Jeremy Fejfar, PharmD
This article highlights common misconceptions related to opioids and looks at some of the alternatives available to help manage pain. It is important for providers and patients to work together to lower the number of opioids prescribed. The first step in doing so is understanding the problem and identifying possible solutions.
Addiction is not easily defined and has a negative image. Many people still view addiction as a character flaw. However, looking at how opioids effect the body can help patients understand why every opioid prescription is important. Opioids cause a number of physiologic changes including the development of tolerance and dependence.
Tolerance is what occurs when the previous dose no longer provides the same effect as it initially did, meaning more opioids are needed to achieve the same benefit as before. Dependence is associated with the negative symptoms which occur when opioids are eliminated from the body after regular use.
The absence of addictive behaviors does not indicate how opioids are impacting the body. It is important to consider the bigger picture. The safety concerns related to opioids go beyond addiction and illegal drug use.
It is a misconception that an individual is not at risk for overdose if they have been taking prescribed opioids for a long time and due to a legitimate need for pain control.
Patients with legal prescriptions for opioids can be at an increased risk for overdose without being at an increased risk for addiction. These risks increase with age, duration of opioids use and interactions with other medications. Drug interactions are especially risky with benzodiazepines such as alprazolam, lorazepam, etc.
Other conditions that increase risk of overdose are also often overlooked. These illnesses include respiratory conditions (COPD, asthma, sleep apnea, etc.), psychiatric conditions (including depression) and others.3 Helping patients understand why this matters for them individually can put these statistics into perspective.
Patients and prescribers alike are sometimes surprised at how quickly our bodies begin to adapt to opioids.4 The physical changes leading to tolerance and the speed it occurs varies from patient to patient.
The body begins to adapt to opioids with the first dose.4 Though it may take time for an individual to notice that tolerance has developed, tolerance increases with ongoing use. It is important for prescribers and patients to closely monitor opioid dispensing. Helping patients understand how to spot the signs of tolerance and dependence will help characterize the impact of opioid use.
Opioids may be the right choice in an acute setting, which is where the clinical judgement of a physician plays a crucial role. The most common reason patients go to the emergency department is pain.6
In a 2007 study of emergency department practices, 70 percent of subjects requested a pain medication and 86 percent of those received one.7
St. Joseph’s Health, Paterson, New Jersey launched a program to manage patients’ pain in the emergency department without utilizing opioids.8 The results from the Alternatives to Opiates Program (ALTO) have not been published, but St. Joseph’s is reporting a 50 percent decrease in opioid use while still providing adequate pain relief to 75 percent of patients.
The program defined alternatives based on the condition or nature of the pain. Some of the alternatives included some over-the-counter (OTC) medications. Other studies support that alternatives, such as ibuprofen plus acetaminophen (taken at the same time, not on an alternating schedule) and condition-targeted pharmacotherapies, may provide equivalent or better relief than opioids in the emergency department, although more study is needed.9, 10, 11
While opioids have a legitimate place in therapy with chronic cancer-related pain, end-of-life care, acute care and others, opioids are not recommended for long-term non-cancer related pain management.12 Guidelines recommend using non-opioid medications and alternative therapies to their fullest benefit before resorting to opioids for these patients with chronic pain. While the risk to patient safety is an important factor when considering opioid therapy, there are other reasons why opioids may not be the right choice for managing chronic pain.
Sufficient evidence that opioids are beneficial at managing pain long-term has not been established. In fact, one study demonstrated that some OTC drugs had a more significant impact on pain intensity after a year than opioids did.16 While more research is needed for alternatives to opioids in addressing chronic pain, tailoring treatment to a patient’s individual condition can help guide physicians to treatment options.17, 18
Opioids are often not the most powerful nor best option for managing pain. If possible, treatment should be targeted towards addressing the primary cause of pain. Studies have shown as many as one third of Americans are in acute or chronic pain at any given time.19 Unfortunately, finding and eliminating the cause of the pain is often a diagnostic challenge.
The prospect of stopping opioids can be frightening to patients who have experienced long-term opioid therapy. It is essential that providers and patients communicate clearly about discontinuing opioid therapy.20, 21
Patient concerns may include –
While more research is needed, studies support that reducing or discontinuing long-term opioids may improve patient pain intensity, quality of life and level of function. Good communication is an essential part of helping patients move off opioid therapy.20-23
Whether pain is acute or chronic, there are alternatives to opioids which can help to alleviate pain.8, 9, 17, 18, 23 Alternatives to opioids take many forms and go beyond prescription solutions.
Non-medication options include hot and cold therapies, physical therapy, massage therapy, acupuncture, strength training, transcutaneous electrical nerve stimulation (TENS), improving sleep hygiene, relaxation techniques or meditation and cognitive behavioral therapy, to name a few.23 Patients and providers can work together to find the most effective approach.
Some non-opioid medications include topical creams or patches, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), anticonvulsants, antidepressants and muscle relaxants.18 One mainstay in managing pain is NSAIDs, such as ibuprofen, which have shown to be effective in managing pain for a variety of conditions. NSAIDs, however, have a ceiling effect. After reaching a certain dose, the level of benefit no longer increases but the risk of side effects does.24 Anticonvulsants, such as gabapentin, pregabalin and topiramate, are beneficial for some nerve pains.23 Antidepressants, such as duloxetine, nortriptyline, fluoxetine and others, may have analgesic effects.18, 25