Opioids: A Double-Edged Sword

Opioids: A Double-Edged Sword

(Editor’s note:  Percy Menzies, M. Pharm, is president of the Assisted Recovery Centers of America, a treatment program based in St. Louis, Missouri that treats patients affected by drugs and alcohol.) 

Percy Menzies

Percy Menzies

Opium, the natural exudation of the opium poppy, has been used since time immemorial for the control of pain and other ailments.

There was intense curiosity to find the ‘gene’ in opium that dulled the pain and caused the dream-like feeling, which we now call euphoria. The active ingredient was isolated in 1805 and named morphine, after the Roman god of dreams – Morpheus.

Morphine was called a miracle drug, a “gift from God” that was effective, safe and could be used for just about any ailment — for patients ranging from newborns to the elderly. The indiscriminate use of morphine that followed was not then a cause for worry.

The invention of the hypodermic needle in the 1850’s made it easier to administer morphine directly into the blood stream and provide near-complete relief to wounded soldiers during the American Civil War. Many became dependent on morphine and the condition came to be known as the Soldiers Disease – the precursor to the term “addiction”. By the late 1800’s and early 1900’s, addiction to morphine was a major public health problem.

Attempts to make opioid drugs more potent succeeded and we now have dozens of drugs like oxycodone, hydrocodone, oxymorphone, hydromorphone, and buprenorphine; as well as entirely synthetic drugs like fentanyl and methadone, that have become mainstays for the treatment of pain.

bigstock-Prescription-Medication-1608757Scientists have been completely frustrated in delinking the potency from the addiction. Indeed, there is a strong direct relationship between potency and addiction. The stronger the drug, the stronger the potential for addiction. A weak analgesic like codeine has a low abuse potential, while fentanyl, a drug about 80 times stronger than morphine, has a very high abuse potential.

The dark and checkered history of opioid drugs led to clinical guidelines of using them only for acute pain, mostly for hospitalized patients and terminal cancer patients. Abuse and addiction became fairly limited.

These guidelines held until the 1990’s, when prescribing practices changed in two directions and converged into the devastating problem of abuse and addiction to opioid pain medications that continues today.

The first change was the introduction of sustained-release formulations that packed 2 to 20 times the normal dose of the opioid drug into a single pill.

The second was the movement to treat chronic pain more aggressively. Physicians were chided for ignoring pain and encouraged to “measure” pain as the fifth vital sign, along with temperature, blood pressure, pulse and respiration. If patients complained of ongoing or chronic pain, the physician was obligated to treat the pain effectively.

Physicians were also bombarded with aggressive promotion by drug companies, backed by clinical studies claiming that potent opioid drugs had little or no abuse potential when used to treat chronic pain. The diagnosis and treatment of chronic pain became a billable item and the sales of opioid pain medications grew at alarming rates. So did a new industry called “chronic pain” treatment. Physicians with little or no training in the treatment of chronic pain and even less knowledge on the pharmacology of opioids drugs got into the field.

Pain is one of the most mysterious and not very well understood functions of human existence. It is part of the drive states involved in survival. Opioid drugs work exceptionally well in the early phase of treatment, promoting recovery from surgery and injuries.

As the injury heals, the body requires less and less of the drug. If the pain continues, as in the case of cancer, the patient will require larger doses or a more potent opioid. If use of the opioid continues, the opioid receptors in the brain and the gut become less sensitive, often referred as down-regulation. This leads to tolerance, where the patient is forced to take a larger dose more frequently to get the same effect and/or switch to a more potent drug.

Pain doctors are then in a quandary. Is the continued pain due to the increased tolerance or increased pain? Doctors will often give in to pressure from patients to increase the dose, or switch to an even stronger drug, worsening the problem and leading to overprescribing and addiction.

Today over 36 million Americans use prescription drugs illegally. More people are dying from prescription drug overdoses than from automobile accidents or from cocaine and heroin overdoses.

This upheaval has created even more problems. Many physicians have no training on how to help patients get off the drugs. Some fled, leaving patients desperate to seek help elsewhere.  Some physicians switched to drugs like methadone, not knowing how potentially dangerous this drug is. Others terminated patients abruptly.

suboxone-2m-8mPatients addicted to opioids are referred to physicians who have completed the training and legal exemption from the DEA to use another opioid drug called buprenorphine, better known by the trade name Suboxone.

The majority of doctors prescribing buprenorphine are not aware of the addictive and abusable potential of the drug.  They have inadvertently created a new epidemic – no different from what we have seen with pain treatment.

The tragic and most overlooked consequence of this national problem is the tens of thousands of patients who do have legitimate chronic pain. People with clinically diagnosed chronic pain are likely to do well on opioid medications, especially if they are under the care of competent physicians. These patients rarely ignore dosing instructions, lose their pills, or doctor shop. Yet these patients find it increasingly difficult to locate the right doctor who will prescribe the appropriate opioid medications.  They have been swept away in the national attempt to curb the abuse of prescription pain medications.

It can get even worse if pain patients are injured or sick, and land in the emergency room or in a hospital, where they are often labeled as drug seekers. I have personally met patients who were not given pain medications because they were considered “addicts”.

The medical community, state and federal agencies, and lawmakers have to be made aware that in the rush to reduce deaths and drug overdoses, the rights of legitimate patients in chronic pain cannot be trampled on.

Pain patients should also know that 90% or more of the patients that come to my clinic for treatment first got hooked on prescription pain medication — and then switched to harder drugs. Patients who have used pain medications illegally are 19 times more likely to use heroin. Heroin has become a cheap and potent substitute for prescription pain medicine.

That is why opioids are such a double-edged sword.

Percy Menzies can be reached at: percymenzies@arcamidwest.com.

Authored by: Percy Menzies

There are 6 comments for this article
  1. david at 9:22 am

    Modern medicine born from the industrial era with its Mcdonaldized machine logic has fooled people in pain into believing that only medications are effective for pain-what kind of false consciousnes is that. What about PEMF, acupuncture, hypnosis, electrobloc, frequency specific microcurrent, ketogenic diet, nerve transfer, stem cell therapy, platelet rich plasma, progressive auto sanguis therapy, exercise, qigong, chiropractic. Oh those pharmacists it is in the darkness of their eyes that they are lost and fool others into thinking their limited knowledge and medications are all that there is for people in pain.

  2. Joy H Selak at 7:59 am

    Thank you for the paragraph on legitimate chronic pain patients who do not abuse their prescriptions. Much of what I read disregards this population.

  3. Saynono at 9:19 pm

    So how are patients with permanent pain supposed to be treated if all doctors care about is addiction. I have permanent nerve damage and my pain will never go away. I can’t live with out medication. How can you be addicted to a pain medicine when you are “addicted” to the pain that it is used to treat? I don’t get it.

  4. Colleen Sullivan at 2:29 pm

    For me pain medicine is a life saver. Not in a “life or death” way but in an “I’m actually able to live my life almost like a normal person” way. I am one of those people with legitimate pain. I am 29 years old and have had rheumatoid arthritis for 12 years now.
    Yes, there is addiction but isn’t there addiction with anything? For example, I take medication to sleep every night and because I’ve been on it so long, I’ve had to switch brands or up my dose. So does that mean I am an addict?

    Why aren’t people more concerned about other additive things that aren’t good for ANYONE like beer or cigarettes? At least pain medicine we know for a fact helps some people.

    For me, pain medicine is a necessity and I am physically dependent on it, yes. But the alternative is a life full of pain which in my opinion isn’t a life at all. I’ll take “addiction” over laying in my bed for the rest of my life. I just want a chance at a life like any other 29 year old girl.
    From the hundreds of hours of research I’ve done I haven’t been able to find any reason not to take it other than the possibility of “addiction”. And thanks to people like Dr. Drew and the mainstream media, addiction is now the #1 demon in the US(especially Florida where I live).
    I do appreciate some of your viewpoints and your willingness to stand up for people like me. Thank you. I just think people throw the word addiction around too much. It shouldn’t even be mentioned when speaking about people with life long ailments or cancer.

    I really think if there were two classes of people it would help clear all this up.
    -People like me with RA or cancer would be put in group A and given a card that states we have very serious, chronic conditions that are expected to last at least a year. And of course, it would have to be renewed periodically.
    -Group B would be people who injured their back, had dental work, or surgery. Things that are short term. They would be given a card as well.
    Then the pharmacists would know who to question and who to treat with respect and compassion. I’m just so sick of the dirty looks and whispered comments when I present my prescription. Frankly, it’s rude and inconsiderate when I think about what I already have to go through everyday and I hope someday soon we come to a solution.

  5. Ryan Lankford at 8:53 am

    I think the fact that he has a financial stake in a chain of rehabs calls his declaration of “epidemic!” into question. Pretending that addiction was kept under control by the Drug War until we stopped blowing off pain patients in the ’90’s is disingenuous at best.

  6. david at 6:10 am

    Mr Menzies- I think given the fact that you are a pharmacist the public should take your statements with a grain of salt. There is a lack of studies on the long term effectiveness of opioids for pain and in addition to addiction, there is the effect on the immune system, cardiovascular and endocrine system. A recent study pointed out the relation of opioids to neural tube problems. Most importantly, opioids dont cure any painful condition and foster an unhealthy dependence on suboptimal treatment. With NIH constantly bragging about the wonders of research for people in pain its sad to note that over the last 20 years there has been mostly reformulations of old medications for pain and the outlook is for the pharmaceutical industry to keep reformulating old suboptimal treatments for pain. Pharmaceutical companies arent on the right track to advance pain care-there focus seems to be profits and not the good of people in pain.