Don’t demonise prescription opioidsBMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4727 (Published 19 October 2017) Cite this as: BMJ 2017;359:j4727
I use an opioid drug, hydrocodone, every six hours, and have done so for about a decade. I have a lot of company. The latest research, a large government survey with over 50 000 respondents, shows that 92 million Americans used a prescription opioid in 2015, 38% of the adult population, few of whom were being treated for terminal cancer. A tiny proportion, just 0.8%, had a drug use disorder.1
The paper received scant attention because it did not fit the current framing of the US’s overdose epidemic as a “crisis,” with its hysteria redolent of “reefer madness.” It has been blown out of proportion by those promoting a war on drugs mentality.
I have chronic pain associated with knee replacement and spinal surgeries. Each incident was accompanied by nerve damage and, while the surgeries helped, there are limits to how much a damaged nerve will recover. As a result, I experience a variety of chronic aches, pains, numbness, and tingling from the waist down. It has affected my ability to walk and restricts the time I can spend on my feet.
A drug seldom works equally well with all patients. Pain drugs, like psychiatric drugs, are among those with the most idiosyncratic patient response. I was given gabapentin 10 years ago and it had little effect. A decade earlier percodan took away the pain but left me catatonic, which was fine immediately following surgery but not later on in recovery. I have been fortunate that, when dealing with chronic pain, hydrocodone works for me with few side effects.
I am as dependent on hydrocodone as I am on the drugs that help manage my blood pressure, or as a diabetic would be on insulin to regulate blood sugar. Hydrocodone has allowed me to remain productive
The fact that there is little long term data on the effectiveness of opioids at controlling pain does not concern me greatly. Nor has it concerned others to the point that they have procured funding to fully answer the question—it is simply an argument used to oppose the use of opioids. Mine is but one of tens of millions of anecdotes that the drug can be an effective treatment for some people. Given the limited arsenal of interventions to effectively treat pain, the expense of increasing our knowledge of long term opioid use by adding a P value is likely to have little effect on the practice of medicine. Most physicians will continue to evaluate the patient in front of them and their response to the chosen therapy.
The surge in opioid related deaths in the US is troubling. But it is important to remember that it is fuelled by street drugs and by fentanyl and its analogues, either alone or laced into a variety of illicit drugs.2 The argument that prescription opioid use leads to addiction is the old “gateway effect” that has been trotted out and debunked before—marijuana use leads to heroin use, a beer leads to chronic alcoholism. It is no more valid for prescription opioids than it was in those earlier examples.
There are serious methodological problems with the Centers for Disease Control and Prevention report on opioid deaths.3 It combined deaths from (illegal) heroin with deaths from (legal) prescription opioids. But its data clearly show that deaths from only prescription drugs have tailed off over the past few years. The increase in deaths is from heroin and street drugs laced with fentanyl.
Opioid policy has been driven by an attempt to control the supply—through legal prosecution of physicians running “pill mills”; by tightening prescribing criteria and the auditing of prescriptions; by limiting prescriptions to 30 days; and through the introduction of tamper resistant formulations that make misuse more difficult. All of these measures were put in place before the recent surge in opioid associated deaths. Little has been done to reduce demand by improving the availability and quality of addiction treatment.
People who have lost access to prescription opioids have turned to cheaper, more accessible, and more potent black market options,4 according to experts, and the death toll has soared. That pattern is the same one seen in alcohol prohibition in the US a century ago.
Our preoccupation with opioid misuse could become the tail wagging the dog. It will blind us to the good that these drugs can do, and may mean that more people will unnecessarily endure suffering that might otherwise be alleviated.
Yes, some people misuse prescription drugs, just as they would likely misuse another drug if opioids were not available. But fear of dependence will lead physicians to deprive responsible patients of access to opioids and drive them to seek relief through drugs on the streets, where unregulated products often contain fentanyl and the spectre of death.
Demonising prescription opioids can come to no good end.
Competing interests: None declared.