Gordon Irving, M.D., discusses the benefits and concerns of opiods as well as the laws surrounding opiod prescribing. To learn more about the Swedish Pain …
Hi, I’m Gordon Irving, Medical Director
of the Swedish Pain and Headache Center. Let’s
talk today about pain and narcotics – another
term for narcotics are the “opioids.”
You know, North America uses 80 percent of
the world’s medical opiods, or narcotics.
Does this mean we’re sicker? Does it mean
that we treat pain better than all the other
countries? Or has the prescribing of these
medications just gotten away from logic with
problems both for the patient and society?
There are good things to say about prescribing
opioids for chronic pain but there are also
concerns. In this talk, we’re going to look
at the role of the opioids in chronic pain
under three main headings: the good, the bad
and the law.
The good: We know that opioids do not damage
the kidneys, heart, liver or gut unlike the
anti-inflammatories, like Aleve and Advil.
Many medical societies, such as the American
Pain Society and the American Geriatrics Society
have all recommended opioids be part of the
treatment for chronic pain. In the late 80s
and 90s, many health-care practitioners felt
pressured by newspaper reports of inadequate
chronic pain treatment and by pharma companies
touting the efficiency and safety of their
own opioids.
The patients themselves, because of the web,
became more insistent on demanding better
pain relief. So opioids were prescribed in
ever-increasing numbers with decreased pain
and increased physical function experienced
by many. Various opioids were developed – some
older ones, such as morphine and codine, they
initially came from the poppy, and then newer
synthetic opioids like oxycodone, hydrocodone
and fentanyl.
We learned that there are numerous opioid
receptors in the body, and even more subtypes
of these receptors. And we’ve also learned
that people have unique populations of these
receptors, so if one type of opioid didn’t
help one person’s pain, another type might.
Opioids were made with different duration
of action – they could be short-acting for
breakthrough pain, they could be long-acting,
lasting all day. They could be taken under
the tongue, applied in the form of a patch.
So the health-care practitioner had a large
arsenal of different preparations. That was
the good. What about the bad?
Although we knew that opioids could be addictive
and cause side effects such as nausea, itching
and constipation, apart from the constipation,
side effects tend to be short-lived. Unfortunately,
as the number of people who are being placed
on high doses of long-term opioids has increased,
we’ve begun to recognize their effects on
other parts of the body.
We now know the effect of various hormone
productions primarily on the brain. So in
both males and females, testosterone production
is lowered. Apart from the loss of sexual
libido, it can adversely affect mood, bone
density, muscle mass. It may even worsen hardening
of the arteries. The production of the stress
hormone cortisol is also lowered, making response
to stress less effective. Opioids may also
lower the body’s immunity, increase sleep
disturbances, and can cause an increased sensitivity
to pain. This increased sensitivity, called
opioid-induced hyperalgesia, means that you
feel more pain because of the opioids so that
if you have an injury or surgery, you feel
pain much more acutely and for longer than
someone who’s not taking opioids. Worse,
increasing the opioids, taking extra to try
and stop the extra pain, does not help very
much.
Finally, we have statistics showing that as
the amount of opioids prescribed has increased,
so has diversion and deaths. In some areas,
highschoolers have said it’s easier to get
a hold of opioids, such as oxycodone, than
alcohol. This has led to the said fact that
there are more deaths involving opioids in
Washington State than death caused by motor
vehicle accidents.
That brings me to the third thing: the law.
In Washington State on January 2, 2012, an
opioid prescribing law, House bill 2876, came
into be. It was an attempt by the legislature
to try and rationalize the prescribing of
opioids. It specifically states, the law does
not stop health-care practitioners prescribing
opioids. But it does mandate that they keep
reasonable records of why they are prescribing
it, what they hope to achieve, and what are
the results of them prescribing these very
strong pain killers. And also, has the patient’s
function improved. Are other problems such
as depression, high anxiety being adequately
treated?
You can imagine there was a huge public outcry
about the government getting involved with
medical care, even though the law itself is
nearly encapsulating recommendations made
by most specialist societies involved with
pain around the world. The fact is, even now
the law has had one effect: opioid-related
deaths have decreased over 50 percent in certain
populations. So even at this early stage,
it appears that lives have been saved by this
law.
So, we’ve looked at the good, the bad and
the law. Are they still recommending opioids
for chronic pain? I personally feel they are
extremely useful in improving the quality
of life in some patients. But if you are taking
opioids for chronic pain, or if you know someone
close to you who is, you should ask a simple
question: what is it that you, or the other
person, is able to do physically when you
were put on the opioids that was not possible
before starting them? In many cases, when
patients take a hard look at their quality
of life and their physical functioning since
being on opioids, all other drugs may take
the edge off the pain, they have not been
very effective over the long term.

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