(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.)
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.
Scientists 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.
Patients 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: firstname.lastname@example.org.