Balancing the risks and benefits of opioids
A conversation with Seddon Savage
Since 1999, sales of prescription painkillers have risen more than 300 percent in the U.S., paralleling a similar increase in the abuse of painkillers. More Americans now die from overdoses of painkillers than from any other type of drug. Pain expert Seddon Savage has seen all sides of this issue, from the effectiveness of opioids in treating pain to the harm opioid abuse can cause. She spoke with Dartmouth Medicine editor Amos Esty about the benefits and risks of prescribing opioids. The conversation has been condensed and edited for publication.
DARTMOUTH MEDICINE: When are opioids called for?
Savage: Opioids are wonderful for the treatment of severe pain. However, we have to use them strategically, weighing their efficacy against a spectrum of risks.
Opioids have fallen in and out of favor over time, literally for five millennia. One generation of physicians has embraced their use. Then the next generation has avoided them due to observations of harm related to their use. In the 1950s, when I was a little girl, people didn't use opioids very aggressively. In fact, they tried to stay away from them. I remember the word cancer would cause a hush to fall over the room—not because of the potential for death so much as the potential for agonizing pain.
Then the hospice and palliative care movement began to treat people dying of cancer more aggressively with opioids. They showed that people could be more active and engaged with their families and have a good death. I don't think anybody disagrees now that opioids are indicated in people with terminal illness who are suffering from pain. Clearly they are also indicated when needed for moderate-to-severe acute pain, whether it's a fracture or a postoperative situation.
The indications for chronic pain are more controversial. Few people think opioids are first-line treatment for most people with non-terminal chronic pain. I think most thoughtful clinicians, researchers, and experts in the pain field would say that they're indicated if the benefit-risk profile is better than it is for other medications or treatments.
DM: What makes opioids addictive?
Savage: Opioids—like other drugs people use to get high—cause an increase of dopamine in brain reward centers, which causes a sense of pleasure. For a certain percentage of people who use drugs or alcohol, that euphoria can trigger neurobiological changes that result in a persistent craving.
- Director of the Dartmouth Center on Addiction Recovery and Education (DCARE)
- Adjunct Associate Professor of Anesthesiology at Geisel
- Medical Director, Chronic Pain and Recovery Program, Silver Hill Hospital
- Chair, N.H. Governor's Commission Task Force on Prescription Drug Abuse
- Columbia University College of Physicians and Surgeons (MS, 1976)
- Dartmouth Medical School (MD, 1980)
- Dartmouth-Hitchcock Medical Center (Residency in Anesthesiology, Fellowship in Pain Medicine)
DM: Why has the use of opioids increased so much in recent years?
Savage: There were a few developments, starting in the late 1980s, that contributed. First, physicians treating cancer pain noticed that some patients were able to continue to use opioids over the long term without developing either addiction or tolerance. In fact, some patients did very well. So physicians began trying opioids with other sources of chronic pain, such as severe arthritis or intractable back problems.
Second, sustained-release opioids came on the market. Everybody thought that was a boon for treatment, because patients wouldn't have to take short-acting opioids several times a day. They could take one in the morning and one at night and go on with their lives. It was also thought—ironically, in retrospect—that these drugs might help prevent addiction, because they don't cause peaks of euphoria. What people didn't anticipate was the fact that it's easy to take a tablet that has a lot of oxycodone in it, chew it or solubilize it and inject it, and use it to get high. So suddenly we had people who wanted to use these drugs recreationally finding that they could take one tiny pill and it was a huge amount of medication.
Third, pain treatment became a high priority. The Joint Commission named pain treatment a quality-of-care issue and started ranking hospitals on how well they did it. The VA adopted pain as the fifth vital sign. People began to expect aggressive pain treatment and doctors felt more responsible for making sure that their patients were comfortable.
Related to that, new products came out, such as stimulators and pumps, and everybody thought we could eradicate pain if we could just use technology and opioids aggressively enough.
DM: How can physicians balance adequate treatment of pain with avoiding addiction and abuse?
Savage: With chronic pain, as with other chronic diseases, it's important to get patients engaged in self-management. The foundational treatment, I think most chronic pain specialists would tell you, is engaging the patient in active self-care that can involve a variety of approaches. Cognitive behavioral therapy, exercise, and meditation have often been used successfully. Multiple studies have looked at the role of meditation in pain treatment and found that it can actually change the processing of pain in the brain.
You have to take the view that if we haven't yet found a surgery or an injection or a medication that can take all the pain away, we need to manage it in the meantime, just like we manage other chronic illnesses. Changing your expectations and acceptance is part of it—understanding that you can have a high quality of life despite coping with some level of pain.
DM: For doctors, if you have a few minutes with a patient, how do you get them to buy into this instead of asking for opioids?
Savage: That's another factor in the increased use of opioids: doctors got pressed to see more patients in less time, which meant they had less time to focus on the whole person. The diabetes community has addressed that problem by engaging nurses in helping to manage diabetes. But in pain treatment, we often continue to focus solely on finding a cure. I think it's important for physicians who treat patients with chronic pain to adapt their office systems to engage patients in a chronic disease management model. It's a challenge, but we do it for our other patients with chronic illnesses.
Everybody thought we could eradicate pain if we could just use technology and opioids aggressively enough.
DM: When doctors treat acute pain should they be prescribing fewer opioids at a time?
Savage: That's something that is being studied now. Ideally, yes. The culture in medicine has been to give patients ample medications. So a patient might get 20 to 50 Percocet after a surgery or injury and use just one or two. The rest sit on the shelf. We know that over 70 percent of nonmedical use of opioids—to get high, for example—is the result of obtaining drugs from people who have a legitimate prescription. That means that there are excess medications out there.
Nobody wants patients to suffer, so we tend to prescribe for the outliers. How can we create a system where you can give somebody just a few tablets, but if they're approaching their last tablet and the pain isn't getting better they can immediately get a renewal? That's a systems issue that we need to solve.
DM: How did you get interested in the policy side of this issue?
Savage: After years of treating people in pain, you see that you can only do so much clinically without beginning to shape the system. It's a very complex problem. We don't want to go back to the 1950s when people with cancer were afraid they were going to die in agony, yet prescription opioid misuse is causing suffering too. The science is still evolving around opioid best practices. It's slow, because we haven't used them consistently in the past. We are finally bringing together key interest groups, and we're starting to catch up.
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