The Opioid Bank. It seems we are facing another global crisis!

Opioids. We all know what they are and that there are a lot of them going around, but it wasn’t until I was asked to write this blog on the information overloading review by Manchikanti and friends (2010) that I realised quite the extent. And to tell you the truth, it’s painfully scary!

In a nutshell, well over half of the review pumped out national statistics about the escalating use and abuse of psychotherapeutics (defined here as prescription-type pain relievers) in the United States.  Those statistics were often given in parallel to overall illicit drug use; which also includes marijuana, cocaine, heroin, hallucinogens and inhalants.  The authors then brought it back more specifically to the use of opioids in chronic non-cancer pain patients, where the evidence for its efficacy is limited. But the statistics they gave were alarming!

Did you know that Americans (4.6% of the world’s population) consume 80% of the global opioid supply, and 99% of the global hydrocodone supply? And it’s not all for medical use. In 2008, 15.2 million people aged 12 and over used psychotherapeutics for nonmedical use within the past year. That’s a 163% increase from ten years earlier.  What I found even more alarming, was that 55.9% of people aged 12 years or more, who used pain-relievers non-medically in the past month, reported they received the drug for FREE from a FRIEND or RELATIVE! And 18% reported that they got the drug from just ONE doctor! Further to this, in 2008, apparently the Drug Abuse Warning Network estimated that the non-medical use of prescription drugs were involved in 1 million emergency department visits. That’s the same number of visits as for illicit drugs. And over the past 40 years, the rates of unintentional drug overdose deaths have been rising steadily.

In regards to chronic pain, Manchikanti and friends discussed some fairly recent systematic reviews by Chou et al (2009 x4- there’s four of them) and Noble et al (2010). Apparently, Noble and friends reported some fairly weak evidence to suggest that patients (well selected with no history of substance abuse or addiction) could use opioids long-term and have clinically significant pain relief, with a small risk of developing addiction, abuse or serious effects. But they also reported that several patients discontinued the opioids due to adverse events or not getting sufficient pain relief. Quality of life and functional improvement were inconclusive. Chou and friends apparently came to similar conclusions in regards to opioids being an effective therapy for a carefully selected group of patients, but reported that it’s also associated with serious opioid related adverse effects or abuse.

My impressions from reading this review were that the evidence for opioid use in chronic pain patients is a bit wishy washy, but what does stand out, are the staggering statistics on the growing abundance of opioids, and their therapeutic use, abuse, and non-medical use.

On another note, and perhaps I woke up with a particularly critical eye this morning, but I was somewhat confused and then bemused whilst reading this article. For starters, there were a few discrepancies between the text and tables (which at the time confused the heebie-jeebies out of me), and then to find that 51/59 of the references (total of 301 references) that had Manchikanti (main author) as either a main or contributing author, were all published in the same journal that this review was published in! Apparently he is not an editor, but this last statistic is worth a raised eyebrow or two too…

About Sarah Wallwork

Sarah is a part-time physio and part-time research-assistant-soon-to-start-PhD with the BiM group in Adelaide. As suspected, her enquiring spirit has sent her back to the dark side, after finishing an Honours thesis in normative left/right neck rotation judgments in 2010. She absolutely loves anything outdoorsy, from rock climbing to kayaking, and cops a lot from her fellow BiMers about her outdoor gear and habits.

Reference

Manchikanti L, Fellows B, Ailinani H, & Pampati V (2010). Therapeutic use, abuse, and nonmedical use of opioids: a ten-year perspective. Pain physician, 13 (5), 401-35 PMID: 20859312

 

Comments

  1. This is admittedly a sensitive subject for me, but as someone who has been dealing with chronic pain for almost ten years now, I have been frustrated by the number of articles I’ve read recently suggesting that opioids are not helpful in the treatment of chronic non-cancer pain. The author writes that her “impressions… were that the evidence for opioid use in chronic pain patients is a bit wishy washy.” With all due respect, when I see someone make a statement like that, it indicates to me that that person has never experienced severe chronic pain herself. I do not take opioids on a regular basis, but when I have what I call a “flare-up” of back pain and am at the point where I cannot function in daily life, opioids have helped me like nothing else. I have never had the desire to take them when I am not in pain (i.e. recreationally). They also allow me to manage my pain safely without the risk of stomach bleeding that comes with NSAIDS (I suffer from chronic gastritis and cannot take more than a few doses of Advil before experiencing severe stomach pain). I firmly believe that there is a time and a place for these medications, and people who genuinely need them for pain management should not have their options closed off because of opioids’ increasingly negative reputation.

  2. An additional point I would like to make is in regards to the statistics about 4.6% of the world’s population (Americans) consuming 80% of the world’s opioid supply. The way these statistics are presented makes it appear that Americans must be doing something wrong, if people in other parts of the world do not need so many drugs. However, the other side of this statistical story is that there is a shortage of pain medications, including morphine, in many parts of the developing world. Because there is not an even playing field in terms of access to these medications, I find these statistics misleading. It makes little sense to compare Americans’ rates of opioid use to populations where these drugs are not readily available. I am sure that if there were universal access to opioid medications, the percentage of these drugs used by Americans would be much smaller.

    Sarah Reply:

    Hi Tina, thank you for your comments. I would agree with both you and soula (below) that there absolutely is a time and a place for opioids. This article reports that opioids can give clinically significant pain relief for people with chronic pain, but also, that this isn’t always the case. So when I say that the evidence is ‘wishy washy’ I’m saying that it is inconclusive because it seems to work for some but not for all.

    In regards to Americans consuming 80% of the world’s opioid supply, this is a staggering statistic! I’m not sure of the reasons why this statistic is so high, but I don’t necessarily think that it’s because people in other parts of the world don’t need them. In some countries (including Europe) these drugs are definitely accessible, but perhaps not as readily prescribed. I think one of the major issues that this article is addressing is the abuse of these drugs for non-medical use, and how readily accessible some of these drugs have become.

  3. Good and interesting catch re authorship and journal of publication of the references. I’ve seen the same sort of thing happening in other fields as well. And I’m not implying that this is the case here, or is always the case, but the quality and validity of the science may suffer as a result. There seems to be such a plethora of journals and studies out there that you can almost pick and choose what you want to prove your point. Only those that really have a solid sense of the other literature out there are going to have the insight to put it in perspective. And the more specialized different fields become the more this seems to happen.

  4. i have to agree with the ‘wishy washy’ description but i also agree with you tina, there is a time and place, everyone just needs to keep a grip about it all (which sounds like you have). i’ve had chronic pain for 5.5 years and i got sick of the attempts from most practitioners who seemed to want to brush the pain under the carpet, prescribing the drugs in hope it’ll all go away, typical of western medicine. i tried the opiods and for months i was an alien version of myself (struggling to simply cross the road, spell, unable to speak etc etc). as it turns out, i persisted in seeking a diagnosis, there was indeed something to be diagnosed, and there was simpler treatment. today (and for a couple of months now) with a nerve block I did team up endep, BUT a half 10mg tablet one day and 3/4 of a tablet the next, and i’m doing very well, in fact making progress as i’m not flattened from ridiculous doses.
    i feel too many practitioners reach for meds way too easily. i found almost everyone, when it comes to back pain, gives up and says ‘quality of life for you’. for me, this is poor and a lazy excuse.
    and no, i won’t be on endep all my life, it’s serving a purpose now, it’s getting me through the next step. i won’t accept i need it for the rest of my life, i will be reducing even these teeny doses to nothing asap.
    basically what i think, is we just need to be aware and realistic about how we use the opiods and PLEASE, easy with the kids!

  5. Hi Sarah,
    I think you would be very interested in the films produced by your fellow Australian Mike Hill and his associates. Mike has produced an incredible series of short films about the shortage of morphine in resource poor countries, international communities, the painful dying, and the need to address this as an urgent issue. In many countries morphine is the ONLY opioid that people can access, and in too many countries, they are not even able to access Morphine. (See their website http://www.lifebeforedeath.com)
    I appreciate your willingness to explore this topic. But as a hospice palliatiave care nurse, and as a thanatologist, I am not sure your comments about opioids not helping people with chronic pain are helpful. Perpetuating negativity about opioids, and perpetuating myths about their use or abuse, makes it even more difficult for people to take the medication when it is needed and when it would be helpful.

    I do appreciate your love of the outdoorsy stuff,… I share that love. I wish we lived in the same town and could go for a great hike to discuss this in more detail.

  6. Matthew Lloyd says:

    Hi Sarah,

    Great post, this has reinforced my previous perception that opiods are generally a poor pharmacological choice for the long-term treatment of chronic pain. Not without their uses in specific and controlled situations such as Tina’s flare-up, of course. I am curious, are their drugs out there that have better evidentiary support for the long-term management of chronic pain? I am unsure what the best-evidence guidlines are, let’s say for either chronic non-specific lower back pain or CRPS 1 or 2, if that helps. Your input is appreciated,

    Matt

  7. “In regards to chronic pain, Manchikanti and friends discussed some fairly recent systematic reviews by Chou et al (2009 x4- there’s four of them) and Noble et al (2010). Apparently, Noble and friends reported some fairly weak evidence to suggest that patients could use opioids long-term and have clinically significant pain relief, with a small risk of developing addiction, abuse or serious effects. But they also reported that several patients discontinued the opioids due to adverse events or not getting sufficient pain relief. Quality of life and functional improvement were inconclusive. Chou and friends apparently came to similar conclusions in regards to opioids being an effective therapy for a carefully selected group of patients, but reported that it’s also associated with serious opioid related adverse effects or abuse.”

    oh, for craps sake!!

    sorry, but articles like this make me furious. it just pushes the pov that anyone (or the majority of people) on opioids is taking the medication for…what…the hell of it?! where, in any study, does the researcher ask people with chronic pain conditions, “WHY do you remain on this medication if it does not work? ”

    what could it be?
    the placebo theory?
    or it actually does help to relieve pain?

    anyone who has talked to people with ongoing pain know that the number one issue for us is the amount of medication we take and how much we loathe it: but there is no choice for us. i am certainly not someone who takes drugs for any high inducing affects (of which i feel none). i take meds to have some semblance of a normal life. i research all the effects and weigh them up. yet the egos, arrogance and ignorance of some of your fellow practitioners seem to forgo the possibility that your patients actually have, and use, their brains. consequently, no proper pain medication to ease the suffering of their patients is given.

    there was NO quality of life for me until i received opioid medical treatment along with medication that forced my body to sleep. it was not until i was on these medications that my body, oh, so slowly, stepped on the road to healing itself. not because of physios, chiropractors or any other physical manipulations you can think of. it was because of the medication. i have not a singular doubt that this is what my body wanted to force it to relax. to have a break from the viscous pain cycle. that this is what i NEEDED to receive the very first few months of seeing the medical fraternity to prevent my brain from rewiring itself to become even more sensitive to pain.

    let me also point out, of all the people that i have talked to with fibro, it is those patients who received aggressive pain treatment within the first year that were able to fully recover by the end of the 2nd year. consequence? i do not think so.

    my story can be seen here: http://bodyinmind.org/phantom-scribbler-smudj-fluid-ink-rainer-galea/?fb_action_ids=10151034974583162&fb_action_types=og.likes&fb_source=aggregation&fb_aggregation_id=246965925417366

    have you any idea what it is like to be in constant pain? have you any idea of what it is like to be thrown around the medical system like you have little relevance and that your pain seems to be the product of a perverted imagination? have you any idea of how insanely difficult it is to receive any type of medication that actually helps? that actually relieves the pain to an extent where you stop merely existing and wanting to take your own life to free yourself from the crippling affects? have you any experience of this at all?

    no, you do not, because regardless of what medical position you have, be you a gp or a specialist in the field of pain, the fact remains, you do not have a shadow of a shadow of an idea of what people with chronic pain go through, every minute, of every day. this is not an area where you can read a book, go to a forum, listen to speakers and come to the conclusion that you know what it is like. the gap between theoretical understanding and actual experience will forever remain a gaping abyss into which any type of real, organic, heartfelt understanding is lost.

    i have sat and listened to the utter despair of people who talk about doctors who will not listen. doctors who only prescribe medication that does nothing. that only, after a long period of begging, receive something that works, not perfectly, but to a point where one can stand and make a cup of tea or go to the toilet by oneself.

    these “studies” do not help people within the chronic pain community. these studies offer no alternative for combating pain. offer no solutions. do not concentrate on the research that needs to be undertaken to fund something that actually helps. .. and that is where the real tragedy is. anyone who is outside the perimeters of 1,2, 3 solution is left stranded on their own. as one doctor said to me,” you’re in the too hard basket that no one want to take the time to help.”

    does drug abuse exist? of course it does. but one should be asking WHY it exists, not blaming, or making it incredibly difficul t to access, or outright deny, medication, to the poor souls who are just looking for a way to escape a pain that will not abate.

  8. Ruth White says:

    Thanks Sarah for the post. I believe the Australian stats would be quite different- these are certainly sobering. Just for interest I typed Laxmaiah Manchikanti into PubMed and it brings up 234 articles – of which 187 are freely available for public scrutiny which seems like a good thing. Further this snapshot shows that he is an author who is published in a wider variety of Journals than this paper would seem to indicate but it seems perhaps that Pain Physician is the place to get your systematic review published perhaps?

  9. Thanks everyone for your comments and contributions. There is no doubt that Sarah’s astute eye has touched on a very important topic and one that is very, well, topical, at the moment. It was a tough gig and one that Sarah has done with rigour, maturity and courage. Well done Sarah. Now, on the topic, which is definitely a hot one, ABC television here in Australia just had an INSIGHT programme on the whole opioid prescription issue and it is in the news here a bit, because good people are worried about what seems to be a rising number of opioid-addicted patients. This worry is not driven by an anti-pharmaceutical lobby group, but a range of people primarily in community service, health and law enforcement. I suspect, like Ruth does, that the US stats are not necessarily reflective of other countries, and there is no doubt that one reason opioids are not used in, for example, Africa, is that they are not available – Tina and Kath make good points here. We must remember that this disparate usage statistic is not proof of foul play and reflects a range of factors, but we can’t ignore the problem. Even if many people get good relief from opioids, many don’t, which is what is reflected in the Manchikanti article.
    I appreciate that for some of you the story that is presented by Manchikanti and synthesised into a blog post by Sarah, is contrary to your experience. This is one of the difficult things about evidence – it has to put into one box everyone and their experience. That box comes up with a label which describes the most likely response – with regards to both pain and side effects and risks. These are the critical questions – in what proportion of people tested has it reduced pain? In what proportion of people has it caused harm (eg addiction, but also side effects such nausea)? In the case of opioids for chronic pain, the body of evidence concludes that this balance is pretty even, if not leaning towards the harm side. A good way to describe that, in a context like this blog, in which which we are trying to decipher clinical pain science literature for clinicians and scientists, is ‘wishy-washy’. This discord between the whole body of evidence and an individual’s experience can work both ways – i have received equally despondent emails from people who have got worse from a treatment for which the body of evidence says ‘this works’.
    Rainer raises a very important point however, and that is that studies like this can be used to perpetuate the myth that everyone taking opioids is a drug addict, or is taking them for some other reason. Clearly that myth is indeed a myth, but I know that such dismissive and disrespectful throw away lines are common when it comes to chronic pain. That is one reason we need to keep our voice heard too. To use an article like Manchikanti, or blog post such as this, in support of that myth is completely out of order and I am not surprised that that such an inference is offensive in the extreme to many people in chronic pain. However, there is no doubt in my mind whatsoever, that these studies are actually very important, and so too are reasoned and provocative blog posts like Sarah’s. Most of us on this side – the side that is searching for better solutions and preventions, the side that is truly trying to help people with chronic pain to have a better life, do not presume for a second to know what it is like to be in shoes such as Rainer’s, but all of us can plainly see it is horrible and it is this observation that keeps us doing what we do.
    Finally, and on a different note, thanks Ruth for telling us about your search. Not just because this fellow is clearly a heavyweight – when you have that many papers, you are bound to cite them a bit, but also because it tells us we are having some sort of impact out there. We are trying to get a measure of whether or not BiM changes behaviour of the end-user and we will take your comment as evidence, n of 1, that Sarah’s post triggered you to look up Manchikanti. Job done. Well done Sarah.

  10. Mike Caruso says:

    We, in the US, are in a crisis due to the long term opioid prescription for musculoskeletal pain. This crisis was predicted by Nortin Hadler in Occupational Musculoskeletal Disorders. Hadler describes musculoskeletal pain as a problem with movement, posture and patient expectations in Worried Sick.
    There are some in the US that are becoming less wishy washy in thinking about this crisis. There is literature from the AMA which is discussed in the following link http://www.wci360.com/files/uploads/June_2012_WCI_News.pdf
    I spend my day with injured workers in chronic pain, many of whom are taking prescribed LT opioids. There are disturbing patterns which seems to lead up to the perception that LT opioids are “needed”. Unfortunately physical therapy is often involved in the early stages.
    Sometime the PT recommends that a patient be sure to take there opioid before coming to a PT session. This often does not work out. This may work in the short-term but often leads to complex problems latter on (probable because opioid use covers up poor movement patterns and alleviates the patient’s need to learn body awareness and pacing, and consider the other social and environmental factors contributing to the pain experience and postural changes). It is often fascinating how an individual patient’s conversation changes as they weans opioids. The unresolved conflicts in their live come alive in the stories they tell.
    Another PT factor that seems to contribute in when a PT takes the orientation that they are responsible for fixing the problem and therefore it’s fine if the patient is on opioids while the fixing is underway. It’s probable better if we consider ourselves the ‘coach’.

    Coach Mike

  11. Late to the party…I was just scrolling through unread BIMs…

    I’d actually like to thank you for pointing this out & writing about it. I’m pretty sure a lack of thorough information is the reason my doctor saw fit to put me on doses of OC (oxycontin) up to 200mg/day.

    Once it became clear that for me the OC wasn’t working I was told to start cutting it back. Admittedly I was told to drop 5mg/week, but I always figure I can do better than that & was dropping 15mg/week until my doc & I agreed on 10mg/week. By then it was far too late. Within that week I went into withdrawal related psychosis (no history of mental illness), where I believed I had to die & was being “told” how & by when. Perhaps we ought to have seen it coming but fatigue – oh I have a diagnosis of chronic fatigue syndrome, that’s nothing, depression/crying – well we did lose the 3rd close relative in 18 months recently & I did cut down my anti-depressant, so that’s clearly nothing. It was only a powerful death wish that made me sit up & realise This Is Not Right.

    Now I’m back to dropping 5mg/week again. I do get withdrawal symptoms (sleepiness to the point I just have to go to bed & sleep it off for 3 days). I’m currently at 115mg/day. I can’t imagine what life will be life at 50, 30 & 10mg. But I’m trying to be ready for it. I’m not addicted after all – “Only physically dependent”.

    I wish more information about the drug had been made available to me by my doctor. OC only arrived in New Zealand in 2010 so it’s still early days.

  12. ken cameron says:

    i am a gp with a special interest and practice in pain management and have read this article and the blogs with interest.
    Based on long experience I would like to make the following comments on prescribing opiates which is something I do every day
    1 Dont expect too much from opiate therapy. An improvement of 30 percent in pain perception can significantly improve functionality.
    Specifically more is not necessarliy better
    2 Nothing beats a good therapeutic relationship in managing persistent pain, so context is very important here
    3 Opiates need to be prescribed in a biopsychosocial context so good physical psycholgical and social management is really important
    I tend to have roughly 3 groups of patients I prescribe opiates to in non cancer pain situations
    (a) patients engaged in a multidisciplinary approach who are being actively managed with the joint goal of restoring function and minimising medication
    (b)
    Usually older patients with severe debilitating degenerative conditions ., eg oa of hips who function better on low dose long term opiates than without(usually patch therapy)
    (c) Unfortunate individuals who come to me on long term high dose opiates with low levels of functiong and high levels of distress
    Long term they are by far the most difficult to manage and any thoughts about how to help this group would be appreciated.
    My current treatment approach in these people is to try and indentify their issues around narcotic (addiction)problems, emotional distress and suffering, and the core pain problem . My ability to help this group is limited

  13. One thing that has never made ant sense to me is why the distinction between cancer patients and everyone else? The brain of a cancer patient does not experience pain in any way different from anyone else. Last I heard a person with cancer is still a person, why the special treatment? There is one and only one reason, that being that everyone is so terrified of the word cancer the cancer patient gets special treatment, this is wrong on many levels, there are other diseases as debilitating as cancer or more that rather than getting treated with extra compassion like the cancer patient they actually get stigmatized. Both are debilitating diseases why should one be treated any different from the other? So, being you have hinted that the opioid medications to be effective for cancer patients, they will be every bit as effective in non-cancer patients.

    Used properly continuous opioid pain medications are safer than acetaminophen, ibuprofen or aspirin for long term use for treating chronic pain whether that pain be from a source cancerous or benign. Acetaminophen is damaging to the liver, ibuprofen or aspirin are both hard on the digestive tract, I learned this the hard way. Opioids are neither, however you need to be intelligent about using them, the object in proper use of opioid pain treatment is not to achieve a state of being pain-free, but rather to reduce the pain to a level that the patient can deal with it, knock the edges off. As long as you follow your dosing schedule, and don’t be falling for the temptation to get rid of the rest of the pain load, you can be safely on continuous opioid therapy for many years far safer than any other long term pain medication. I live with 2 different co-morbid severe pain sources, prior to being put on continuous opioid therapy the pain level was bad enough that I was seriously suicidal, since being put on them that isn’t a problem. It has been over 11 years and counting, I’m still on a fairly low dose they make the medication I’m on in tablets 20 times stronger than the ones I take, I have never gone looking for more from any other source, and I have never come up short at the end of any month in all that time.

    My biggest fear is idiot politicians who know nothing at all about the realities of living with chronic pain reading an article like yours and pushing through a law that would return me to the nightmare I was living in 12 years ago.