Opioids – Threat or Menace?

Please forgive me for paraphrasing the title of an article about drug use published in the humor magazine the National Lampoon more than 30 years ago. I couldn’t resist the temptation.

Opioids are a class of drugs that are either derived from opium or synthesized to be chemically similar to it. These drugs range from codeine to heroin, tramadol to fentanyl. They are as famous for their analgesic qualities as for their addictive qualities. Used and abused for hundreds if not thousands of years they are a prime example of how drugs can be vilified or romanticized in literature and popular culture. Some view these drugs as the ultimate painkillers, others, as a scourge that can threaten the fabric of civilization.

There is some truth to both these views, but as a pain physician I am more interested in a rational perspective on their use. In this series I’ve argued that this is the only sensible way to regard drugs. Unfortunately, when it comes to opioid use, sensational often trumps sensible in the minds of many people, including doctors.

In my experience, many patients look at opioid analgesics as a kind of Holy Grail of pain relief. Many if not most chronic pain patients complain of not being given adequate access to potent painkillers and rightly so. However, many patients focus on drugs unrealistically to the exclusion of other, equally or more important ways to manage their pain. In my opinion, drugs are not the answer to chronic pain but simply another possible part of the answer. Their use carries specific, known risks.

Some pain simply fails to respond to opioids. In almost all of the patients who use opioids appropriately in my practice, some, but not complete relief is obtained and pain continues to interfere with their lives. Those I’ve seen using them inappropriately usually wind up with even worse lives. Quite a few don’t tolerate these drugs because of side effects that include respiratory depression, nausea, itching, sedation, urinary retention, constipation, headaches, dysphoria (the opposite of euphoria) and even increases in pain. Potential long term effects include addiction, impotence, memory loss and brain cell death.

There is another popular conception of opioids that contrasts dramatically with their undeserved status as being the ultimate in chronic pain control. Many see these drugs as highly addictive and inherently dangerous. Yet, evidence shows that the death rate from opioid use is roughly equal to or less than the death rate from gastrointestinal complications alone of non-steroidal anti-inflammatory drugs (NSAIDs). (see Canadian Medical Association Journal, American Journal of Gastroenterology and Pain Topics for detailed discussions).  Notably, NSAIDs also have potentially fatal complications occurring in other body systems that increase their overall death rate in relation to opioid death rate.

The medical literature indicates that some patients may benefit from opioid use. Official guidelines exist for opioid use, easily available to doctors and patients alike, to decrease the risk of addiction and other potential harmful effects. Opioids may alleviate the actual harm caused by pain. Allowing actual harm to continue for fear of the potential harm of a treatment represents ethical failure. Nevertheless, legitimate opioid users and prescribers face more suspicion than would seem warranted by the actual risks of appropriate use when compared to other drugs. Both opioids and NSAIDS are potentially beneficial in chronic pain. Opioids are often more effective for severe pain, have a lower death rate and are far more difficult obtain for many with chronic pain.

Please think of the above and learn the facts about risks and benefits of opioids before making a decision about them. It might help to look at drugs as tools. Tools can hurt you when you don’t use them properly but can help you do a job. But drugs are only one kind of tool. You need a whole toolbox and more to build a house.

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