September 4, 2017
Last month, a White House panel declared the nation’s epidemic of opioid abuse and deaths “a national public health emergency,” a designation usually assigned to natural disasters.
A disaster is indeed what it is, with 142 Americans dying daily from drug overdoses, a fourfold increase since 1999, more than the number of people killed by gun homicides and vehicular crashes combined. A 2015 National Survey on Drug Use and Health estimated that 3.8 million Americans use opioids for nonmedical reasons every month.
Lest you think that people seeking chemically induced highs are solely responsible for the problem, physicians and dentists who prescribe opioids with relative abandon, and patients and pharmacists who fill those prescriptions, lend a big helping hand. The number of prescriptions for opioids jumped from 76 million in 1991 to 219 million two decades later. They are commonly handed to patients following all manner of surgery, whether they need them or not.
A new review of six studies by Dr. Mark C. Bicket and colleagues at Johns Hopkins University School of Medicine found that among 810 patients who underwent seven different kinds of operations, 42 percent to 71 percent failed to use the opioids they received, and 67 percent to 92 percent still had the unused drugs at home.
Two of the six studies examined how the drugs were stored, finding that 73 percent to 77 percent where not kept in locked containers. And all six studies revealed that patients had no plans for safely disposing of the pills they no longer needed.
To reduce diversion for nonmedical use, the authors called for better ways to limit the oversupply of opioids prescribed after surgery.
Aside from surgery, opioids are often — probably too often — prescribed for people with chronic pain. Although these potent drugs may offer temporary relief, “they tend to lose their effectiveness over time, and one pill today can become three later,” said Dr. James Campbell, a neurosurgeon who specializes in pain management.
“As with alcohol, opioids are not a problem for most people, but some people can fall into an abuse syndrome, especially when taken for chronic pain,” said Dr. Campbell, a professor emeritus of neurosurgery at Johns Hopkins Medical Institutions.
With 100 million Americans living with chronic pain, according to a 2011 report by the Institute of Medicine, there is a vast market available for people “legitimately” prescribed an opioid to become hooked on ever-larger doses of these drugs.
But while opioids are now prominent in the national cross hairs, they are only one of many drug-related problems associated with pain management. In fact, opioids aside, the vast majority of medical difficulties pain patients encounter result from the use and abuse of pain-reducing medications that are sold over the counter.
“We’ve seen in recent years that each class of drugs used to treat pain has its downsides as well as upsides,” Dr. Campbell said. “Patients – and doctors – need to be mindful of the risks, especially when drugs are taken long term and in large doses.”
Some people assume that if one pill is good, two must be better. And it’s not uncommon for older people, who may have an acute pain problem on top of chronic pain, say, from arthritis, to be taking more than one pain medication at a time.
Many people think pain medications like NSAIDs (nonsteroidal anti-inflammatory drugs like ibuprofen and naproxen) that they can buy without a prescription are safe. As George Gershwin wrote, “It ain’t necessarily so.”
A 2013 analysis of data from the National Ambulatory Medical Care Survey revealed that NSAIDs were used by 95 percent of the nearly seven million patients in the study who took at least one chronic pain medication. Athletes, from recreational to elite, also often take these drugs to counter muscle aches and joint pain.
“These are powerful medications for a whole variety of acute pain problems, and when taken for a few days or a week, they are very safe for most people,” Dr. Campbell said. “But for people with a history of coronary artery disease, even when taken short term, NSAIDs can precipitate clogging of the vessels.”
In addition to cardiovascular risks, NSAIDs can cause gastrointestinal problems, damaging the lining of the digestive tract, especially when they are not taken with food. Their most serious side effects include ulcers, bleeding, kidney failure and, in rare cases, liver failure.
“Because of possible adverse effects, the European Guidelines for the Management of Chronic Low Back Pain recommend using NSAIDs for up to three months, and the American College of Physicians and the American Pain Society guidelines on chronic back pain recommend the shortest duration possible,” a Dutch team reported in June in JAMA.
Older patients, who may have diminished liver and kidney function, are especially at risk of NSAID complications.
When treating localized pain, a topical NSAID, like a gel of diclofenac or ibuprofen, is a much safer alternative. Unfortunately, currently these are only available by prescription in the United States, making them far more costly than in other countries, where a tube can be purchased over-the-counter for about $10. (My advice: bring some back when traveling abroad, or ask someone to get it for you.)
Nor is acetaminophen (Tylenol and its generic imitators) always safe. It can damage the kidneys when used in large doses, as might happen when taken for chronic arthritic pain. Because acetaminophen (called paracetamol in Europe) is an ingredient in many over-the-counter drugs as well as some prescription medications, patients don’t always realize when they are taking a hazardous dose.
Last year the Food and Drug Administration required manufacturers to warn consumers that severe liver damage can occur at daily acetaminophen dosages above 4,000 milligrams in a 24-hour period. The agency previously told manufacturers to limit the amount of acetaminophen in prescribed combination drugs to 325 milligrams, and reminded health care professionals not to dispense medications that exceed this amount.
But problems of an acetaminophen excess can arise when patients take both prescribed and over-the-counter drugs containing acetaminophen, not realizing that the total dosage is dangerously high. That means patients should read the label on any drug they buy, and always tell their doctors truthfully what and how much of a drug they are taking that was prescribed by another doctor or purchased over-the-counter.