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Prescription painkillers: 5 surprising facts

Why you should be concerned about opioids—the most prescribed drugs in America

Published: January 2014

America is in the midst of an opioid epidemic. About 45 people a day, more than 16,600 people a year, die from overdoses of the drugs, including methadone, morphine, and oxycodone (OxyContin) and hydrocodone combined with acetaminophen (Lortab and Vicodin). And for every death, more than 30 others are admitted to the emergency room.

Why so many? Partly because more people than ever are taking opioids. Prescriptions for the drugs have climbed 300 percent in the last decade or so. In fact, Vicodin and other hydrocodone-combination painkillers are the most commonly prescribed drugs in the U.S.

In response, the Food and Drug Administration (FDA) recently proposed tighter controls on drugs that contain hydrocodone, including popular prescription cough and pain drugs. The new rules would mean less convenience for consumers: they would need to take written prescriptions to the pharmacy, rather than having their doctor phone them in, and they could not get refills without a new prescription. But those steps should help curb intentional abuse as well as encourage physicians to monitor long-term users more closely.

Still, it’s not enough to stop people from inadvertently misusing these drugs. While opioids are very effective at relieving some types of pain, many people wind up taking them in situations where they don’t work well and are not as safe. And even when an opioid painkiller makes sense, choosing the right form and understanding how to safely take it are key to avoiding serious side effects.

"Opioids can be very safe if used as prescribed, but they are powerful medications that need to be respected,” said Seddon Savage, M.D., associate professor of anesthesiology at Geisel School of Medicine at Dartmouth and Director of the Dartmouth Center on Addiction Recovery and Education in Hanover, N.H. “Taking someone else’s medication, combining them with the wrong thing, or just taking too much on a single occasion can be a fatal mistake.”

We reviewed the research and talked to the experts to identify five things you need to know if you are considering taking an opioid for pain.  

1. They don’t work well against long-term pain

Opioid drugs work very well to alleviate severe short-term pain due to, say, surgery or a broken bone. They can also help with pain associated with terminal or very serious illnesses, such as cancer. But for longer-term pain from, for example, arthritis, lower-back pain, or nerve pain, research suggests that other medications and even nondrug treatments often provide relief with less risk.

Still, an estimated 90 percent of people with chronic pain are prescribed opioids. Unfortunately, most probably don’t find much relief. For example, in a 2010 study of more than 1,000 people suffering chronic pain, mostly commonly leg and back pain, most of those taking opioids reported that they still suffered moderate-to-severe pain that interfered with their everyday activities.

Truth is, there’s limited evidence that opioids help or are safe when used long term. Most of the research involves lower-risk patients who used the drugs for just a few weeks. Very few studies have compared opioids to safer options for relieving pain, such as OTC drugs or even nondrug measures.

“What concerns me is that there is no clear evidence that people who take opioids over the long term can do more or get around more easily,” said Gary Franklin, M.D., research professor of environmental and occupational health sciences at University of Washington in Seattle. “But we do know that the higher the dose of the drug and the longer you take it, the greater your risk.”

Some people do find that high doses take the edge off their pain, but the nausea, constipation, and “fuzzy-headedness” that commonly result from taking strong doses of an opioid make it not worth the benefit.  On the other hand, people who start on lower doses often develop a “tolerance” to the drug, so it takes progressively larger doses to get the same relief. In an unfair twist, occasionally, the drugs can actually make people more sensitive to pain.

As if that’s not enough, long-term use of opioids can weaken your immune system and affect sex hormones—disrupting women’s menstrual cycles, causing men to have difficulty achieving an erection, and reducing sexual desire in both sexes.

“The old perception about opioids is that they are reasonably effective and safe for chronic pain,” Roger Chou, M.D., associate professor of medicine at Oregon Health and Science University in Portland, said. "But what we’ve come to realize is for many types of pain they don’t work all that well and are actually associated with significant harm.”

What to do: For some types of pain—in particular, nerve pain, migraines, and fibromyalgia—other prescription medications often work better than opioids. For other types of chronic pain, talk to your doctor about trying garden-variety pain relievers such as acetaminophen (Tylenol and generic), ibuprofen (Advil, Motrin IB, and generic), or naproxen (Aleve and generic) before resorting to the stronger stuff. Research suggests that people with mild-to-moderate chronic pain can also find significant relief through nondrug measures.

If you have severe, debilitating pain that hasn’t responded to other treatment, then opioids may be option. But your doctor should prescribe the lowest possible dose for the shortest possible time and monitor you regularly for side effects.

For more details on using opioids to treat chronic pain, see our Best Buy Drugs report.

2. Leftover pills from an old prescription could be dangerous

People who’ve built up a tolerance to opioids can often take higher doses without serious side effects. But when you stop taking the drug, you’re back to square one. So if you took higher dose pills in the past and now decide to pop one, say, for a pulled muscle or bad headache, you could accidentally overdose on your own prescription.

It’s also a bad idea to take someone else’s pills. Many people who die of overdoses were not taking a drug prescribed for them according to a 2012 report by the Centers for Disease Control and Prevention (CDC). “Our bodies metabolize opioids differently based on a variety of factors,” Savage said. “What constitutes a safe dose for one person could be deadly for someone else.” Generally speaking, the larger the dose, the greater the risk, but the CDC analysis found that low doses also sometimes cause emergency room admissions and deaths.

What to do: Never borrow someone else’s prescription pain pills and don’t hang on to leftover pills of your own (See the box for advice on the best way to get rid of unused pills.). If you resume taking opioids after a break, talk to your doctor about starting with a lower dose.

3. Your nightly glass of wine should be off-limits

Many people who take an opioid pain killer don’t give much thought to what they combine it with, especially if they’ve been taking the drugs for a long time. For example, about 12 percent of people reported consuming two or more alcoholic drinks within two hours of taking an opioid, according to a recent survey of people who regularly take the drugs for chronic pain. About one-third admitted to taking sedatives with an opioid. Most disturbing, about 3 percent of respondents combined the painkiller with alcohol and sedatives.

That’s a dangerous mistake. Opioids, alcohol, and medications such as sedatives all affect the central nervous system to make you fuzzy-headed, with slowed and depressed breathing. Combining them renders you much more impaired than if you just had a drink or taken a medication alone and can even be deadly. Most opioid deaths involve alcohol or other drugs, research shows.

"A high percentage of deaths from overdoses occur in patients who are also using alcohol or benzodiazapines," Chou said. While many people assume there's no harm in having a couple of glasses of wine or beer, Chou and our other experts advise against it. "It's not clear that there's a safe level to consume while you're taking an opioid," Chou said.

Among the most dangerous types of drugs to combine with an opioid are benzodiazapines, which are used as anticonvulsants, anti-anxiety medications, muscle relaxants, and sedatives—for example, alprazolam (Xanax and generic), clonazepam (Klonopin and generic), diazepam (Valium and generic), and lorazepam (Ativan and generic).

What to do: As long as you are taking prescription painkillers, consider yourself a teetotaler. And before taking an opioid, ask your doctor and pharmacist if it could interact with any other prescription or OTC drugs you take.

4. Extended-release versions are not as safe as you thought

Doctors can now prescribe extended-release or long-acting versions of several opioids, including hydromorphone (Exalgo), oxycodone (OxyContin, generic), morphine (Avinza and generic), or the newly approved hydrocodone (Zohydro ER). These stay in the body longer and are typically stronger than short-acting opioids. The drugs allow patients to take fewer pills and help prevent breakthrough pain because of a missed dose. Many doctors also believe that long-acting drugs are less likely to cause a drug “high” and, therefore, are less likely to lead to addiction.

But clinical trials suggest that short-acting versions work just as well, even for chronic pain. And there’s no good evidence that long-acting drugs are less addictive. Moreover, long-acting versions are more likely to cause potentially fatal overdoses, even at recommended doses.

So the FDA recently required new labeling indicating that the drugs should be reserved for patients needing strong, round-the-clock help, such as people battling pain from cancer or a terminal illness; for other patients, safer, less potentially addictive options should be considered first.

What to do: If you need an opioid, short-acting versions are typically your best bet. Stronger, long-acting opioids may be overkill and the convenience is not worth the increased risk. The long-acting versions are far more likely to be stolen, misused, and abused, so if your doctor does wind up prescribing them for you, he or she may take special precautions to monitor your use of the drugs, such as pill counts and urine tests.

Guide for safe use of opioid drugs


• Read the label and take the drug exactly as directed. Never take more than directed; don’t take it with alcohol; don’t combine it with any other drug without your doctor’s OK.


• Make sure your doctor knows if you have sleep apnea. (If you snore loudly, you should be checked for the condition.) Opioids can make it worse or even fatal.


• If you develop a cold, an asthma flare-up, bronchitis, or any other respiratory problem that makes breathing difficult while taking an opioid, let your doctor know as soon as possible. You may need a lower dose until you recover.


• Don’t drive or do anything where it’s important that you be fully alert until you know how an opioid will affect you. That’s especially important when you first start taking an opioid or whenever you change the type or dosage, Savage said. Drivers who had been prescribed an opioid drug were significantly more likely to wind up needing to be treating in the emergency room after an accident according to a recent Canadian study.


• Put opioids in a locked drawer or cabinet to prevent children from taking them or others from using them for recreational purposes. “People often think no one I know would take my medication, but you just cannot predict who might be looking for the drugs," Savage said. "It could be anyone—your teen’s friends, workers, a real estate agent. Lock them up. Don’t just hide them in your sock drawer.”


• If you are using opioids for chronic pain, talk to your doctor about how you will be monitored. “You doctor should assess you at regular visits. If pain and function do not improve at least 30 percent after starting the drugs, then they probably are not working well enough to justify the risks,” Franklin said. Also expect your doctor to do urine tests and take other steps to make sure that you are taking the drugs as prescribed.


• Discard unused pills. You can give them back to your pharmacy if it takes part in a take-back program. If not, the FDA recommends that you flush excess medication down the toilet. Read more about safe drug disposal.


5. Opioids can be addicting, even when used legitimately to combat pain

Some people become dependent on prescription pain pills and have trouble stopping them even if the drugs are hurting them physically or mentally. They often ratchet up their dose, taking more than the doctor prescribes. Over time, obtaining and taking the drugs may grow to dominate their lives.

Because traditionally painkiller addiction has affected fewer women than men, many doctors don’t consider women as vulnerable. But women may actually become dependent on prescription pain killers more quickly than men and are more likely to “doctor shop”—that is, get prescriptions from multiple providers.

Many doctors might also mistakenly think that people who are using the drug to treat pain—and not recreationally to induce a euphoric high—cannot become addicted to them, an idea that was bolstered by a few short, poor-quality studies. But in 2010, a longer-term study that used standardized criteria to assess dependence concluded that even those seeking pain relief risk addiction. Researchers from leading research institutions—the Geisinger Health System in Danville, Penn., Johns Hopkins Bloomberg School of Public Health in Baltimore; the Temple University School of Medicine in Philadelphia, and the Mount Sinai School of Medicine—found that of about 700 patients who consistently took opioids for a year or longer, more than one-quarter were dependent on the drugs. Factors that increase the risk of dependence include being younger, in poor health, or in severe pain, according to the study authors. In addition, the study supports other research showing that several mental-health factors increase the risk of addiction, including depression, anxiety, other psychiatric illnesses, a history of substance abuse (including alcoholism), and being a current or former smoker.

What to do: “Before you consider taking opioids for long-term pain, you should have a frank discussion with your doctor about your medical history,” Franklin said. “Having risk factors for addiction doesn’t mean that you can never take an opioid, but you and your doctor need to be especially cautious.” You may want to first try alternatives, including nondrug measures.

In a recent survey of physicians, most rated their knowledge about treatment of opioid dependence as only moderate. So if you are concerned that you may have become dependent, ask for a referral to a pain specialist who can help wean you off the drug and help you find other ways to help manage your pain.

Manage pain without drugs


Studies show that nondrug treatments, including exercise, lifestyle adjustments, behaviorial therapy, acupuncture, and massage—can significantly reduce pain and increase the ability to function. So much so that some people with mild and even moderate chronic pain manage well without taking any medications regularly.


Here are some options that can help, depending on your kind of pain.


▪ Back pain. Staying physically active often helps. Acupuncture, massage, physical therapy, and yoga, might work, too.


▪ Headaches. Cutting back on alcohol and avoiding foods that set off your headaches might help, as can controlling stress with meditation, relaxation therapy, or other means. Exercise can also help.


▪ Osteoarthritis. Low-impact exercise, such as walking, biking, and yoga, can ease pain and improve function. But it’s best to avoid high-impact activities, such as running or tennis, that might aggravate your symptoms.


▪ Fibromyalgia. Regular exercise can help reduce pain and fatigue. Other options to consider include cognitive behavioral therapy—a type of psycho-therapy—meditation, and tai chi, which is a form of exercise involving slow, gentle movements combined with deep breathing.


Editor's Note: This article and related materials are made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by the multi-state settlement of consumer-fraud claims regarding the marketing of the prescription drug Neurontin (gabapentin).
   

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