The Opioid Crisis

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The opioid crisis is a real and growing concern in the U.S. As the only legal and regulated source of opioid prescriptions, physicians are increasingly under the regulatory agencies’ microscope and many physicians, including me, are reluctant to prescribe them at all. The problem is, however, that there are many people with chronic pain disorders who rely on these drugs for pain relief. Today I would like to delve into the use of opioids for pain relief.

There is a distinction between chronic use of opioids for pain relief and opioid use disorder, commonly known as addiction. Patients who take opioids daily for pain relief do not necessarily have opioid use disorder, even if they have a physiologic dependence on them (i.e. withdrawal from and tolerance of opioids). Physiologic opioid dependence is often confused with opioid use disorder, however it is the expected result of regularly taking these drugs. Opioid use disorder is a chronic disease of the brain characterized by loss of control over opioid use, resulting in harm. The Diagnostic and Statistical Manual, fifth edition, excludes physiologic dependence on opioids (tolerance and withdrawal) from its criteria for opioid use disorder if the patient is taking opioids solely under medical supervision. To be diagnosed with opioid use disorder, patients need to do only two of the following within 12 months: take more of the drug than intended, want to try to cut down without success, spend a lot of time in getting, using, or recovering from the drug, crave the drug, fail to meet commitments due to the drug, continue to use the drug even though it has caused social or relationship problems, give up or reduce other activities because of the drug, use the drug even when it’s not safe, continue use even when it causes physical or psychological problems, develop tolerance (but not if taken as directed under a doctor’s supervision), or experience withdrawal (again not if under supervision).

In a country where nearly 40 percent of adults are prescribed an opioid annually, the question is not why people start taking opioids, but rather why some struggle to stop. A recent study looked at nearly 1,000 opioid-naïve patients who received an opioid prescription. Of those given at least a one-day supply, six percent were still taking them one year later and 2.9 percent were still taking them three years later. The study concluded that the total amount of opioids prescribed for acute pain was the best predictor of chronic opioid use and that chronicity begins earlier than thought. In other words, if opioids must be prescribed for pain (for example after surgery), the lower the dosage and number of pills prescribed, the better. More importantly, it must be remembered that there are many people with chronic pain conditions like advanced osteoarthritis, spinal stenosis, and fibromyalgia, just to name a few, who rely on opioids for legitimate pain relief. We need to make sure that these people do not get unfairly stigmatized as having opioid use disorder.

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