Pain often accompanies the aging process, and medications containing opioids similar to morphine have brought enormous relief to millions over the past two decades.
But these drugs also have caused large numbers of unintentional and often fatal overdoses.
Doctors, with black humor, often refer to this problem as "waking up dead." A person taking OxyContin, for example, or Vicodin, or Percocet, takes the prescribed dose, but then takes a cough medication containing codeine, and goes out drinking, and then comes home and takes a sleeping pill. During sleep this combination depresses breathing until it stops altogether.
Sometimes the overdose results from the illegal use of pain medications, which have become the most popular illicit drug after marijuana. Many states including Florida, in an effort to curb abuse, have passed laws clamping down on the prescribing of these potent drugs.
But overdoses happen to people who have a legitimate prescription.
"The abuse of prescription drugs has increased dramatically, and is now viewed as an increasingly significant public health concern," says Dr. Russell Portenoy, a pain specialist at Beth Israel Medical Center in New York. "But there has also been an increase in unintentional overdose among those not abusing."
How did opioids become such a problem?
Opioids used to be reserved primarily for cancer pain, but starting about 25 years ago pain specialists, including Portenoy, advocated extending their use to the general population. In 1986, for example, Portenoy co-authored a study, published in the journal Pain, of 38 patients who took opioids without becoming addicted or dependent on the drugs. Drug companies quickly developed opioid compounds that were convenient to take, and marketed them aggressively.
Soon primary care physicians were prescribing these powerful drugs without sufficiently coaching patients about their dangers or monitoring their use. "There were not enough guidelines to alert physicians to problems related to chemical dependency and unintentional overdose," Portenoy says. "There was a lack of recognition of the risks, and as an educator in the 1990s I was part of the problem because I was teaching that abuse was a minor problem when you treat people with severe pain. I thought we needed to destigmatize these drugs and reassure doctors."
However, the most obvious reason for the rapid spread of these drugs, according to Portenoy, is that chronic pain is a widespread problem, and opioid drugs usually provide significant relief.
"With maybe 30 percent of Americans having chronic pain, these strong painkillers were taken up by doctors trying to do good for their patients," he says.
With few other options, physicians may prescribe opioids and increase the dose to maintain pain relief as the patient develops tolerance to the drug. While a beginning dose may be 30 or 40 milligrams, it is not unusual for a patient with chronic pain go work up to 100 milligrams or more per day, and above 100 milligrams the risk of accidental overdose becomes nine times greater, according to a study in the January 2010 issue of the Annals of Internal Medicine.
But people can take large doses of opioids over a long period — if they are carefully monitored, Portenoy says. One of his patients, for example, has been taking a daily dose of an opioid large enough to kill someone just starting on the drug, but because this patient built up tolerance gradually, he is able to work and function normally without the constipation, mental fogginess and other side effects associated with opioids. Plus his pain is well controlled.
So Portenoy opposes laws that specify the maximum permissible dose of an opioid. Rather, he advocates careful, customized management of chronic pain.
"Pain is so variable," he says. "If you give an opioid to an older person with osteoarthritis of the knees and shoulders, and you reduce the pain by 70 percent while preserving normal function — how can you do better than that? But if you have a person who has had multiple spinal surgeries, and suffers terrible back pain, and you give an opioid and the pain gets only 10 percent better, with little improvement in function, that is not a successful therapy."
Tom Valeo writes frequently about health matters. He can be reached at firstname.lastname@example.org.