OPIOIDS

Opioid drugs are prescribed to relieve pain and cough, to treat diarrhea not caused by poisoning, and to cause drowsiness before an operation. These drugs, while undoubtedly effective, can be addictive and are associated with many adverse effects. In general, as with other drugs, their use should be limited to the lowest dose for the shortest period of time in those patients for whom an opioid is indicated. However, for patients with pain associated with a terminal illness, most notably the intractable pain of cancer, the risks with longer-term use become more acceptable. Indeed, there is much evidence that pain medications are woefully underused for such patients. There is simply no need for anyone to die in significant pain.

Unfortunately, there is increasing evidence of massive overprescribing of opioids for other types of medical problems that could more safely be dealt with using non-opioid drugs. Overprescribing can lead to drug-induced dependence (see Abuse and Misuse, below).

In response to this trend of overprescribing, Public Citizen has recently joined 36 prominent experts, including health commissioners and leaders in the fields of pain medicine, addiction and primary care, in petitioning the Food and Drug Administration (FDA) to change the government-approved labeling on all opioids for treatment of non-cancer pain. The requested changes include: striking the term “moderate” but retaining the use for severe pain, adding a suggested maximum dose equivalent to 100 milligrams of morphine and adding a suggested shorter duration of use.[1]

Pain relief is the primary legitimate use of opioids, which are effective for severe pain that has not responded to non-opioid painkillers such as aspirin and other salicylates, acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs).

Most of the time, when someone is able to swallow, they should first try a non-opioid drug, such as acetaminophen, aspirin, ibuprofen or naproxen, taken by mouth. If one of these drugs alone is not effective, it can be combined with an opiate, such as codeine. These two types of drugs work in different ways, and when used together, they generally relieve pain that would otherwise require a higher dose of opioid while causing fewer adverse effects.[2],[3] A sedative or antianxiety drug may be as effective as an opioid without causing vomiting like opioids can.

On the other hand, severe pain from late-stage cancer that has spread throughout the body is often undertreated. Because opioids are addictive and can cause a number of adverse effects, doctors may be reluctant to prescribe them. However, in an editorial in The New England Journal of Medicine, Dr. Marcia Angell wrote, “Pain is soul destroying. No patient should have to endure intense pain unnecessarily. The quality of mercy is essential to the practice of medicine; here, of all places, it should not be strained.”[4]

Wanted and unwanted effects of opioids

Opioids affect the central nervous system, producing pain relief and drowsiness. For patients in pain, these drugs can substantially alleviate suffering. Older adults may require less than the usual adult dose to produce the desired effects because of their bodies’ greater sensitivity to opioid drugs. Some of the adverse effects more frequently seen in older adults are slow or troubled breathing (opioids should never be given to anyone with depressed breathing), stimulation or confusion,[5] hallucinations, and unpleasant dreams (seen more in people using pentazocine).[6]

Other adverse effects are dizziness; feeling faint or lightheaded; nausea or vomiting (which might go away after lying down for a while); abdominal pain; constipation (more often with long-term use and with codeine); difficult or painful urination; headache; dry mouth; loss of appetite; red or flushed face (more often with meperidine or methadone); abnormal increase in sweating (more often with meperidine and methadone); and abnormal nervousness, restlessness, tiredness or weakness.

Opioids will add to the effects of alcohol and other drugs that slow down the nervous system: examples include antidepressants, antihistamines, antipsychotics, some blood pressure medications (reserpine, methyldopa, beta-blockers), motion sickness medications, muscle relaxants, sedatives, sleeping pills and tranquilizers. Combining one opioid with another also will increase the risk of adverse effects. Do not take any of these drugs or drink alcohol when you are taking an opioid, unless your doctor has told you otherwise.

One hazard of taking opioids continuously for longer than several weeks (long-term opioid therapy is considered to be daily doses for 90 days or more)[7] is drug-induced dependence. Most experts feel that although the risk of dependence is real, it is less common than many clinicians and patients believe. Nonetheless, you should not stop taking your opioid drug suddenly if you have been taking it for a prolonged period of time. With the help of your doctor, you should work out a schedule for slowly decreasing the amount of the drug you take by about 5 to 10 percent each day. Keep a written record of the dosage-reduction schedule with you. These steps will make it much easier to become drug-free without developing distressing symptoms of drug withdrawal. Common withdrawal symptoms include body aches, diarrhea, goose bumps, loss of appetite, nausea or vomiting, nervousness or restlessness, runny nose, shivering or trembling, sneezing, cramps, trouble sleeping, unexplained fever, abnormal increase in sweating or yawning, abnormal irritability, abnormally fast heartbeat and weakness.

Tolerance of opioids can also develop over time, which results in loss of effectiveness and the requirement of a higher dose to produce the same effects. However, neither dependence nor tolerance is a predictor of addiction, a behavior of complusive use.

Abuse and misuse of opioids drugs

According to the Centers for Disease Control and Prevention (CDC), there has been an "epidemic of prescription drug overdoses in the United States"[8],[9] with deaths from opioid drugs contributing in large part. The CDC emphasized that it is critical to "strike a balance between reducing misuse and abuse and safeguarding legitimate access." They pointed out that much of the large increase in overdoses could be traced to illegitimate pain clinics treating large volumes of patients without proper evaluation or follow-up. The CDC also noted that in one study, 3 percent of physicians were responsible for 62 percent of opioid prescribing, resulting in a large increase in overdose death rates.

Washington state is the first state trying to limit opioid doses prescribed for chronic pain by legislating a "morphine equivalent dose," or daily ceiling. Physicians are limited on the amount of opioid they can prescribe before patients must consult a pain specialist. Acute and cancer pain are not covered in this legislation, nor are those who are functioning well on a stable or tapering dose.[10]

Taking Opioids

Taking opioids by mouth is preferred and is usually effective unless pain is very severe.[11] These drugs can also be given by injections into the muscle or under the skin; intravenously into the bloodstream; alone or mixed with a solution; or into the spinal canal.

The table below lists several of the more common opioids. Higher doses of weaker opiates are as effective as lower doses of strong opioids. For example, 200 mg of codeine is as effective as 20-30 mg of hydrocodone. The occurrence of side effects with one opioid may be resolved by switching to another.

Morphine sulfate is available as extended-release tablets, which must be swallowed whole, but tablets of the other opioids can be crushed. Meperidine sulfate oral solution should be mixed with half a glass of water before consuming to decrease possible numbness of the mouth and throat.

If you are on a regular dosing schedule and you miss a dose, take it as soon as possible. But if it is almost time for the next dose, skip the missed dose and go back to the regular schedule. Do not take double doses. Drink plenty of liquids, as this may help decrease constipation. Call your doctor if you do not have a bowel movement for several days and feel uncomfortable. If you have diarrhea, do not take a drug to stop it. Instead, consult your doctor.

Examples of prescription opioid medications

Other ingredients may be present in these preparations. Only opioid ingredients are listed in the table.