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Drug takers beware ; New caution surfaces about opioid pain relievers

The pendulum is swinging back to more caution and restrictions on long-term use of powerful opioid pain relievers.

For years, there was great reluctance to use opioid pain relievers like morphine to treat pain unless it was for a very short period or the person had a terminal disease, usually cancer -- and even then there were misgivings. Both doctors and patients worried about addiction and side effects, especially the consequences these drugs sometimes have on mood and thinking. Laws and regulations made it difficult for doctors to prescribe opioids, which in a legal context are called narcotics. The legalities reinforced fears and negative connotations.

But starting about 1990, the qualms about opioids began to fade as the medical thinking about pain changed. Doctors began to see chronic pain as a condition that needed to be actively treated, not just tolerated or toughed out.

The shift in attitude occurred partly because of research documenting that, in addition to the suffering it causes, chronic pain leads to depression, sleep loss and immobility. Meanwhile, several studies downplayed the risk of opioid addiction. Drug makers developed longer-acting versions of the drugs that didn't need to be taken so often.

Adoption of the term opioids, instead of narcotics, helped make the drugs more acceptable. The opioid drugs became some of the most commonly prescribed drugs in the country.

>Overdoses are up

But now, attitudes are swinging back to wariness and concern about the harm these drugs can cause. Pain specialists and government officials are walking a fine line: they don't want to go back to the old days when pain was undertreated, but they're also seeking ways to reduce overuse and abuse of opioids.

The main reason for the change is the alarming increase in the number of Americans dying and getting sick from overdoses of prescription opioid medications. In 1999, about 4,000 Americans died from opioid "poisoning" -- a category that includes suicides as well as unintentional deaths from the drugs. By 2007, the opioid death toll had more than tripled: about 14,500 Americans died of opioid poisoning that year.

We tend to associate overdoses with illegal street drugs, but federal statistics show that prescription opioid drugs are now a factor -- people are often abusing other substances as well -- in more overdose deaths than either cocaine or heroin. In fact, in 2007, there were more opioid overdoses than heroin and cocaine overdoses combined. Trends in emergency department visits have followed a similar trajectory.

Opioids produce a euphoric feeling -- a high -- so people abuse them for nonmedical reasons. The pills can be crushed and altered so the drug can be snorted, smoked or injected for a quick high. A study of fatal overdoses in West Virginia showed that half of the people who died from opioid overdoses had never gotten a prescription from a doctor. But it's also common for people to abuse opioids after initially getting a prescription for pain that then led to dependence and addictive behaviors.

In some cases, people acquire the drugs from friends or family members who have surplus pills. They may also "doctor shop" to get multiple prescriptions from multiple doctors. Some doctors and clinics write prescriptions too freely; a few do so fraudulently. People also sell opioids illegally. Arrests for the illegal sale of prescription drugs, including opioids, have increased dramatically in recent years.

Not all overdoses are the result of illegal diversion. Results of a study published in the Annals of Internal Medicine of 10,000 people who were presumed to be taking long-term opioids legally over long periods showed that 51 experienced overdoses. Six people died. That works out to one overdose in every 200 cases, so overdoses aren't that common, but they add up given the large number of opioid prescriptions.

>Narcotics get name change

Any drug, natural or synthetic, with morphinelike properties is called an opioid. The terms narcotic and opioid are often used interchangeably, but narcotic has a legal and regulatory pedigree that opioid doesn't, so opioid has become the preferred term in medical circles.

The prototypical opioids are morphine and codeine (which is milder than morphine). Fentanyl (Duragesic), hydromorphone (Dilaudid), and meperidine (Demerol) have been available for years. Methadone, which is better known as a treatment for heroin addiction, is also prescribed for pain. The opioid drugs are also combined with other pain drugs into a single pill. Vicodin is the brand name for a combination of the opioid hydrocodone and acetaminophen. Percocet is oxycodone with acetaminophen, and Percodan is oxycodone with aspirin.

As opioids became more acceptable, drug makers reformulated some of them so they stay active longer. OxyContin, a sustained-release form of oxycodone, is the prime example.

>Other problems

Overdoses have gotten most of the attention, but there are other problems with using opioids on a long-term basis for chronic pain. Initially, most people experience great pain relief from opioids, but the drugs often become less effective over time. In fact, some evidence suggests that long-term use can affect the nervous system so people become more sensitive to painful stimuli.

Rotating different drugs may help maintain the effectiveness of opioids, but some people end up becoming dependent on them even after they have lost their power to control pain.

Nausea, constipation, dry mouth and sedation are common side effects associated with short-term use of opioids. They can be troublesome, but they can usually be tolerated or managed. But long-term use may cause a separate set of more serious side effects, including diabetes, suppression of the immune system and osteoporosis.

>Solutions

In 2007, the company that makes OxyContin, the sustained-release form of oxycodone, pleaded guilty to charges that it marketed the drug in ways that deliberately minimized its dangers. In addition, prominent pain specialists have complained that drug makers have had too much influence on educational programs about pain medicine for doctors. Reining in irresponsible marketing campaigns and taking steps to make educational programs more independent could help curb the overuse of opioids.

The U.S. Food and Drug Administration has proposed requiring drug makers to work with an independent organization to develop special prescriber training programs for long-acting opioids like OxyContin. But doctors who prescribe opioids won't be required to get the training, in contrast to an earlier proposal by a group of drug makers that would have made training mandatory.

Two professional groups, the American Pain Society and the American Academy of Pain Medicine, released new treatment guidelines in 2009 for chronic noncancer pain (treatment of pain from cancer is a separate specialty).

Here are a few of the recommendations in the guidelines that might help curb the use and abuse of opioids:

*Try other treatments first. Examples include anticonvulsants for trigeminal neuralgia, disease-modifying antirheumatic drugs for rheumatoid arthritis, and various abortive and prophylactic therapies for migraine headaches.

Some pain specialists say exercise and other nonpharmacological approaches to pain have been given short shrift because of the undue influence of drug makers on medical education.

*Assess the risk for abuse. Risk factors include a personal or family history of alcohol or drug abuse and some psychiatric conditions. Risk factors don't rule out an opioid prescription, but they should prompt caution and closer monitoring.

*Keep expectations realistic. Total pain relief with opioids is rare. Trials suggest that improvement on a 0-to-10 scale averages less than 2 to 3 points.

*Start with a short-term trial. The initial course of an opioid should be limited to several months at most.

*Weigh the potential harms and benefits. This has to be done on an individual basis. As the guidelines point out, the harm-benefit equation is pretty good for someone who is 60 with disabling arthritis who has tried lots of other pain medications and has no history of psychiatric problems or drug or alcohol abuse. It's not so good for a 30-year-old with fibromyalgia with a recent history of intravenous drug abuse and depression who has poor eating and exercise habits.

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