If you’ve ever had a major accident, or a loved one with bone cancer, you know that there’s pain, and then there’s pain. The kind of pain that no amount of ibuprofen can touch. The kind that almost makes you wish you were dead. For people in this kind of pain, opioid medications, formerly known as narcotics, can be lifesavers.
They can also be deadly, if misused or abused.
Opioids work by changing the way the brain perceives pain. Commonly prescribed drugs in this class include codeine, hydrocodone (example: Vicodin), hydromorphone (example: Dilaudid), methadone (example: Dolophine), morphine (example: Kadian), meperidine (example: Demerol), and oxycodone (examples: OxyContin, Percocet).
For people who require heavy-duty pain relief, these drugs can ease needless suffering. “We’re lucky we have them because they are some of the best painkillers around. There are times when it is appropriate to use them,” says James A. McGowan, MD, an interventional pain physician at Mercy Medical Center in Baltimore, Maryland. Dr. McGowan says they’re appropriate for short-term use following injuries, fractures, sprains, and surgeries, as well as for pain from cancers that have invaded the bones or other organs.
But these powerful painkillers have real downsides. Side effects include constipation, nausea, and confusion. (Keeping the dose as low as possible can help you avoid them.)
What’s worse, “they can be very sedating,” says Dr. McGowan. In people who take too much, “they will cause respiratory depression and can ultimately be lethal.”
Drinking alcohol and taking certain other medications ratchets up the danger. “The number one offender in terms of increasing the risk of opiate medications would be alcohol,” which magnifies the drugs’ effects, says Dr. McGowan. So do medications called benzodiazepines, which include the anti-anxiety medications alprazolam (Xanax) and clonazepam (Klonopin). These are “very oftentimes linked to opioid overdoses,” says Dr. McGowan.
The risks don’t end at side effects. Using an opioid for as little as two to four weeks can cause physical dependence — essentially, what happens when your body gets used to the drug. “Everyone who takes this stuff for a prolonged period of time will become dependent on it,” says Dr. McGowan. “At the same time, it becomes less effective,” which may tempt people to take more.
If you’re dependent on an opioid and you go off of it, you’re likely to suffer withdrawal symptoms, according to the National Institute on Drug Abuse. These can include sweats, body aches, restlessness, insomnia, diarrhea, and vomiting.
You may not realize that you’re dependent until you stop the drug and experience some of these symptoms. (Opiate withdrawal is not fatal, though it can be very dangerous for people with heart conditions. Patients don’t necessarily need to go to a rehab center to cope with it, but some find it helpful.)
Addiction is another lurking hazard. “Addiction is a mental state in which you’re using a substance despite the fact that it’s causing harm to your work relationships, your personal relationships, your health or when it’s causing you to engage in risky behaviors,” says Dr. McGowan. About 5 percent of people who take these drugs as directed over the period of a year will become addicted, according to the National Institutes of Health.
How Long Is Too Long?
Until recently, opioids were used mainly to treat short-term pain. Today, they are increasingly used to treat long-term pain, too — a more controversial practice. “For chronic pain it becomes a whole lot trickier,” says Dr. McGowan. “There are a lot of folks on opiates for chronic pain issues. Some of them end up doing well, and some of them end up doing very badly.” Even though the drugs become less and less effective over time, “it becomes very hard to stop taking them.” They can even backfire. “Sometimes taking pain relievers on a long-term basis can actually increase your body’s sensitivity to pain. Instead of helping, it’s actually making the situation worse.”
The FDA has taken steps to discourage inappropriate use of extended release and long-acting (ER/LA) opiates. Labels must now state that the drugs are “indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate.”
The thought here,” says Dr. McGowan, “appears to be the need to reinforce to clinicians that, because of the risks of addiction, dependence, overdose, and death, these types of medications should only be used if other treatment options have been tried and failed. They should not be a first line choice of therapy, and they should not be used for mild pain.”
Labels also must now indicate that use of ER/LA opiates during pregnancy can result in a potentially fatal condition in the baby called neonatal opiate withdrawal syndrome.
In some cases, long-term use of opioids may still be appropriate. “If you can keep the dose low, if you can keep yourself from escalating the medications, some folks will do okay on these medications, particularly when they’re out of other options, when they have health conditions that prevent them from taking anti-inflammatories or some of the other medications,” says Dr. McGowan.
Curbing an Epidemic of Abuse
More people than ever before are misusing or abusing opioids. In 2011, the last year for which data is available, 420,000 trips to the ER were due to overdoses of these drugs. Deaths from opioid-related overdoses now outnumber deaths involving all illicit drugs, including heroin and cocaine, combined.
The epidemic of abuse — driven in large part by recreational users seeking a high, but also by people who began taking these medications for legitimate reasons and became addicted — has spurred drug companies and the government to action. Some drug manufacturers have made their products more tamper resistant, changing their physical and chemical properties so that it’s harder to crush, break, or dissolve the tablets in order to snort or inject the drugs.
In April 2013, the FDA approved updating labeling for an abuse-deterrent formulation of OxyContin extended-release (ER) tablets. “While there are other opioids formulated to deter abuse (Opana ER is an example), reformulated OxyContin is the first product to be labeled as such,” says FDA spokesperson Morgan Liscinsky.
State governments are doing their part, too. As reported by the American Society of Health-System Pharmacists, most states have instituted prescription monitoring programs which collect data from pharmacies to help determine when patients are seeing more than one doctor for opiate prescriptions and filling them at different pharmacies.
The Drug Enforcement Agency is also on the case. “When we see a trend that two or three pharmacies are over-prescribing these medications, our diversion investigators can do audits of doctors and pharmacies,” says special agent Joseph Moses. The agency, he says, can then remove the DEA number that allows medical professionals to prescribe controlled substances, “and they can’t write prescriptions anymore.”
The bottom line on opioids is that they provide necessary relief for people suffering from severe, chronic pain but since they are often misused and abused, they need to be prescribed and taken with great caution.