concurred with this request. To date the FDA has declined to reconsider its decision regarding the approval of Zohydro.
I mention this development because the latest research evidence, and Consumer Reports’ analysis, indicates that extended-release or long-acting forms of opioids — which are often more expensive — are no more effective than short-acting formulations. They are simply more convenient since fewer pills need to be taken. There’s also preliminary evidence that extended-release formulations pose a heightened risk of overdose compared to short-acting formulations, the report notes.
Partly in response to the Zohydro controversy, the FDA in April 2015 issued guidelines for the future development of opioid drugs and formulas that would make the drugs more difficult to abuse. For example, the FDA urged manufacturers to create formulations that are resistant to crushing for the purpose of snorting or injection. The science of abuse-deterrent technology is still new, however, and it is unlikely to be a panacea for problems with opioid overuse and abuse anytime soon.
Safe Opioid Use Checklist
✔ Read the label and take the drug exactly as directed. Never take more than advised, , don’t take it with alcohol, and don’t combine it with any other drug without your doctor’s OK. Most opioid deaths involve alcohol or sleeping pills.
✔ Don’t drink alcohol when taking an opioid, and don’t combine it with any other drug without your doctor’s approval. Many opioid deaths involve alcohol or sleeping pills.
✔ Get tested for sleep apnea. If you snore loudly, get checked for the condition. Opioids can make sleep apnea worse — and, rarely, prove fatal.
✔ Watch out if you have a respiratory problem. Opioids can interfere with breathing if you have a cold, an asthma flare-up or bronchitis. So let your doctor know right away, and see whether you need a lower dose until you recover.
✔ Don’t drive or do anything that requires you to be fully alert. That’s especially important when you first start taking an opioid or whenever you change the type or dosage.
✔ Put opioids in a locked drawer or cabinet to prevent children from having access to them or others from using them for recreational purposes.
✔ Expect regular monitoring. If you are taking opioids, your doctor should assess you at regular visits. If pain and function do not improve at least 30 percent after starting the drugs, then they probably are not working well enough to justify the risks.
✔ Discard unused pills. You may be able to give them back to your pharmacy. If not, opioids are so risky that excess pills should be flushed down the toilet.
The Dangers of Painkillers: A Special Report (Consumer Reports)