published Thursday, June 18th, 2009

Cleaveland: Our secret drug problem

Overuse and inappropriate prescribing of narcotics (opioids) places millions of Americans at risk of addiction.

Classified as Category 2 medications by the Drug Enforcement Administration because of this risk, the group includes such well-known drugs as codeine, morphine, meperidine (Demerol) and newer agents such as Oxycodone (Oxycontin, Percocet), Hydrocodone (Vicodin), and Fentanyl (Duragesic).

Newer drugs are stronger and last longer. Fentanyl, for example, is 50 to 100 times more potent on a weight basis than morphine.

Used for acute, severe pain, these medications may offer immediate relief. In treating severe, chronic pain encountered in cancers and other conditions, the medications may add quality to lives otherwise wracked with terrible pain. Problems with addiction arise when opioids are used outside these settings.

Wide geographical variations are seen in the use of opioids for acute and chronic pain. One recent study looked at acute, work-related low-back pain. Twenty-one percent of patients received at least one opioid during the first 15 days of symptoms. Frequency of such prescriptions ranged from a low of 5.7 percent in Massachusetts to a high of 52.9 percent in South Carolina.

Tennessee has traditionally been a high-use state. Usage was lowest in states with pharmacy, cost-containment programs and highest in states with more physicians per capita and wider income gaps.

A 2007 study in the Annals of Internal Medicine evaluated opioid use in chronic back pain lasting longer than 16 weeks. The article reported that 19 percent of working adults suffered from chronic back pain. This detailed review concluded that opioids offered little or no benefit compared to placebo or non-opioid medication. No differences in effectiveness were noted among five different opiods.. The risk of lifelong dependence upon opioids ranged from 5 to 24 percent. A detailed analysis of opioid use in chronic back pain in the Cochrane Database similarly found "questionable" benefits.

Uncertain benefits in treating many conditions characterized by chronic pain must be weighed against risk of opioid addiction. Addiction describes a chronic, recurring or relapsing state characterized by compulsive drug-seeking and drug-taking. Opioids over time alter both the structure and function of the brain. The threshold for addiction is unpredictable and varies widely from one individual to another.

Studies funded by the National Institute of Drug Abuse (NIDA) show an increasing use of opioids for non-medical purposes by teenagers. Among 12th graders, almost 10 percent reported abuse of Vicodin and five percent reported non-medical use of Oxycontin. The initial dose was most frequently given at no cost by a friend or family member. Sometimes the source of opioid was the family medicine cabinet.

Prescription opioids can be valuable in short-term treatment of severe, acute pain such as experienced with kidney stones, herniated discs and broken bones. Unproved effectiveness and a substantial risk of addiction characterize the use of these agents in treating a variety of chronic pain situations. There is no justification for the casual use of opioids for non-medical conditions.

To reduce the risk for opiod addiction to ourselves and our family members, we should:

* Engage our caregivers in discussing risks and benefits whenever we are prescribed a medication for acute or chronic pain. If an opioid is advised, are there alternatives that might be used? Is physical therapy or alternative therapy such as acupuncture an alternative.

* If an opioid is prescribed for acute pain, we should request sufficient doses for only a few days, thereby avoiding risks associated with longer-term therapy.

* We should secure opiods or any potentially addictive medications in our homes medicine so that they will not fall into the hands of others, especially children.

* We must not casually give or receive opioids or experiment with their use.

* If family members are on athletic teams, we must make certain that trainers and team physicians do not dispense opioids for injuries. This is a matter for one's personal physician.

* We should support programs in our schools directed to preventing drug dependence and promote such teachings in our homes.

For their part, physicians must prescribe opioids wisely and only after considering other less risky therapies.

The NIDA Web site ( is a valuable source for further information.

Contact Clif Cleaveland at

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