Recently while preparing a talk on safe prescribing, I spoke to a colleague who said that his patients rarely seem to understand why a good doctor minimizes the use of opioid-containing medications. They mostly hear “no” or “I don’t want to lose my license” or “we don’t prescribe opioids here.” Most people by now know the story of the opioid crisis, how the lies of a wealthy and powerful few persuaded doctors and the general public that these drugs were safe and effective, with zero research to support their claims. The perpetrators made billions but since 1999, more than a million Americans have died from drug overdoses, most involving opioids.
August 31 was International Overdose Awareness Day. In memory of those who’ve died, with condolences to those who’ve lost mothers and brothers, daughters, fathers, lovers, and sons, here are 10 reasons to avoid opioid-containing medications if possible….
1. The 2022 CDC Guidelines for the Treatment of Pain clearly state that non-opioid treatments are as or more effective–and much safer–for most types of pain. Non-opioid treatments are first-line recommendations for chronic non-cancer pain.
Opioid-containing medications are still overprescribed in the United States. Things have improved some but the June 2023 issue of the British Journal of Pain showed that in 2020, opioid overprescribing in the US caused a death rate of 20.7 per 100,000 people, compared to 4.0 per 100,00 in England.
2. The leading cause of death in people 50 years old or younger in the US is accidental drug overdose.
These are unnecessary deaths. Drug addiction increases the risk of overdose death, but you can die from an overdose without having an addictive disorder or misusing substances. The risk increases if you take opioids with certain other medications (listed below), have a respiratory condition (pneumonia, COPD, asthma, obstructive sleep apnea), suffer from a serious medical illness, or are malnourished or debilitated.
3. The higher the opioid dose, the greater the risk of overdose and death.
Overdose risk is additive. At higher opioid doses it takes less of other risky substances such as alcohol or benzodiazepines (anxiety medicines like Xanax) to kill. The reverse is also true. Death can occur at lower doses of opioids if the amounts of alcohol or benzodiazepines or other risky drugs are higher.
4. Opioids interact dangerously with many other medications.
Sedatives (“sleeping pills”), anxiety medications (benzodiazepines), and other pain medications increase overdose risk by increasing the risk of respiratory depression, which is how people die by overdose—breathing stops. Muscle relaxers and other non-opioid pain medications (gabapentin, pregabalin, etc.) can increase the danger if combined with opioids. All of these medications are riskier if alcohol or illicit drugs are added to the mix.
5. Overdose risk increases significantly if opioid-containing medications are combined with alcohol and/or any drug of abuse, including marijuana, methamphetamine, and a host of newer synthetic opioids and/or street drugs (tianeptine, xylazine, kratom, and many others).
Illicit or “street” drugs are often “cut” with other substances to enhance the “high” and/or decrease dealer cost, so even occasional use is dangerous. Dealers have dealers up the chain so I am not reassured when a patient tells me that she isn’t in danger because she “knows and trusts” her drug man. The opioid crisis is entering its “fourth wave” with the current rise in fentanyl plus stimulant fatalities. The first wave in the early 2000’s was related to deaths from prescription opioids. The second began around 2010 and involved heroin. 2013 brought fentanyl overdoses–the third wave–followed by a sharp rise in polysubstance overdose deaths due to illicitly manufactured fentanyls.
6. One opioid prescription can end in a lifetime of addiction.
“Doc,” said the young man seeking treatment for his opioid use disorder, “I got my wisdom teeth out at 18, took my first oxy, and it was on.” Dentists are the most frequent prescribers of opioids to people 25 years of age and younger, a high-risk group for later misuse of substances. Another factor may be a genetic variation in 30% of people that causes them to experience opioids as stimulating. Does everyone who takes an opioid develop an addictive disorder? Of course not, but addiction is genetic and early exposure in a susceptible individual is a risk factor. And we’re talking about a potentially deadly medication for which there are less dangerous alternatives! Current recommendations are to prescribe opioids only if there’s no alternative and/or less dangerous options are tried first. If opioids are necessary, they should be prescribed at the lowest possible dose for the shortest possible time, with close monitoring throughout.
7. Opioids can make pain worse.
“Opioid induced hyperalgesia” is increased pain sensitivity caused by chronic exposure to opioids, which paradoxically worsen the pain they were prescribed to treat. The increased sensitivity to pain is not limited to the original area of pain. So, someone taking opioids for chronic back pain develops increasingly severe pain and feels the need for escalating doses. Every dose increase further increases the overdose risk. The only treatment is to stop the opioids and use nonopioid alternatives.
8. Pain is physical and perceptual, and the pain threshold depends on the individual, as does the amount of suffering a person in pain experiences.
Pain is complicated. It begins with a physical STIMULUS or injury that activates the brain’s perceptual RESPONSE, which determines how much focus goes toward attending to or ignoring the pain. People have different pain THRESHOLDS, the point at which a person experiences pain, and individual SUFFERING may or may not to correlate with the degree of physical damage.
9. Opioids do not fix suffering.
Many things affect both the pain threshold and how much suffering an individual experiences from pain. Depression, anxiety, anger, frustration, fear, anhedonia (loss of pleasure in things), feeling helpless or isolated, low activity levels, and addiction, especially to medications, all lower the pain threshold and increase suffering. Good general resilience in life has been found to increase pain tolerance and decrease individual suffering regardless of pain or circumstance.
10. Yes, it can happen to you.
Pain is not the “5th vital sign.” It’s not a vital sign at all. That was an advertising slogan invented to sell drugs. It worked, and it killed a lot of people. I can’t count the number of times I’ve received what I think of as “the horrible phone call,” telling me someone is dead from a drug overdose. In the first half of my 40 years taking care of people, I received exactly 0 of those phone calls. In the second half, it’s rare for a month to pass without one.
Good medical care is “evidence-based.” That means decisions and recommendations are based on good science and solid research. Safe prescribing of any medication is a clinical judgment based on education and science. A good doctor weighs potential benefits against all known risks before making recommendations. In the case of opioid-containing pain medications the evidence tells us that chronic pain and almost all acute pain can be treated at least as well or better—and much more safely—with non-opioid options.
