Why opioids are not the best way to treat chronic pain

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In Brief

The Facts: One in five Canadians lives with chronic pain, according to a new report by the Canadian Pain Task Force. The pain is often moderate or severe in intensity and it disproportionately affects women, older people, veterans and Indigenous populations. In the past 20 years, chronic pain management has been a public health concern with significant increases in the use of opioids for pain relief. But there is indeed a corresponding growth in the number of opioids prescribed and the overdose from those drugs. For instance, the number of opioid deaths in Alberta has almost doubled in 3 years (with 135 overdoses in the first quarter of 2019, compared to 70 overdoses during the same period in 2016). 

The Takeaway: There's a pendulum that we need to strike in making opioids available for pain treatment while minimizing their risks. These days, doctors still do not realize that they are not always helping patients by offering an opioid. 

How to know if you’re suffering from chronic pain

Chronic pain is pain that persists for longer than three months and is associated with emotional distress (anxiety or depression, for instance). People may have chronic pain related to an underlying medical condition or after a car accident, for example. 

Their daily life is impacted since simple activities such as getting dressed, holding down a job or participating in hobbies can quickly become unbearable. 

Opioids can be very addictive.

Back in the day, doctors, such as Russell Portenoy at the Memorial Sloan Kettering Cancer Center in New York, painted the drugs as silver bullets against chronic pain. Initially, physicians were misinformed that addiction to these medications was highly unlikely in a clinical setting, causing a shift towards prescribing opioids as the drug class of choice to treat moderate to severe pain. One theory, promoted by Dr David Haddox, was that patients experiencing pain could not become addicted to opioids because the pain neutralised the euphoria caused by the narcotic. In 1993, Portenoy told the New York Times of “growing literature showing that these drugs can be used for a long time, with few side-effects, and that addiction and abuse are not a problem”.

Since then, times have changed, and the addictive properties of opioids and their lack of proven effectiveness for treating chronic pain is now increasingly recognized.

Consequently, some health care professionals are cutting off their opioid prescriptions, leading to new problems. Their patients are going into withdrawal, suffering in silence or going to emergency rooms, seeking illicit opioids on the street and dying and some are considering and have committed suicide. 

Opioids have serious side effects and risks.

The obsession with ensuring people were not in pain comes at the expense of ignoring the dangers of giving large amounts of opioids to people recovering from surgery or serious injury. The drugs may kill the pain but they also slowly kill the patient. Last year, more than 72,000 Americans died of drug overdoses, the vast majority from opioids such as tramadol, codeine, morphine and fentanyl.

In Canada, we have a big problem with opioid painkillers. It’s not as bad as in the US, where it is estimated that every 11 minutes somebody dies due to opioids, but it’s an issue nonetheless.

Today, we finally know that the serious and potentially fatal risks of opioids can outbalance their alleged benefits in many situations. It is estimated that for every 10 patients who are given opioids for chronic pain, only one will have any benefit from treatment. The other nine patients are taking a medication that is not only ineffective but may also cause a myriad of unwanted side-effects including nausea, constipation, lowered libido, falls and difficulties breathing – a bad situation is made a lot worse.

Opioids are not very effective.

Potentially addictive opioid painkillers are often prescribed for chronic pain, but they actually work only slightly better than placebo pills, a new study shows

Indeed, Jason Busse of McMaster University in Ontario and colleagues went through the known research on the effectiveness of opioids. The analysis, of 96 clinical trials, found that on average, opioids made only a small difference for people with conditions like osteoarthritis, fibromyalgia and sciatica.

“Compared with placebo, opioids were associated with small improvements in pain, physical functioning, and sleep quality; unimportant improvements in social functioning; and no improvements in emotional functioning or role functioning,” the report says.

The researchers said the findings add to evidence that for most people with chronic pain, opioids should be a last resort if they’re prescribed at all. In parallel, the Centers for Disease Control and Prevention has been trying to get doctors to prescribe opioids only when absolutely necessary, and to prescribe as low a dose as possible for the shortest time possible.

Norm Assiff

Norm Assiff

Norm was awarded the Alberta Civil Trial Lawyers Association (ACTLA) President's Award for 2012--awarded to a member of the Alberta bar who has distinguished himself or herself by his or her contribution to the profession or the community, the advancement of the law or their service to ACTLA. He has appeared at all levels of court in Alberta (Provincial Court, Queen's Bench and the Alberta Court of Appeal) as well as the Supreme Court of British Columbia and the Federal Court of Appeal.

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