Opioids
Sonya Collins
In the midst of the COVID-19 global pandemic, the opioid epidemic in the United States rages on. A recent perspective1 in the New England Journal of Medicine debunked some of the myths that contribute to both overprescribing and underprescribing of opioids. The discussion may serve as a useful reminder of counseling points for pharmacists who dispense these drugs.
“Pharmacists may bear the brunt of opioid-related challenges, often playing the middleman between patients and physicians, which can be a very uncomfortable position,” said Michael Barnett, MD, author of the perspective and assistant professor of health policy and management at Harvard T. H. Chan School of Public Health. “But communication—between pharmacist and patient, physician and patient, pharmacist and physician—is what’s really important.”
Myth: Opioids have power over pain
Patients, and indeed many clinicians, cling to the myth that opioids are the most powerful painkillers. Some patients may feel that “real” pain deserves treatment with opioids. But in reality, there is little evidence that opioids are more effective than NSAIDs, muscle relaxants, or other pain medications.
“Pharmacists can help patients understand that if they haven’t tried other medications first, there’s really not much evidence that opioids are going to be more effective,” Barnett said. On the other hand, that doesn’t mean that opioids are not effective at all. “It’s really just that they are not better—at least not in most of the circumstances that have been studied.”
Myth: Opioids are uniquely suited to treat acute pain
Many scenarios in which prescribers once believed that opioids were the best response have been disproven, including for kidney stones, migraines, and back pain, among others. For some conditions, such as postsurgical pain, sickle-cell crisis, and other severe pain, prescribers still tend to go to opioids first.
“I wouldn’t want to deny any of those patients effective pain control, but I wouldn’t be surprised if opioids aren’t as magical, even in those situations, as we think,” Barnett said.
Myth: Short courses of opioids bring little risk of long-term use or misuse
Patients should understand that they are taking a medication that, while not better than the alternatives, does bring more adverse effects than many of the other options. Besides uncomfortable physical side effects, such as itching, sedation, nausea, and constipation, patients face the risk of dependence.
“It’s important for patients to understand not just how quickly dependence can develop, but also that anyone who’s exposed to these might be more vulnerable to addiction in the future,” said Barnett. “If someone is spooked by that idea, they might want to talk to their doctor about another medication.”
The risk of dependence or future addiction after short-term use, though not high, is similar to that of major bleeding on warfarin. “Side effects such as these, with similar clinical incidence, affect clinical decision making in other therapeutic settings,” Barnett said.
Fact: Opioids have a role in pain management
Though opioids are not necessarily more effective than other options, they continue to have a role in pain management. Like all medications, they come with the risk of adverse effects. But the risk is not so great that patients who are appropriate candidates for these medications should not try them.
Patients whose pain continues after trying other options may benefit from opioids. The painkillers are an effective therapy for a small subset of people who live with chronic pain. Some people take and benefit from opioids for years without misuse.
For pharmacists who have concerns about a patient’s opioid use, Barnett pointed out that it’s difficult for any single clinician to identify misuse with certainty. “Pharmacists and physicians have a clinical sense based on their experiences, but any given person usually has incomplete evidence.”
Because opioids don’t come with automatic refills, even when patients do everything by the book, they can experience delays in getting the prescription filled, which can lead to behaviors that might be a challenge for pharmacists.
“But,” Barnett said, “these are our patients, and no matter what, more than tough love or discipline, they need our compassion and empathy.”
Reference
Barnett ML. N Engl J Med. 2020;382(12): 1086–88