Recently there has been a lot in the news about opioid addiction, abuse and its negative effects especially in the USA.

Opiates are a family of drugs that are naturally derived from opium from the poppy plant. Opioids are both the natural and synthetically produced drugs. They work by triggering the release of the body’s natural ‘feel-good’ neurotransmitters (chemicals in the brain) called endorphins. Endorphins act on receptors in the part of the brain that is responsible for pain and pleasure and results in reducing your perception of pain and boosts feelings of pleasure. However as the opioid dose wears off, people start to feel themselves wanting those feel good feelings back and this is the start of the road to addiction.

If opioids are prescribed appropriately and only for the very acute ‘short-term’ pain relief (for non-malignant pain) then not too many problems should arise. However, if opioids are taken repeatedly over time, the body slows its production of endorphins. The same dose of opioids stops triggering such a strong flood of good feelings and this is called ‘tolerance’. Essentially this means you need to take an increasing dose of opioids to get the same effect. One reason opioid addiction is so common is that people who develop tolerance may feel driven to increase their doses so they can keep getting the pain relief and importantly the good feelings.

So Why Are Opioids Prescribed For Long Term Pain???

The main reason is that, other than NSAIDs (which not everyone can take), there are not too many options for strong pain relief and people are prescribed them initially on a short-term basis but are re-prescribed them as they appear to help with their symptoms.

In 1981 and 1986 two American doctors, Kathleen Foley and Russell Portenoy,  published two highly influential articles in which they reported that “chronic pain patients who received opioids rarely became addicted”. Although their intentions were good this now known to be wrong; Foley and Portenoy had no long term data on opioid use and their study group consisted of only 38 patients. Unfortunately these reports resulted in opioids being regularly prescribed on a long term basis and has resulted in the USA being in the midst of an opioid crisis.

In the USA, between 1999 and 2014, drug overdose deaths nearly tripled and in 2016, more than 60,000 people died from drug overdoses, and opioids were responsible for most of these deaths. For the first time since 1999, life expectancy decreased for US citizens compared with citizens of other developed countries, and opioid overdoses were a factor.

In general opioids should carefully be prescribed for short-term pain – this does not refer to, or include, the control of malignant (cancer) pain.

The NICE (National Institute of Clinical Excellence) guidelines state that “a weak opioid, either alone or with paracetamol can be used to manage acute low back pain only if an NSAID is contra-indicated, not tolerated or ineffective.  In patients with chronic low back pain who have had an inadequate response to non-drug treatment, NSAIDs should be considered as first-line therapy. Opioids should be the last treatment option considered and should be considered only in patients for whom other therapies have failed and only if the potential benefits outweigh the risks for individual patients. If indicated, opioids should only be prescribed for a limited period of time. Long term opioid therapy should be avoided.”