June 29th, 2015

Chronic Non-Cancer Pain, Opioid Medication, And Addiction: How Dangerous?

Can opioid medications for chronic non-cancer pain cause addiction? This issue was on the minds of many people in the audience when I spoke recently to a group of clinicians and patients at the Pain Connection – an organization “dedicated to empowering people with chronic pain to improve their quality of life, decrease their sense of isolation and take a more active role in their treatment.”

It was difficult to provide a satisfactory response to their concerns. While the development of physical dependence is very likely, the frequency of actual opioid dependency is a matter of considerable controversy. Here’s how the pendulum of opinion about this issue has swung over time.

Opioid medication has always been seen as a “double-edged sword,” dating back to the admonition of Hippocrates in 400 B.C. to use them sparingly. Over the centuries, efforts to make these medications safer have been persistent, but reassurances have often proved to be empty. In 1898 the pharmaceutical company Bayer introduced what it thought would be a safer alternative to morphine for cough suppression, a non-prescription medication which they named “Heroin.”

Early in the 20th Century, opioid medications were unregulated, and their dangers were not fully appreciated. Resulting problems were sufficiently widespread, so laws were passed to severely restrict their use. One of the consequences was that physicians prescribed fewer of them and pain was undertreated. As recognition of this problem grew in the 1990s, corrective efforts were made, including introducing the idea of pain being “the 5th vital sign.” Many believe, however, that an over-correction occurred.

In 1996, Oxycontin was released and aggressively marketed as being safer than previous alternatives – a reassurance that proved to be false. At the same time, some prominent pain experts advised the use of opioid medication for the treatment of non-cancer chronic pain – again with reassurances that the development of addiction was negligible. The result was the “epidemic” of prescription pain pills that has received so much recent attention.

Readjustments are already underway. Congress gave the FDA expanded powers to address the problem. DEA’s focus on the prescribing of these medications has reduced their availability, leading to a shift to heroin use by some persons already addicted to the prescription opioids. The State of Maryland has imposed mandatory training in the prescribing of opioid medication and addiction as a requirement for physicians to maintain their license to practice.

For many years, the specialty fields of addiction and pain management were isolated from one another. Interactions, however, have fortunately begun to increase. One of the oldest of these occurs at the Annual Meeting of the American Society of Addiction Medicine. “Common Threads” is an all-day session devoted to presentations on this combination of problems that has now been occurring for 16 years.

I am hopeful that the increased interaction will lead to true collaboration between these areas of medical practice and we will come to a balanced sense of the benefits and dangers of these fundamental medications. Perhaps one day, pharmacological research will actually bring to us an opioid preparation which will actually provide the safer version that has been sought for so long.

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