Imagine that I invented a medicine for a common, widespread chronic medical problem. I could mass produce and spread this imaginary pill to the entire American population as needed and the medicine was reasonably inexpensive and effective in the short term but it came with some major caveats.
The first caveat is that the medicine was only helpful and effective for short amounts of time. In fact if this medicine is used for longer than a few weeks based on the body’s adaption to the medicine it loses its effectiveness outright. This would lead to increased dosage requirements.
The Second caveat is that the medicine comes with a side effect of severely altering level of consciousness in users and also causes depression. The medicine leads to powerful sedation and has been shown to ultimately hinder people’s ability to function normally or do things like work jobs, care for children, drive vehicles or operate machinery.
The third caveat is that because the medicine causes a short lived sense of euphoria the medicine is highly addictive. In fact this medicine is actually one of the most addictive substances known to exist and has been known to ruin millions of lives.
A shocking fourth caveat is that in a substantial amount of patients who take this medicine continued use will actually make the underlying condition worse. Many users from taking this pill will become “super” sensitized to the medical condition by this medicine and will experience horrible symptoms which require even more potent and massive doses of the medicine and it’s side effects.
A fifth caveat is that the medicine can powerfully alter human respiratory physiology and routinely cause death in cases of overdose. In fact this imaginary medicine ends up being one of the leading causes of medically caused death worldwide.
A sixth caveat is that if patients take the medicine for a few weeks and then stop abruptly they will go through a several week period of physically and psychologically painful withdrawal.
Clearly I have invented a medicine that has a long and dangerous list of cons to accompany it’s usefulness in the short term. Further imagine that you are a patient being asked to take my medicine. Would you do it? What about if you were a policy maker for our government. Would you allow this medicine to be widely used? If you were a physician, would you routinely prescribe it?
The frightening reality is that my medicine and all these caveats is not at all an imaginary pill. It is indeed terrifying that the above scenario actually describes the single most widely used classes of drugs in our country at present time. The above “imaginary” medicine is opiate drugs. And the millions of Americans who suffer from chronic non cancer pain and take high doses of these medicines are living with the above caveats whether they realize it or not.
Opiate drugs are powerful pain medicines that have a well established role in the management of acute pain and trauma and in chronic cancer pain. However studies show that the outcomes of using opiates for chronic non cancer pain are not as good.
Despite their widespread use in this area many investigations have shown that these drugs do not have great long term efficacy. For example one large meta-analysis ( a type of study that pools that results of several smaller studies together) showed that the use of opiods in patients with chronic back pain, compared to placebo or non-opiod analgesia, did not result in significant long term improvement in pain scores or functioning.
The side effects and consequences are well established however. People who take high dose opiates for long periods of time have lower functioning and more disability than others. Because the body quickly adapts to opiates they gradually lose their therapeutic effect and require higher and higher doses to produce the same amount of pain control. This phenomenon is known as tolerance. With higher doses of opiates come more and more side effects, sedation and risks of addiction.
Another issue is that for reasons not entirely understood chronic high dose opiate use often makes the body much more sensitive to pain thereby ultimately worsening the underlying problem for which the drug was started. This leads to horrible discomfort and even sometimes can make normal sensations horribly painful a phenomenon known as allodynia. Imagine taking a treatment for a medical condition that may help in the short term but ultimately could make the underlying problem much worse is the long term. Who would make such a trade off?
Addiction remains a major problem for prescription opiods. Recent epidemiologic studies have shown that overdose with prescription opiods is now more common than overdose with street heroin. It is estimated that almost 5 million Americans engage in non medical use of prescription pain relievers each year. Opiate dependence can happen rather quickly and Withdrawal symptoms occurs after only 1-2 weeks of daily use and can take several weeks to stop.
Besides it’s negative impact on functioning and disability, another danger is that opiates are a powerful respiratory depressant and overdose of cause thousands and thousands of deaths every year.
Opiates are an important and needed component of managing acute pain and cancer pain. However on a population level opiates have grown from a way of alleviating pain and suffering in acute situations to a widely used panacea for all types of chronic discomfort, aches and pains. Prescriptions of opiates have increased exponentially over the past few decades. This happens in spite of medical evidence that these medicines may not be very effective for long term use and come with debilitating side effects, impairments to overall functioning, risks of overdose and addiction and the potential to actually make the underlying pain syndrome worse.
The imaginary drug I described painted a complicated scenario that happens in the real world routinely. When we use opiates to manage chronic non cancer pain we are making a dangerous trade. The benefit is short term comfort but the price is the above mentioned caveats and it is a large price to pay.
To me the bottom line is that the cons of using opiates for widespread management of chronic non cancer pain out weight the pros. Opiates may have a role in select cases of severe chronic, refractory non cancer pain (especially in people who have little hope of functioning normally anyways) but the pervasive way that they are currently being used is a dangerous and ineffective way to treat a challenging medical problem.
Who could feel comfortable knowing that such a medicine is the most widely used drug in America right now?
Widespread use of opiates has created nothing less than a public health emergency for our country. Millions are dying or being harmed every year because of the short sighted way that opiates are presently being used in the management of chronic non cancer pain. If a virus or bacteria came along that killed as many people every year as misuse of opiates did it would be in every newspaper and television show and would be considered one of the sentinel events in the history of the human race.
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