In Defense of Opiates
As with all band wagons the opiate epidemic has poisoned public opinion about one of the most useful class of drugs ever discovered: opiates. When John's Hopkins Medical school opened the chief of medicine was Dr. William Osler would not allow any medications to be used in the hospital until they were approved by the pharmacy committee after considering all the scientific evidence of effectiveness, except one - morphine - which he called God's Own Medicine. Morphine was humane. It relieved the suffering of patients in pain no matter what the cause, treatable or not. And it and its cousins still have that ability today.
The increased deaths from opiates over the last two decades is a direct result of over prescribing by physicians and the policies of institutions that influenced this prescribing. Beginning in the early 90s hospitals and health care organizations, not physicians, began a program to ensure the humane relief of pain for all patients. Every patient who came into my emergency department was asked, before I saw them, if they were having pain and to rate their pain on a scale of 1-10 with ten being the worst pain imaginable. It was the expectation of the institution, including the nursing staff, that the patients would be rendered pain free. This attitude extended to the hospital, clinics, and private practices.
Opiates have only two significant side effects: constipation and addiction. Constipation is unavoidable. Addiction is entirely avoidable if the patient understands how to use opiates and uses them in conjunction with other medications and treatments. The advent of long acting opiates such as oxycontin unfortunately enhance the number of people who became addicted. These medications remain in the body and specifically in the opiate receptors for a long time, long enough for the body to get used to having them around so that the body begins to think that having opiate stimulation is normal. However, with proper monitoring and proper prescribing, opiates are a perfectly reasonable treatment for chronic pain that is not able to be treated in another way.
Let me give you an example from my own life. For almost thirty years I have taken small doses of opiates almost daily. This began when I developed an idiopathic peripheral neuropathy. My mother had the same issue. I got classic migraine headaches from her also. The pain and tingling in my feet and legs was okay during the day but when I went to bed and lay there quietly the sensation became so dominant I couldn't sleep. My physician tried three different anti-depressant type medication (some drugs in the tricyclic class can reduce neuropathic pain) without improvement. Finally, I tried one acetaminphen with codeine and slept like a baby. So, when I needed it, I took it an it worked great. This went on for years without an increase in meds.
Later in life I developed low back pain with no cause except my back was curved and wearing out. If I walked far enough it would get quite painful and sometimes, like when my wife and I hiked across England with another couple, after 6 or 7 miles my back would be very uncomfortable so I would take a 5mg of codeine. It helped and I went on. As an interesting aside, the world power lifting championship were held in Portland once and we saw some of the injured contestants. The most common injuries were ruptured tendons such as the tibial-patella tendons or biceps tendons. I talked to the a couple of these massive guys and learned that before a big lift they sometimes take an opiate, usually Percodan (oxycodone - short acting). They called this 'percing up' because the pain reduction allowed them to lift more, sort of like allowing me to go on hiking without suffering.
Eventually I ruptured a lumbar disc and afterwards developed increasing low back pain. I went to physical therapy which helped some. I couldn't take NSAIDs regularly because I was also on anti-coagulants. So I took one or two short acting opiates a day to make life easier. I could have suffered along without them but chose not to. Chronic pain makes life seem less good and makes my mood worse.
During treatment for my second lymphoma I received vincristine and my neuropathy got a lot worse, enough worse that they stopped the vincristine after three treatments. The neuropathic pain improved a little but remained far worse than it had been before the chemotherapy. We tried all kinds of medication to calm my feet and legs down but most were either ineffective, or, like duloxetine, worked but had side effects that just were intolerable and didn't go away after two years.
So now I take three or four hydrocodone 5mg tabs over a twenty-four hour period, usually one at bedtime along with a dose of gabapentin (another anti-neuropathic pain reducer) and one in the early hours of the morning when the first one has worn off. During the day, I take one or two for my back to keep doing all the stuff around the house that need to be done.
Recently I have added knee pain to my accumulation of parts that are wearing out. Even though it is a risk for me to take NSAIDs I have started doing that because it works so well for my knee.
Opiates have made it easier for me to live with some of the chronic problems that many people face. They have improved my mood. They have 'perked me up' to some extent to get projects done that would otherwise have caused enough discomfort I might have avoided doing them. Some people prefer to suffer but not me. I am not addicted but I am habituated, meaning that if I don't take 3-4 hydrocodone a day, I wouldn't sleep well, I would hurt more and I would do less.
The opiate epidemic was caused by a policy promoted by people who don't have the responsibility for dealing with individuals. No policy will get us out of the opiate epidemic unless it is a policy to stop telling physicians how to manage these patients and to allow the physicians enough time with each patient to uncover the causes of their pain, experiment with different remedies, and get to know the person within the patient. Cramming every patient into a 15 minute time slot and then asking the patient to fill out a 'patient satisfaction survey' has probably done more to promote opiate prescribing than any overt policy. Once again I am blaming the 'business of medicine' for a large part of this problem, as I blame it for many other problems in the modern patient-physician relationship.
My suggestions for the opiate epidemic is to stop prescribing long acting opiates except in patients with terminal conditions. Combine opiates with all the other pain relieving strategies: physical therapy, pain-modifying non-opiate drugs, acupuncture, and surgical intervention when clearly indicated.
While there were about 50,000 deaths from opiates in 2015 there were also about 15,000 deaths from gastrointestinal bleeding from non-steroidal anti-inflammatory drugs like ibuprofen and naproxen; not an insignificant number. NSAIDs are not benign and a dangerous alternative especially in older people. My feeling is that when used properly, opiates are safer and more side-effect free, than any of the alternative medications. Any policy that attempts to stop the use of opiates entirely is ill-informed, dangerous, and inhumane.
The increased deaths from opiates over the last two decades is a direct result of over prescribing by physicians and the policies of institutions that influenced this prescribing. Beginning in the early 90s hospitals and health care organizations, not physicians, began a program to ensure the humane relief of pain for all patients. Every patient who came into my emergency department was asked, before I saw them, if they were having pain and to rate their pain on a scale of 1-10 with ten being the worst pain imaginable. It was the expectation of the institution, including the nursing staff, that the patients would be rendered pain free. This attitude extended to the hospital, clinics, and private practices.
"Unrelieved pain is a major, yet avoidable, public health problem."Quotes like this from a nursing journal in 2000 reflected the sentiments and intention of policy makers for many health care organizations. Many physicians bought into this idea and the bandwagon for that era was to relieve the suffering of patients in pain. This was accomplished most easily with opiates. Subsequently other medications were added to the armamentarium such as steroid injections, anti-depressants, NSAIDs, and some seizure medications which were found effective for chronic pain. But, the most effective medication remained those of the opiate class.
Opiates have only two significant side effects: constipation and addiction. Constipation is unavoidable. Addiction is entirely avoidable if the patient understands how to use opiates and uses them in conjunction with other medications and treatments. The advent of long acting opiates such as oxycontin unfortunately enhance the number of people who became addicted. These medications remain in the body and specifically in the opiate receptors for a long time, long enough for the body to get used to having them around so that the body begins to think that having opiate stimulation is normal. However, with proper monitoring and proper prescribing, opiates are a perfectly reasonable treatment for chronic pain that is not able to be treated in another way.
Let me give you an example from my own life. For almost thirty years I have taken small doses of opiates almost daily. This began when I developed an idiopathic peripheral neuropathy. My mother had the same issue. I got classic migraine headaches from her also. The pain and tingling in my feet and legs was okay during the day but when I went to bed and lay there quietly the sensation became so dominant I couldn't sleep. My physician tried three different anti-depressant type medication (some drugs in the tricyclic class can reduce neuropathic pain) without improvement. Finally, I tried one acetaminphen with codeine and slept like a baby. So, when I needed it, I took it an it worked great. This went on for years without an increase in meds.
Later in life I developed low back pain with no cause except my back was curved and wearing out. If I walked far enough it would get quite painful and sometimes, like when my wife and I hiked across England with another couple, after 6 or 7 miles my back would be very uncomfortable so I would take a 5mg of codeine. It helped and I went on. As an interesting aside, the world power lifting championship were held in Portland once and we saw some of the injured contestants. The most common injuries were ruptured tendons such as the tibial-patella tendons or biceps tendons. I talked to the a couple of these massive guys and learned that before a big lift they sometimes take an opiate, usually Percodan (oxycodone - short acting). They called this 'percing up' because the pain reduction allowed them to lift more, sort of like allowing me to go on hiking without suffering.
Eventually I ruptured a lumbar disc and afterwards developed increasing low back pain. I went to physical therapy which helped some. I couldn't take NSAIDs regularly because I was also on anti-coagulants. So I took one or two short acting opiates a day to make life easier. I could have suffered along without them but chose not to. Chronic pain makes life seem less good and makes my mood worse.
During treatment for my second lymphoma I received vincristine and my neuropathy got a lot worse, enough worse that they stopped the vincristine after three treatments. The neuropathic pain improved a little but remained far worse than it had been before the chemotherapy. We tried all kinds of medication to calm my feet and legs down but most were either ineffective, or, like duloxetine, worked but had side effects that just were intolerable and didn't go away after two years.
So now I take three or four hydrocodone 5mg tabs over a twenty-four hour period, usually one at bedtime along with a dose of gabapentin (another anti-neuropathic pain reducer) and one in the early hours of the morning when the first one has worn off. During the day, I take one or two for my back to keep doing all the stuff around the house that need to be done.
Recently I have added knee pain to my accumulation of parts that are wearing out. Even though it is a risk for me to take NSAIDs I have started doing that because it works so well for my knee.
Opiates have made it easier for me to live with some of the chronic problems that many people face. They have improved my mood. They have 'perked me up' to some extent to get projects done that would otherwise have caused enough discomfort I might have avoided doing them. Some people prefer to suffer but not me. I am not addicted but I am habituated, meaning that if I don't take 3-4 hydrocodone a day, I wouldn't sleep well, I would hurt more and I would do less.
The opiate epidemic was caused by a policy promoted by people who don't have the responsibility for dealing with individuals. No policy will get us out of the opiate epidemic unless it is a policy to stop telling physicians how to manage these patients and to allow the physicians enough time with each patient to uncover the causes of their pain, experiment with different remedies, and get to know the person within the patient. Cramming every patient into a 15 minute time slot and then asking the patient to fill out a 'patient satisfaction survey' has probably done more to promote opiate prescribing than any overt policy. Once again I am blaming the 'business of medicine' for a large part of this problem, as I blame it for many other problems in the modern patient-physician relationship.
My suggestions for the opiate epidemic is to stop prescribing long acting opiates except in patients with terminal conditions. Combine opiates with all the other pain relieving strategies: physical therapy, pain-modifying non-opiate drugs, acupuncture, and surgical intervention when clearly indicated.
While there were about 50,000 deaths from opiates in 2015 there were also about 15,000 deaths from gastrointestinal bleeding from non-steroidal anti-inflammatory drugs like ibuprofen and naproxen; not an insignificant number. NSAIDs are not benign and a dangerous alternative especially in older people. My feeling is that when used properly, opiates are safer and more side-effect free, than any of the alternative medications. Any policy that attempts to stop the use of opiates entirely is ill-informed, dangerous, and inhumane.
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