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    The opioid pain reliever epidemic

    What ob/gyns need to know about the devastating man-made epidemic of overdose deaths from medically prescribed opioids.

    Every day in this country, at least 40 people die from an overdose of prescription opioid pain relievers (OPRs). This is almost half of the 90 Americans that die each day from all opioid overdoses, including deaths from heroin and increasingly other very potent synthetic opioids such as fentanyl and carfentanil, a statistic that continues to rise1. In 2015, the number of overdose deaths attributable to prescribed painkillers was over 15,000, a 3-fold rise since 2001.2 Even more unsettling, many of these deaths occur in people who receive their prescriptions from one doctor, meaning they were not doctor shopping to obtain the drugs, or taking or buying them from others.3

    These statistics likely understate this crisis due to under-reporting and difficulties such as lack of resources in certifying so many drug deaths. Statistics also do not take into account the contribution of OPRs to other injuries and deaths, such as from motor vehicle accidents. The development of very potent oral formulations increases the risk of sedation and respiratory depression, which may be heightened further by alcohol and some other medications such as diazepam.4 Overdose deaths in people with illnesses such as heart disease may not be investigated fully, with the cause of death deemed to be “natural causes.” I know of more than 1 patient who likely died in her sleep from inadvertently taking too many pills, but who did not undergo autopsy.

    The aim of this article is to educate ob/gyns about what not to do for acute and chronic pain, in the hope that increased awareness will help us prevent suffering and loss of life from OPRs. Misconceptions about opioids are still commonly held by clinicians, and interfere with proper prescribing and monitoring of opioid treatment. I highly recommend the enlightened review by Volkow and McLelland, Opioid Abuse in Chronic Pain —Misconceptions and Mitigation Strategies.1

    Table 1 lists generic and brand names of commonly used OPRs. Most people who have had surgery or dental extraction have been prescribed one of them. New formulations with different potencies and brand names continue to be developed and marketed.

    Historical perspective

    Chronic pain is a huge problem in the United States: 25.3 million adults report suffering from pain on a daily basis.5 Chronic pain patients are at high risk for OPR overdose death and adverse effects. Over the past 20 years, OPRs have been the main response of the medical system and the pharmaceutical industry (as well as the research it sponsors) to this very common problem of chronic pain. The steady increase in prescribing OPRs for chronic pain has paralleled the increase in the overdose death rate. In 2010, enough opioid painkillers were prescribed to medicate every American adult around-the-clock for a month; this was a 300% increase over the previous decade and 4 times the rate of OPR prescribing in Europe.4 Although OPRs are prescribed by us for a medical purpose, many patients purposefully or inadvertently misuse them, and some pills end up in the hands of people who abuse them; this may lead to progression to a chronic relapsing illness, which we now call opioid use disorder.6

    As a gynecologist focusing my practice on chronic pelvic pain, I became alarmed at seeing the rapidly rising use of OPRs in patients seeking my care as well as the increasing rate of overdose deaths in women.7 While more overdose deaths still occur in men, there has been a 400% increase in death rates for women since 1999, to almost 7000 currently, a number higher than female motor vehicle accident deaths. Because more women than men suffer from chronic pain, they are more likely to receive OPR prescriptions, and in higher doses and for longer periods of time; they also may become dependent on them more quickly than men.7 Women are more frequently prescribed benzodiazepines and antidepressants, medications frequently involved in OPR overdose deaths.4 In my practice, new patients sometimes came in already physiologically dependent on OPRs, and these medications were usually not providing any benefit to their pain or function. In some instances, the patients did not even realize that what they were taking were opioids that caused dependency. Two patients described emergency room visits for withdrawal symptoms that scared and puzzled them.

    Recommended: Ob/gyns voice their thoughts on medical marijuana

    Amazingly, pregnant women are also increasingly being prescribed OPRs for pain during pregnancy, resulting in the rate of newborns with withdrawal symptoms, called neonatal abstinence syndrome, rising three-fold between 2000 and 2009.7 From 2008 to 2012, 28% of women aged 15 to 44 on private insurance and 39% of women on Medicaid filled a prescription written by a health professional for an OPR.8

    Opioids for chronic pain

    Perhaps the risks of taking OPRs long-term, including death and the other serious adverse effects (AEs), would be worth it for some patients, if these medications actually helped chronic pain. Unfortunately, that is not the case. OPR use spread from the acute pain setting, to use in terminally ill and cancer patients, to use in chronic pain patients, without studies scientifically showing benefit. Clinically, I found this out the hard way, through experience, that OPRs really didn’t work well at all for my patients. Most reported back that their pain persisted, but they just didn’t care as much because their brains felt “out of touch with it.” I had a similar personal experience with Percocet for acute postoperative pain. It helped if I was just going to stay in bed, but not if I wanted to function and go on with my life. In 2014, a systematic analysis of 39 studies found no evidence of long-term benefit of OPRs for chronic pain, but did show an increased risk of serious harm.9 Why so many medical professionals continue to write these prescriptions for chronic pain, despite the evidence, is difficult to understand.

    In addition, recent studies are casting doubt on whether OPRs are any better than non-opioid medications for acute pain. In an emergency department setting in the Bronx, a randomized, controlled study showed that patients with acute back pain who were assigned to take an OPR did not have improved functional outcomes or reduced pain at 1-week follow-up compared to patients who were not treated with opioids.10 Much of what we have believed about the usefulness of these strong and dangerous medications is being called into question. An unanswered question I have is whether the use of OPRs for acute pain increases the risk of the pain becoming chronic, or is unrelieved pain a culprit in that process?

    Because most OPRs that are misused and abused originate directly or indirectly from prescription medication, and one in 20 Americans admits to non-medical use of OPRs, how did we medical professionals let this tragic epidemic come about? I think one reason is that we did not question the pharmaceutical industry’s marketing and involvement. After all, the 23.4 million American adults that report “a lot of daily pain” needed our help.5 We began to consider that pain needed to be treated at all costs, even deeming pain level to be a vital sign, like pulse and blood pressure. We got into the habit of prescribing a week’s supply of pills “for the patient’s convenience” even if the need was only for 2 days postoperatively; in effect this supplied family medicine cabinets with leftover OPRs that could easily fall into the hands of teens and adults likely to abuse them. Most of us have heard of tragic accidental OPR overdose deaths in young people who may dangerously combine them with alcohol.

    As products of our modern society, “magic pills” and quick fixes are very attractive to physicians and, also, desired by our patients. Many expect to be handed a prescription at every doctor’s visit. As we became “opioid-centric,” we neglected the importance of continuing to look for underlying root causes of pain in our chronic pain patients and forgot that our bodies have amazing self-healing abilities that can be enhanced by life-style changes and mind-body practices.

    NEXT: Long-term use and adverse effects

    Deborah Coady, MD, FACOG
    Dr Coady is Clinical Assistant Professor of Obstetrics and Gynecology at NYU Langone Medical Center, New York.

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