Abstract
I
For most of the 20th century, a common belief among the public, including physicians, is that an opioid like morphine, even if prescribed by a physician for a medical indication, causes addiction. The consequence was extraordinary and unnecessary suffering after surgical operations, trauma, and cancer. The worst thing I read was advice in the Journal of the American Medical Association in a paper written in the 1940s that, when a doctor prescribes morphine to a patient dying of cancer in the hospital, he should alternate “real” drug with placebo in order to see if the patient really needs the drug. Yikes!
When I was taught pain management starting in medical school in 1982 and finishing oncology fellowship in 1993, this phenomenon was explained in the following way. The notion that prescription opioids cause drug addiction comes from methodological flaws in studying addicts. It's a numerator and denominator issue. If you put the number of opioid addicts who were first introduced to opioids as prescription drugs before taking heroin in the numerator, and put all opioid addicts in the denominator you get a very large number. That large number (anywhere from 60% to 100% depending on the population studied) frightened everyone. But it's the wrong math.
If you put all people with pain who are treated with an opioid and become an addict in the numerator, and all people treated with pain and an opioid in the denominator, you come up with a very small number, somewhere between 0.01% and 4% depending on the kind of pain you are looking at. Patients with cancer pain are among the least likely to become addicted. Patients with low back pain with a pending labor law action are among the most likely to become addicted.
The 1990s and 2000s saw an increase in the willingness of physicians to prescribe opioids because of the correction of this fundamental misunderstanding. Although we learned that pain is complex, and multifactorial, and that opioids are good for some kinds of pain (e.g., cancer pain, postoperative and posttraumatic pain), there are other kinds of pain (e.g., muscle strain, low back pain without radiological abnormalities) where it doesn't work at all. But nuance doesn't make for good marketing, and opioids as all-around safe analgesics for everything that hurts made for promiscuous prescribing. The pendulum swung to the other end of its arc.
But now, a generation has passed. The newspapers are full of stories of the number of deaths from prescription opioids rising precipitously. It seems to me they are making the same mistake—looking at those abusing the drugs and falsely imputing causation: the drugs caused the addiction. The numerator and denominator are wrong again. The politicians are in a hurry to be seen to be “doing something” and new laws and restrictions on prescribing are multiplying. I see the chilling effect on all prescribers every day. The meta-message to physicians is clear—be very afraid if you prescribe any opioids to anybody or you will cause them to be an addict and die. Better to let the patient suffer than be suspected of causing a rise in the number of addicts and opioid-related deaths. The pendulum is hurtling back to the place it had in 1940.
Sigh.
From what I can tell, it is true that people are getting access to prescription opioids. Sometimes it is from opioids prescribed by a physician to the person abusing the drug. More often, the prescription drugs are diverted for that misuse. Frequently it's from taking pills from mother's or grandmother's prescription in the medicine chest in the bathroom. The data about the ability of opioids to cause addiction haven't changed. But that “old” news can't compete with the fire-breathing, vote-getting, be-seen-to-be-doing-something mentality of our political and regulatory folks.
Please be a voice to stop the pendulum from swinging. Where you can, reach out to stop the swing and bring it to rest where it is at rest. None of us want to see opioids abused or misused. Abuse deterrent formulations that permit opioids to retain their therapeutic effect when used appropriately are a nice advance, but at considerable cost. None of us want to see opioids prescribed for conditions where they won't make the patient function better. All of us want patients to have access to opioids for safe and effective analgesia when it is needed and in sufficient quantities to last through the expected duration of pain. Please be a leader in your local environment and speak up as a voice of reason when someone starts breathing fire about the evil opioids and the evil doctors who are maliciously ensnaring the unsuspecting. Let's not repeat history and fight the opium wars of the late 1800s again.