If you tune into current events, at least prior to this pandemic, you’ve probably heard that there is an opioid epidemic in America. But if you haven’t been personally affected by this, you may not know much about it. In this article, we’ll go over some of the important details surrounding opioids, so you are better informed if/when confronted with the option to use opioids in the future.
What are opioids?
Opioids are a class of drugs naturally found in the opium poppy plant that work in the brain to produce a variety of effects, most notably pain relief. Opioids can be derived naturally from the poppy plant (e.g. morphine) or synthesized in a lab (e.g. fentanyl) (1). They can be illegal (e.g. heroin) or available by prescription (e.g. Vicodin, OxyContin, etc.)
Opioids travel through your blood stream, eventually entering your brain and attaching to receptors that trigger the release of endorphins, which result in decreasing your perception of pain and boosting feelings of pleasure (e.g. feeling relaxed, happy or “high”). When taken at higher doses, opioids can slow or even stop your breathing (2).
Opioids are prescribed to treat moderate to severe pain. Standard prescription guidelines (3) suggest prescribing no more than 3 days of short-acting opioids for surgery where rapid recovery is expected; no more than 7 days of short-acting opioids where medium term recovery is expected; and no more than 14 days of short-acting opioids where longer term recovery is expected. It’s recommended to use the lowest effective dose and transition to non-opioid pain relief methods as soon as possible. Data from the IMS Lifelink+ database (4) show that there is a substantial increase in the probability of long-term opioid use after as little as just 5 days.
Opioid Tolerance, Dependence & Addiction
When you take opioids and experience the flood of dopamine that leads to feelings of pleasure and a decrease in pain, the effects are short-lived and once they wear off, the brain is often eager to get those feelings back. With continued use of opioids, your body becomes less sensitive to the opioids and slows the production of dopamine. When this occurs, it means your body has developed a tolerance to the opioids and it takes a higher dose, or more frequent doses, to elicit the same level of good feelings and pain relief.
Continuing the use of opioids can lead to dependence. Dependence occurs when the brain adapts to the drug, and only functions normally in the presence of that drug. In this case, the opioids cause a physiological change in the brain. In the absence of the drug, you may experience several withdrawal symptoms ranging from mild to severe.
Drug addiction is a condition in which something that started as pleasurable begins to feel like something you cannot live without. It is characterized by an irresistible craving for a drug, out-of-control and compulsive use of the drug and continued use of the drug despite repeated, harmful consequences.
Overdose can occur at any of these stages, as all stages encourage continued use of opioids and an increase in the amount or frequency of the dosing. Opioid overdose kills by depressing your respiratory processes to the point that your body stops receiving the oxygen necessary to survive. On average, 130 Americans die every day from an opioid overdose.
How did we get to this point?
In the 1990s, pharmaceutical companies began to push their new synthetic and semi-synthetic opioids to doctors. The companies assured the doctors that opioids were non-addictive and did not have dangerous side effects. Doctors began to prescribe opioids to patients, based off these false assertions. For many of these patients, once their prescriptions ran out, they turned to illegal drugs, like heroin, which was often stronger and less expensive than prescription opioids. According to the National Institute of Drug Abuse, 80% of heroin users started with prescription opioids. The US problem emerged with the over-prescription of opioids and an increase in the availability and affordability of illegal opiates coming from abroad.
Since 1999, we have seen three waves of opioid overdose deaths (5). The first wave began in 1999 and consisted of the rise in prescription opioid overdose deaths, stemming from the push to prescribe opioids to address patient pain beginning in the 1990s. The second wave began in 2010 with the rapid increase in deaths from heroin overdose. And the third wave began in 2013 with a significant increase in overdose deaths from synthetic opioids, particularly fentanyl, which is 50 times more potent than heroin.
What Can We Do About It?
The dangers of opioids are now widely known. Guidelines have been created and doctors have become much more hesitant to prescribe opioids and are less likely to prescribe refills. And, just recently a pharmaceutical executive, John Kapoor, was sentence to 66 months in prison for his company’s role in the opioid epidemic. Kapoor and four other executives were found guilty of orchestrating a criminal conspiracy to bribe doctors to prescribe their company’s medication, even to patients who didn’t need it (6). Having well-informed doctors and holding pharmaceutical companies accountable for their role in public health will go a long way to decreasing the number of new users who become addicted via prescription opioids.
However, we each have to take ownership of our choices. Now that you know a little more about how opioids work and how dangerous they can be, you can make a better-informed decision about whether or not opioids may be appropriate and necessary in your case. Have an open discussion with your doctor about all your options to manage pain. And if you find opioids are necessary in your case, create a plan with your doctor to take the lowest possible effective dose for the shortest time necessary before transitioning to safer, less addictive pain management alternatives, such as prescription NSAIDS, acetaminophen, injections, acupuncture, chiropractic care, meditation, exercise, heating pads, etc.
Just remember, all medications have side effects. And if you’re not comfortable with your doctor’s recommendation, you can always seek a second or third opinion. It’s your body and you have to live with the consequences of your decision. It’s important that you make the right one for you.
(1) Krieger, Carrie Pharm.D. https://www.mayoclinic.org/diseases-conditions/prescription-drug-abuse/expert-answers/what-are-opioids/faq-20381270
(2) Johns Hopkins Medicine. What Are Opioids? https://www.hopkinsmedicine.org/opioids/what-are-opioids.html
(3) Dr. Robert Bree Collaborative. (2018). Prescribing Opioids for Postoperative Pain – Supplemental Guide. http://www.agencymeddirectors.wa.gov/Files/FinalSupBreeAMDGPostopPain091318wcover.pdf
(4) Shah, A, Hayes, C.J., Martin, B.C. (2017). Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use – United States, 2006-2015. MMWR Morbidity and Mortality Weekly Report. v66 (10): 265-269. DOI: https://www.cdc.gov/mmwr/volumes/66/wr/pdfs/mm6610a1.pdf
(5) Graph of 3 waves of Rise of Opioid Overdose Deaths: https://www.cdc.gov/drugoverdose/images/epidemic/3WavesOfTheRiseInOpioidOverdoseDeaths.png
(6) Emanuel, G. & Romo, V. (2020). NPR KQED. https://www.npr.org/2020/01/23/798973304/pharmaceutical-executive-john-kapoor-sentenced-to-66-months-in-prison-in-opioid