Opioids

Written by staff | 06 July 2011

Opioids are controversial narcotic drugs known for their powerful pain-relieving (analgesic) properties. The therapeutic benefits of opioids have been recognized for thousands of years, with the use of the opium poppy chronicled throughout human history.

In modern times, commonly used opioids include morphine, codeine, oxycodone, and hydrocodone. The controversy surrounding these prescription drugs involves their addictive potential, which makes them a widely abused and even dangerous substance. The controversy is compounded by the documented dangers of taking these drugs. Multiple adverse consequences are associated with opioid use, including hormonal and immune system complications, abuse, dependence, tolerance, and hyperalgesia, or increased perception of pain that may result from a lowered pain threshold¹.

According to the United States Food and Drug Administration (FDA), "Opioids are at the center of a major public health crisis of addiction, misuse, abuse, overdose and death. FDA is taking action to protect patients from serious harm due to these drugs. This action represents a careful balance between continued access to these necessary medications and stronger measures to reduce their risks." In fact, in April 2011, the White House unveiled a multi-agency plan aimed at reducing the “epidemic” of prescription drug abuse in the U.S.—including an FDA-backed education program focused on reducing the misuse and misprescribing of opioids.

The problem with opioid usage in the US is hard to overlook. Although Americans comprise only 4.6% of the world's population, they consume 80% of the global opioid supply, and 99% of the global hydrocodone supply. Further, the use of opioids for chronic noncancer pain increased 222% from 1992 to 2002².

With the increasing administration of opioids for therapeutic use, the supply and retail sales of opioids are mirrored by increasing abuse in patients receiving opioids³. This increase amounts to approximately 20% of Americans reporting use of prescription opioids for nonmedical use, and is associated with an annual cost of nearly half a trillion dollars arising from the medical, economic, social, and criminal effects of this abuse⁴. In fact, a recent study showed that patients who abuse opioids generate mean annual direct health care costs 8.7 times higher than nonabusers⁵. Opioid dependence has also increased significantly, leading to a burden on patients, employers, insurers, society, and the entire health care system⁶. As a result, the costs associated with opioid misuse are significant, and physicians, employers, and managed care organizations must be proactive in halting misuse to lessen the economic burden⁷.

Within the body, opioids work by binding to special receptors within the central and peripheral nervous systems and the gastrointestinal tract, where they block the perception of pain, decrease reaction to pain, and improve pain tolerance. In addition, certain opioids can be used to treat cough and diarrhea.

Although opioids produce beneficial effects in many patients, they elicit certain side effects. These may include sedation, respiratory depression, and constipation. Opioids may also produce euphoria, which motivates some people to use them recreationally. Unfortunately, tolerance and dependence can develop with prolonged opioid use, and abrupt discontinuation of opioids can cause an unpleasant withdrawal syndrome. Symptoms of opioid withdrawal may include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps, and involuntary leg movements.

An even graver consequence of opioid misuse and abuse is overdose, which can cause severe respiratory depression resulting in death. A National Center for Health Statistics (NCHS) report stated opioid analgesic-related deaths are among the fastest increasing drug poisoning deaths⁸. Other key findings included that the number of fatal poisonings involving opioid analgesics more than tripled from 4,000 to 13,800 deaths from 1999 through 2006, and opioid analgesics were involved in almost 40% of all poisoning deaths in 2006.

In spite of the risks of taking opioids, the properly managed, short-term medical use of these drugs is safe and rarely causes addiction⁹. However, due to the dangers involved, opioids are not typically prescribed unless the provider feels the potential benefits outweigh the risks. In general, such indications include relief of pain from acute (short-term) conditions, surgeries and certain procedures. Opioids are not usually indicated for the management of chronic pain conditions, except in cases of palliative care (e.g., terminal cancers, degenerative diseases). Common adverse reactions in patients taking opioids for pain relief include: nausea and vomiting, drowsiness, itching, dry mouth, miosis (constriction of the pupil of the eye to less than or equal to two millimeters), and constipation¹⁰.

Infrequent adverse reactions in patients taking opioids for pain relief include: dose-related respiratory depression (especially with more potent opioids), confusion, hallucinations, delirium, urticaria, hypothermia, bradycardia/tachycardia, orthostatic hypotension, dizziness, headache, urinary retention, ureteric or biliary spasm, muscle rigidity, myoclonus (with high doses), and flushing (due to histamine release, except fentanyl and remifentanil)¹¹.

Alternatives to Opioids

• Nonopioid medications
• Cognitive Behavioral Therapy
• Physical Therapy
• Implantable electrical pain-relieving devices
• Minimally invasive pain-relieving interventions
• Chiropractic
• Surgeries

Opioids have beneficial effects in appropriately chosen patients. However, the misuse, abuse and physical dependence surrounding these drugs is increasing, amounting to a growing problem with costly and disastrous consequences. Judicious prescription of these drugs is warranted, and alternative pain-relieving strategies should be explored for the safety and well-being of the patient, as well as the optimization of the health care system.

References

1. Manchikanti L, & Singh A. (2008). Therapeutic opioids: a ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician, 11(2 Suppl), S63-88.
2. Jan SA. (2010). Introduction: landscape of opioid dependence. J Manag Care Pharm., 16(1 Suppl B), S4-8.
3. Manchikanti L, & Singh A. (2008). Therapeutic opioids: a ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician, 11(2 Suppl), S63-88.
4. Ruetsch C. (2010). Empirical view of opioid dependence. J Manag Care Pharm., 16(1 Suppl B), S9-13.
5. Ruetsch C. (2010). Empirical view of opioid dependence. J Manag Care Pharm., 16(1 Suppl B), S9-13.
6. Jan SA. (2010). Introduction: landscape of opioid dependence. J Manag Care Pharm., 16(1 Suppl B), S4-8.
7. Ruetsch C. (2010). Empirical view of opioid dependence. J Manag Care Pharm., 16(1 Suppl B), S9-13.
8. Warner M, Chen LH, & Makuc DM. (2009). Increase in fatal poisonings involving opioid analgesics in the United States, 1999-2006. NCHS data brief, No. 22. Hyattsville, MD: National Center for Health Statistics.
9. National Institutes of Health (NIH), National Institute on Drug Abuse (NIDA). (2005). Research report series - prescription drugs: abuse and addiction.
10. Doyle D, Hanks G, & MacDonald N, eds. (2004). Oxford Textbook of Palliative Medicine, 3rd ed. New York: Oxford University Press, 2004).
11. Doyle D, Hanks G, & MacDonald N, eds. (2004). Oxford Textbook of Palliative Medicine, 3rd ed. New York: Oxford University Press, 2004).