The opioid epidemic has changed the conversation about painkiller prescriptions, with many people wondering how they can get much-needed pain medications from their doctor. They might have questions about the potential for addiction, but they might also want to know about alternatives for pain management and what their doctors think about the controversy.
What should a patient know about opioids? Understanding the mechanism of action of opioids will shed light on the dangers of the drugs, especially as those dangers pertain to an individual patient’s situation. It will also answer questions about whether opioids are necessary, how non-opioid alternatives to pain therapy work, and how to go about taking opioids if there really is no better option.
Opioids are typically prescribed to help with moderate-to-severe levels of pain, especially in a post-surgery setting; however, they are also given to help patients experiencing cancer-related breakthrough pain. Many substances fall under the general category of opioids. Some are derived from natural sources, like the opium produced by the poppy flower; these drugs are known as opiates but are now commonly referred to under the umbrella of opioids. Some are made entirely in a laboratory, with their chemical compounds based on those found in nature. Some are a hybrid, so-called semi-synthetic opioids.
When a person takes an opioid, the drug is broken down in the body to a molecular form; these molecules then attach to specific receptors in the central nervous system throughout the body. The process of attachment impedes the brain from perceiving any pain and also causes a brief burst of pleasure. Additionally, the opioids also reduce the functioning of certain body systems, such as breathing.
When used properly, opioids can give patients much-needed relief from pain, allowing them to rest and recover as their body heals. Unfortunately, this same mechanism also raises the possibility of addiction. Patients who have certain risk factors, such as a family history of substance abuse or mental health problems, or an unstable living environment, may be likely to increase their consumption of opioids to feel the drugs’ pleasurable effects. This causes a psychological and physical dependence on opioids for their pleasure, a bond that is incredibly difficult to break. Further abuse of opioids in this way can lead to long-term damage to the body and brain, ultimately leading to an overdose, which can quickly result in death.
When opioids are taken as they should be, with the full knowledge and direction of a physician, the risk for any adverse health effects is low. Nonetheless, opioids are very powerful and potentially habit-forming substances, so they should never be taken for longer than necessary. One of the most important things to know about taking opioids is how long they should be taken; a patient should never continue to consume opioids beyond their prescription date, even if the pain persists. If there is still physical discomfort beyond the prescription date, the patient should check with their doctor first and not continue taking their opioids.
Additionally, the patient should not increase the dosage of the opioids. This can be tempting to do; pain is often persistent, and well-being seems to be better while under the effects of the medication. However, this is the path of addiction on which many people unwittingly stumble. Assuming that there is nothing wrong with taking more of the opioids to treat the pain, they find themselves hooked more and more on the analgesic effects of the drugs. Even when the pain is brought under control, discontinuing use becomes too difficult to bear.
For this reason, a patient should know how long the opioid prescription lasts, and what the intended dosage of the prescription is, before starting the prescription. It is critical that patients work closely with their doctors to decide if opioids are even the right form of treatment. The safest rule of thumb is for the doctor and the patient to jointly determine the lowest possible dose, for the shortest period. The patient should be completely honest with their doctor about any risk factors or side effects that might arise as a result of the opioid therapy. This kind of honesty and collaboration goes a long way in ensuring that the patient steers clear of succumbing to the insidiousness of addiction.
Another thing patients should know is that they should properly dispose of leftover medication once they are done with their prescription. In the past, too many people would leave unused tablets and pills in their possession, or they would even share them with friends and family members. For a number of people, this is how addiction starts. Opioids are potent drugs that should never be taken without a doctor’s explicit instructions, and people who are not aware of the dangers of opioids are unlikely to know the level of risk to which they are exposing themselves.
Patients should talk to their physician and pharmacists about safe disposal options. Even some police departments have started public take-back programs for unused opioids because of the extent to which the unlawful diversion of prescription medication has become a criminal problem.
The spread and scope of the opioid epidemic have led to much research into safe alternatives for alleviating pain. There are a number of over-the-counter medications that do an equally good job, if not an outright better job, of managing many common types of pain as opioids.
For example, Dr. Roy Soto of the Michigan Prescription Drug and Opioid Abuse Commission points out that opioids are ineffective at helping women who are experiencing menstrual cramping pain as the result of dilation and curettage, but many opioid prescriptions have been written for just that purpose. Instead, Dr. Soto points to “a lot of medications available for pain control that are not opioids,” including nonsteroidal anti-inflammatories such as Motrin and Advil, acetaminophen, and other medications like tricyclic antidepressants, which are highly effective at treating nerve pain.
To Dr. Soto’s point, a study published in the Journal of the American Medical Association found that opioids were not any better at reducing pain than combining non-opioid medications like ibuprofen and acetaminophen. An opinion writer in The New York Times told the story of how she was prescribed ibuprofen after a hysterectomy in Germany, where her entire medical staff was firmly of the opinion that she did not need Vicodin for post-surgical pain.
Other substances have emerged as possibly safer alternatives to opioids. An herb known as kratom, which is grown in Southeast Asia, has been floated as a new form of treatment for pain and opioid abuse itself. Research has suggested that the chemical compounds in kratom can attach to the same receptors that would normally receive opioids, and as a result, they have the same effect as opioids.
Kratom is not without controversy. In 2016, the U.S. Drug Enforcement Administration announced its intention to categorize kratom as a Schedule I controlled substance, which would render it completely illegal to own and distribute in the United States; high doses of kratom have been known to induce a sedative effect in users.
After a public and political outcry, the DEA withdrew its intention to subject kratom to the highest level of regulation, but the U.S. Food and Drug Administration (FDA) continues to maintain that kratom is too dangerous to use as an opioid alternative. The FDA cites 15 deaths from 2014 to 2016 that were related to kratom use. FDA Commissioner Scott Gottlieb has stated that kratom has “no reliable evidence” that would support its use as a treatment for pain, and he has argued against the use of kratom for any medical purposes.
However, there remains a lot of support for the idea of using kratom as an opioid replacement. An emergency physician wrote on Medium that kratom is “an alternative to traditional pain management that America desperately needs,” and the Pain News Network noted that a survey of active kratom users showed that 90 percent of respondents felt that kratom was “very effective” for treating their chronic pain.
Many doctors themselves have mixed feelings on prescribing opioids. The American Journal of Law and Medicine explains that physicians often find themselves “between a rock and a hard place,” compelled to prescribe effective opioids to help their patients experiencing severe pain, but fearful of the legal consequences of unintentionally setting patients down the path of substance abuse. Some doctors outright refuse to prescribe opioids to their patients, leading many patient advocates to claim that the backlash against opioids is preventing very sick patients from getting the only medication that can help them.
Is it wrong to ask a doctor for opioids? That is a question posed in The Conversation, where the writer (a research scholar at the Berman Institute of Bioethics, Johns Hopkins University) agreed that American medicine needs a cultural overhaul in the wake of the opioid epidemic, but it will require changing how patients expect their pain to be treated. This will entail opening up more channels of communication between patients and doctors, specifically with regard to whether opioid therapy is needed after a medical procedure. This also will entail honest and uncomfortable conversations about the reality of injury, trauma, surgery, and pain, and that no amount of medicine will make all those problems go away.
The most important point, says The Conversation, is that patients should not be stigmatized if they want opioids to help them with their chronic and severe pain. It is the doctor’s responsibility to work closely and openly with the patients on determining whether opioids are right for them and, if so, to come up with a prescription plan that minimizes the exposure and risk of addiction to the medication.
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