TWELVE MYTHS ABOUT OPIOID USE
Ryle Holder PharmD, Dr. Scott Guess PharmD, and Dr. Forest Tennant M.D., Dr. P.H.
1. Above 100 mg of morphine equivalence opioids are ineffective. NONSENSE! They have no ceiling in most patients and may remain effective at dosages in the thousands.
2. All pain patients who take over 100 mg of morphine equivalence are diverting or selling part of their prescription allotment. NONSENSE! Most patients who have a bad enough pain problem to need this much opioid don’t usually want to part with it.
3. All patients who use the “holy trinity” of an opioid, benzodiazepine, and muscle relaxant are either selling their drugs or will shortly overdose. NONSENSE! The original “holy trinity” was a simultaneous ingestion of the combination of the short-acting drugs hydrocodone (Norco®), alprazolam (Xanax®), and carisoprodol (Soma®). A different, (e.g. long-acting drug from either of the 3 classes (opioid, benzodiazepine, muscle-relaxant) markedly lowers the risk. So does taking the drugs separately. Many severe, centralized pain patients have to take a drug from the 3 classes and do it safely and effectively. In other words, they take the drugs “as prescribed”. Additionally the “Holy Trinity”, originally called the “Houston Cocktail”, is a term coined by law enforcement; addicts tend to use mono-syllabic terms to refer to their poison of choice, “Holy Trinity” is too many syllables.
4. Centralized, intractable pain doesn’t exist. NONSENSE! Much research documents that pain from an injury or disease may cause glial cell activation and neuroinflammation which may destroy brain and spinal cord tissue. Multiple, high dose drugs may be needed to prevent tissue damage and control the immense pain that this condition may produce. As inflammation develops the overall stress on all organ systems increased dramatically and occasionally to a life-threatening level.
5. The risk of an opioid dosage over 100 mg of morphine equivalence is too great to prescribe opioids above this level. NONSENSE! If a severe, chronic pain patient can’t find control with opioid dosages below 100 mg or with other measures, the benefit of the high dose far outweighs the risks.
6. Overdoses occur even if opioids and other drugs are taken as prescribed. NONSENSE! If this even happens it is extremely rare. Overdose victims often take alcohol, marijuana, and other drugs in combination; but, opioids and the prescribing doctors are always blamed.
7. There are no “proven” benefits to long-term opioid therapy. NONSENSE! Simply talk to someone who has taken them for 10-20 years. Never has there been nor will there ever be a double-blind, placebo-controlled study to provide “evidence”. Opioids are a last resort when all else fails. Opioids in doses >100 mg have improved quality of life and prevented death in some instances.
8. Chronic, severe or intractable pain is just a nuisance that doesn’t warrant the risk of opioids. NONSENSE! Severe pain has profound detrimental effects on the cardiovascular, immune, endocrine (hormone) and neurologic systems. Pain must be controlled or pain patients may die of stroke, heart attack, adrenal failure, or infections due to a suppressed immune system.
9. Genetics has no effect on the need for a high opioid dosage. NONSENSE! Bigger and heavier people need a higher dose of medications (just add 1 drop of food coloring to a 1 gallon and 5 gallon bucket and observe). It is well documented that some genetic variations impede opioid metabolism to the active form of the drug, or increase the speed the body excretes the opioid. Both metabolic variations will require a higher dosage.
10. All pain patients can get by on standard opioid dosages under 100 mg. NONSENSE! There are persons who are outliers with all disease conditions such as heart failure, diabetes, and asthma. Same with pain. A few unfortunate individuals will always require high dosages. Remember our friend the bell curve? What if YOU were on the extreme end?
11. All patients started on opioids some time ago can just suddenly stop opioids. NONSENSE! Once a person is on high dose opioids they don’t dare suddenly stop because sudden withdrawal may cause hypertension, tachycardia, adrenal failure, and sudden heart stoppage. Some patients who have stopped too suddenly have committed suicide because they had no way to control pain. Montana reports that 38% of all suicides in the state are UNDER treated pain patients.
12. There are plenty of alternatives to opioids. NONSENSE! Common pain problems are generally mild to moderate and respond to a variety of non-opioid treatments. Unfortunately, there are some severe, intractable pain patients who can only control their pain with opioids.
- Long-term opioid use results in opioid-induced hyperalgesia, a heightened sensitivity to pain caused by the medications.
- Opioid-induced hyperalgesia causes intractable pain.
- High doses of opioid medications cause respiratory depression.
- High doses of opioid medications cause life-threatening risk of respiratory depression.
- Rapid, forced tapering to reduce daily doses of opioid medications is appropriate and will not cause harm.
- No one has ever died from pain.
- Pain is harmless.
- Doctors do no harm to patients by refusing to treat their pain.
- It is impossible to tell the difference between a chronic pain patient and an addict.
- People who are dependent on opioid medications have opioid use disorder.
- Being dependent on opioid medications is the same as being addicted to opioids.
- Prescribing opioids for long-term use for chronic pain carries a significant risk of the patient becoming an addict.
- Persons on long-term high-dose opioids will develop tolerance to the medications and require dose escalations.
- Dose escalation will almost certainly be required if opioids are used for long-term treatment.
- Any high-dose opioid patient will eventually overdose.
- Long-term opioid use brings a high risk of overdose.
- Persons on long-term prescription opioid medications are dysfunctional.
- The risks of long-term use of opioids always exceed the benefits.
- Persons with fibromyalgia and other central pain syndromes do not respond well to opioids.
- The side effects of opioids are significant and very difficult to manage.
- Many doctors have used opioids as the treatment of choice without trying anything else first.
- Long-term opioid use will mean increased visits to the emergency room for overdose or other adverse events.
- Reducing the availability of opioid pain medications will prevent addiction.
- Reducing the prescribing of opioid pain medications will reduce overdoses and deaths.
#1 and #2. HYPERALGESIA: NO REASON TO STOP OR REDUCE OPIOIDS
“One of the excuses that some health practitioners are using to stop opioids is to claim a patient has hyperalgesia (HA). This is a most dishonest, devious, and dangerous ploy.
First, the definition of hyperalgesia is simply that a stimulus such as hitting your thumb with a hammer is more painful than usual. Second, there is no way to measure or quantify the presence of HA in a chronic pain patient who takes opioids. Practitioners who claim that a chronic pain patient has HA usually do so because they don’t like the dosage that a patient must take to relieve pain or they have a bias against opioids. Some practitioners are actually telling patients that HA is harming them, and that their pain will improve or even go away if they stop opioids!! This dishonesty and deviousness may go further. Once off opioids, the practitioner may recommend that a patient have expensive, invasive or unneeded procedures. Danger may come with abrupt cessation of opioids in a severe chronic pain patient. There may be a combined or dual result of a severe pain flare along with severe opioid withdrawal symptoms. This combined effect may result in a stroke, heart attack, psychosis, or adrenal failure. Some patients may commit suicide.
All who read this need to know that many expert pain specialists either do not believe that HA even exists or that it is irrelevant to clinical practice. In other words, if a certain dosage of opioids is effective, continue treatment with opioids. There is no reason to stop or reduce opioids just based on HA.
Any time a patient is told they have HA and should stop or reduce opioids, they and their family or advocate should ask the following questions of the prescribing practitioner:
- What test or evaluation did you do to determine that I have HA?
- If I do have HA, what damage is it doing? (Show me some studies!!)
- When did I get HA? (Nothing has change in some time!)
- I’ve heard that HA may be the result of too much neuroinflammation or hormone deficiencies? Don’t I need to be tested for these?
- If I stop or reduce opioids and still have some pain, what are my alternatives? (Will you return me to my original opioid dosage?)
The author’s personal recommendations are: (1) If your opioids don’t seem to be as effective as they once were, get a hormone panel blood test. I’ve seen many patients boost their opioid effect by replenishing pregnenolone, testosterone, estradiol, or another hormone that has diminished.; (2) If you wish to reduce or stop your opioids, reduce your dosage about 5% a month. By slowly tapering you may be able to greatly reduce or even stop opioids.
Please inform all parties that HA is not, per se, a reason to stop or reduce opioids. More important, if you reduce or stop opioids, what is your alternative, and, if the alternative doesn’t work, what will you do?” (1)
1- Tennant, Forest, MD-MdPH, Dr. Forrest 5/30/17
#6. No one has ever died from pain- People Do die from untreated and under-treated pain. Untreated or under-treated pain will cause a bed-bound or house-bound state that can lead to early death due to cardiac arrest, stroke or adrenal failure. “Unrelieved pain increases cardiac work, increases metabolic rate, interferes with blood clotting, leads to water retention, lowers oxygen levels, impairs wound healing, alters immune function, interferes with sleep, and creates negative emotions.” (1)
1 Cole, B.Eliot, MD “Pain Management: Classifying, Understanding, and Treating Pain”, June 2002, Hospital Physician.