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THE M.D.

Opioid painkiller overload

Amid the weed scare there grows a thornier problem: the misuse of opioids. The pills may be prescribed, but the abuser's behavior isn't.

January 11, 2010|By Valerie Ulene
(Lawrence K. Ho / Los Angeles…)

The local popularity of medical marijuana aside, the prescription drug of choice these days seems to be the opioid painkiller. And small wonder.

The medications are highly effective in controlling pain -- whether from dental procedures, surgery, traumatic injuries or chronic conditions such as back pain and cancer. They're remarkably safe when used properly. And they produce a sense of well-being -- yes, a "high" -- that makes them irresistible to millions of Americans who take them for relaxation or recreation.

And therein lies the problem. The risks of addiction and accidental overdose are far greater when the drugs are abused this way. That's why the U.S. Food and Drug Administration last year ordered several manufacturers to develop plans to help curb inappropriate use.

Maybe those efforts will ultimately work. But it seems the request is a bit like asking automobile makers to stop people from speeding. The speeders need to take responsibility for their own actions.

Addiction, OD threat

Even among those at high risk, addiction to opioids doesn't occur overnight.

The drugs work by attaching to specific receptors in the brain and blocking the perception of pain; over time they can cause physical and chemical changes in the brain's pathways. Those changes can lead to compulsive drug use.

"Somewhere between 5 and 10% of people who take opioids regularly become addicted," says Dr. Nora Volkow, director of the National Institute on Drug Abuse at the National Institutes of Health. People with a personal or family history of drug or alcohol abuse are the most susceptible.

Then there's the risk of overdose. Taking too much of an opioid can cause breathing to slow and, in some cases, stop entirely. As abuse of these drugs has grown, so has the number of overdoses. The federal Centers for Disease Control and Prevention report that fatal poisonings involving these medications more than tripled from 1999 through 2006 -- from 4,000 to more than 13,500.

Even the threat of death doesn't seem to be stopping people from using these drugs inappropriately.

More than 5 million Americans currently use pain-relieving medications like Vicodin, OxyContin and Percocet for nonmedical reasons, according to the 2007 National Survey on Drug Use and Health, conducted by the Substance Abuse and Mental Health Services Administration.

The problem is particularly high widespread among adolescents. A survey performed by the National Institute on Drug Abuse in 2007 found that almost 1 in 10 high school students had used prescription pain relievers in the past year without a doctor's supervision.

Experts on drug abuse and addiction worry that people have come to overestimate the safety of prescription opioids. The drugs are fundamentally similar to heroin, but many people don't view them as such. "After all, they're FDA-approved, doctor prescribed and pharmacy dispensed," says Dr. H. Westley Clark, director of the Center for Substance Abuse Treatment, part of the Substance Abuse and Mental Health Services Administration.

The widespread availability of these medications likely contributes to abuse as well. Although drug dealers, shady Internet sites and disreputable doctors are often blamed for putting these drugs into people's hands, the source is typically much closer to home. Sharing (not to mention selling and stealing) prescription drugs has become commonplace.

The 2007 SAMHSA survey found that almost 56% of people who reported taking painkillers for nonmedical purposes obtained the drugs from a friend or family member, almost 9% bought them from a friend or relative, and roughly 5% took them from a friend or relative without asking.

It's difficult to decipher how these drugs are being prescribed and for whom. One thing, however, is abundantly clear. "We're prescribing much more than we were 15 years ago," Volkow says.

Hydrocodone -- one of the active ingredients in the drug Vicodin (the other one is acetaminophen) -- is currently the most widely sold medication in the country. More than 124 million prescriptions for hydrocodone were filled in 2008, according to a national audit conducted by IMS Health, a medical data provider.

Over-prescribed drug

Some prescriptions for opioids are unnecessary. Physicians often recommend opioids when an alternative analgesic (like a nonsteroidal anti-inflammatory medication such as ibuprofen) would suffice. Or they rely too heavily on the drugs to the exclusion of non-opioid medications and mind-body treatments to control pain.

Even when the use of opioids is justified, physicians frequently dispense more medicine than necessary. Because it's hard to anticipate exactly how many pills a patient will need, doctors often provide too many and then allow for unnecessary refills.

Drug manufacturers undoubtedly bear some level of responsibility to ensure their products' safety. But people who take these medications -- as well as the doctors who prescribe them -- also need to be held accountable for the drugs' misuse.

"The burden of responsibility must be spread around," Clark says.

Just weeks ago, the drug makers sat down with representatives of the FDA to lay out possible strategies for addressing the opioid issue. Most emphasized further education of patients and physicians about the inherent dangers and safe use of these drugs.

Education is rarely a bad idea, but I'm not convinced in this case that it will have the desired effect. Much time, energy and money could be spent restating what many people already know and, for a variety of reasons, choose to ignore.

An education campaign highlighting the risks of opioids could have negative repercussions for the "non-speeder" -- people who need these medications and who use them responsibly. Their pain may go under-treated as physicians become more hesitant to prescribe opioids and patients become more reluctant to use them.

Ulene is a board-certified specialist in preventive medicine practicing in Los Angeles. The M.D. appears once a month.

themd@att.net

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