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July 09, 2013 8:20 AM America’s Painkiller Problem

By Keith Humphreys

A number of commentators have unhelpfully framed debate about the astonishing rate of opioid prescriptions in the U.S. (more annual prescriptions than adults in the entire population at this point) as a “war” between those who care about preventing addiction/overdose and those care about reducing pain for patients in need. From this vantage point, any attempt to reduce or even question the number of opioid prescriptions is an attack on people in pain, another front in the heartless drug war, evil cops interfering with angelic docs etc.

This framing is medically and scientifically wrong, as New York Times reporter Barry Meier points out in this interview. Prescription opioid overdose and addiction are currently huge problems in the U.S., but even if they weren’t, the indiscriminate prescription of opioids would be dangerous to public health. Opioids typically have a miraculous effect on acute pain, but this does not necessarily translate into chronic pain relief, particularly as tolerance sets in over time. Even more disturbing, my colleague Dr. Jodie Trafton and I are among many researchers who have found that a portion of long-term opioid users became hyperalgesic, i.e., they experience more rather than less pain.

This is not the only line of scientific findings that flies in the face of the assumption that if opioids are used less often, more pain will be the inevitable result. In a study my colleagues and I conducted with surgery patients (first author Dr. Ian Carroll; publication here), the amount of time individuals stayed on opioids after surgery, surprisingly, bore no relationship to their level of pain. People stay on opioids for a range of reasons not necessarily linked to pain; in our study taking them for long periods was well-predicted by pre-existing depression, for example. Many people who are on these medications would be in better health and equal or less pain if they were weaned off them.

A further dangerous side-effect of long-term opioids is hormonal, as Meier explains:

These drugs have a very powerful impact on our production of sexual hormones — testosterone in men and estrogen in women. Lower hormone production is not just about growing hair or sexual performance; it’s about your entire energy level. These drugs are depleting people of energy. There are even data showing that the more powerful opioids, the long-acting OxyContin, methadone, fentanyl, which is sold as Duragesic, have an even more powerful effect on depressing hormone production than short-acting opioids.

What Meier is saying will come as a shock to those who foment over-simplified policy debate about opioids, but will not be surprising to pain medicine specialists. Although that field has a few extreme voices regarding opioids, for the most part pain management experts are already doing what the rest of the country needs to do: Trying to find the right balance between the benefits and costs of these drugs rather than declaring them horrible or flawless.

[Cross-posted at The Reality-based Community]

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Keith Humphreys is a professor of psychiatry and behavioral medicine at the Stanford University School of Medicine.
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