Arun George on Opioids

The United States has been undergoing an opioid epidemic which has been the main contributing factor for drug related overdose deaths. Both prescription and illicit opioids have contributed to 33,091 deaths in 2015. Compare this to the provisional data from CDC’s National Center for Health Statistics which indicate opioid overdose deaths have increased from an estimated 70,029 in 2020 to 80,816 in 2021. In Kansas state alone the predicted percentage increase in opioid related mortality is 20.3% from 2021 to 2022.^1,2,3 

Four out of five heroin users cite prescription opioid abuse as what led to their addiction.⁴ Opioid prescriptions drastically increased per capita by 7.3% from 2007 to 2012. In 2012 alone, 259 million prescriptions for opioid pain medications were written, enough for every adult in the United States to have a bottle of opioid medications.⁵

Many guidelines and recommendations have been published to try to address our country’s increasingly deadly opioid epidemic. This article focuses on facts for patients on the ill effects of chronic opioid use and alternatives available for pain management.

Adverse Effects Associated with Long-Term Opioid Use ^6,7,8

• Constipation
• Mental clouding
• Upper gastrointestinal symptoms (pyrosis, nausea, bloating)
• Endocrinopathy (hypogonadism/hyperprolactinemia)
• Fatigue
• Infertility
• Osteoporosis/osteopenia
• Reduced libido
• Reduced frequency/duration or absence of menses
• Neurotoxicity
• Myoclonus
• Other changes in mental status (including mood effects, memory problems, increased risk of falls in elderly patients)
• Risk of opioid-induced hyperalgesia 
• Sleep-disordered breathing
• Increased risk of concurrent benzodiazepine in patients predisposed to sleep apnea
• New-onset sleep apnea
• Worsening of sleep apnea syndromes

Alternatives to opioids:

1. Non opioid medications: 

• Acetaminophen: often recommended as the first choice to relieve short term pain
• NSAID’s: help relieve pain and reduce inflammation. Naproxen, Celexoib, piroxicam, indomethacin
• Amine Reuptake Inhibitors: Desipramine, Doxepin, Nortriptyline, Duloxetine, amitriptyline
• Membrane Stabilizers: mostly useful for nerve pain. Gabapentin, Pregabalin, Topiramate, Lamotrigine, Levetiracetam, Oxcarbazepine
• Muscle Relaxants: Methocarbamol, Carisoprodol, Cyclobenzaprine
• Mixed Amine Reuptake Inhibitor/Opioid: Tramadol, Tramadol/acetaminophen
• Topical Therapies: Capsaicin cream, Capsaicin Patch
• Botulinum Toxins
• NMDA antagonists: Memantine
• Opioid Antagonists: Low-Dose Naltrexone 
• Local Anesthetics: Topical Lidocaine patch, local anesthetic intramuscular injection, local anesthetic drops, sprays, creams, or injections
• Steroids
• Cannabinoids or Cannabis 
• Miscellaneous:  Bisphosphonates, calcitonin, IV immunoglobulin, IV magnesium, IV mannitol, tadalafil, TNF alpha inhibitors, ketamine.

2. Physical modalities: 

• Exercise,
• Physical therapy: heat/cold pack, hydrotherapy
• Massage
• Mind and body techniques, yoga, meditation
• Acupuncture
• Transcutaneous electric nerve stimulation (TENS): low voltage electric currents pass through the skin via electrodes prompting a pain-relieving response from the body
• Community and support groups

3. Psychological intervention: 

• Cognitive behavior modification: form of psychological therapy which can help the patient learn to change how they think, perceive, and react/behave to pain. 
• Stress management

4. Interventional therapies: 

• Pain management focused on injections. Like facet joint injections, epidural steroid injections, selective nerve root injections, sacroiliac joint steroid injections

5. Definitive/optimal medical or surgical treatment

*All pain medications should be taken with caution, and it is always ideal to discuss any medicine with your doctor or pharmacist.

Choosing the right pain medicine for you will depend on various factors:

There are various factors which need to be taken into consideration when deciding the right modality for pain management. These include but are not limited to:

• Pain location, intensity, and duration
• Factors increasing or decreasing the pain
• Associated medical conditions and medications 
• Impact of pain on the person’s life

Where you can get help:

• Doctor
• Psychologist
• Physiotherapist
• Occupational therapist
• Counsellor
• Pharmacist

References:

1. Barnett ML, Olenski AR, Jena AB. Opioid-prescribing patterns of emergency physicians and risk of long-term use. New England Journal of Medicine. 2017 Feb 16;376(7):663-73.
2. Franklin GM, Stover BD, Turner JA, Fulton-Kehoe D, Wickizer TM. Early opioid prescription and subsequent disability among workers with back injuries: the Disability Risk Identification Study Cohort. Spine. 2008 Jan 15;33(2):199-204.
3. Centers for Disease Control and Prevention. US overdose deaths in 2021 increased half as much as in 2020—But are still up 15%. Centers for Disease Control and Prevention. Retrieved July. 2022;22:2022.
4. Lembke A. Why doctors prescribe opioids to known opioid abusers. New England Journal of Medicine. 2012 Oct 25;367(17):1580-1.
5. Levy B, Paulozzi L, Mack KA, Jones CM. Trends in opioid analgesic–prescribing rates by specialty, US, 2007–2012. American journal of preventive medicine. 2015 Sep 1;49(3):409-13.
6. Paice JA, Portenoy R, Lacchetti C, Campbell T, Cheville A, Citron M, Constine LS, Cooper A, Glare P, Keefe F, Koyyalagunta L. Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology clinical practice guideline. Journal of Clinical Oncology. 2016 Sep 20;34(27):3325-45.
7. Correa D, Farney RJ, Chung F, Prasad A, Lam D, Wong J. Chronic opioid use and central sleep apnea: a review of the prevalence, mechanisms, and perioperative considerations. Anesthesia & Analgesia. 2015 Jun 1;120(6):1273-85.
8. Lee M, Silverman SM, Hansen H, Patel VB, Manchikanti L. A comprehensive review of opioid-induced hyperalgesia. Pain physician. 2011;14(2):145.