Opioids may not be the most harmful pain drugs after all…

We have seen plenty of media reporting of the harm done by “overprescribing” of opioid drugs for chronic pain (I use the quotation marks because I challenge anyone to identify what the “right” level of opioid prescribing is) but perhaps this hype is misleading. A new paper from a Melbourne research group suggests we may be looking in the wrong spot for the worst harms.

In this study, published in the journal Pain Medicine a scale for rating medication-related detrimental effects was used to assess a sample of 224 patients being treated at a large metropolitan Melbourne pain treatment centre.

Some patients were only taking one prescribed medication, a few were taking as many as nine. The average patient was taking three medications, with some 80% taking at least one opioid drug. The authors were able to identify five groups within the sample. For those interested in such things, the statistical methods used were quite clever, and worth a read of the full text.

Interestingly perhaps, the smallest of the five groups was those suffering above-average harm from multiple drug classes (5% of the sample). The largest group suffering above-average levels of harm from their medications was the 34% of patients in the sample with problems from the “simple” analgesics such as over-the-counter paracetamol, codeine, ibuprofen and similar preparations. The next largest group were experiencing above-average detriment from non-opioid drugs used for pain such as pregabalin (Lyrica) and amitriptyline (Endep). The opioids came in third at 20% with the other group being combined opioid and benzodiazepene harm at 14%.

These real-world results are fascinating for a couple of reasons.

The first is that they go against received wisdom that opioids are the source of all evil in pain prescribing. I am not disputing that deaths from inadvertent opioid overdoses have increased in the last decade, this has not been in proportion to the growth in prescribing. And while we have been paying attention to the sobering Coroner’s figures on tragic deaths, we may have been looking right past a whole cavalcade of grief caused by codeine addiction, ibuprofen-related gastrointestinal and kidney injury and paracetamol-related liver problems. Not to mention the fractures and other injuries caused by falls, car accidents or workplace incidents due in whole or part to side effects from adjuvant analgesic drugs.

Another reason I’m intrigued by these results is that they are in accord with my own clinical experience. As a rule I have learnt to distrust any research which confirms my own prejudices. This study tends to support my own experience in the clinic where I have observed that non-opioid analgesics cause at least at much adversity to patients as the much-maligned milk of the poppy.

The third reason I like these results is that they tend to support my belief that chronic pain sufferers are not opioid-seeking pleasure fiends, but desperate individuals who are looking for relief. Opioids are capable of providing some people with better quality of life if carefully used. We also know that this is not the case for the majority of chronic pain sufferers. Whether intentionally or not, the literature on prescription opioid issues in both the media and professional journals contains a thread of judgement that does not mirror the people I meet every day of my working life.

It’s rational to seek relief from pain, and if all someone has found even partly effective is an opioid, well why wouldn’t you ask for more of it? I have a solid minority of patients who obtain valuable relief with more than acceptable side effects from opioids. These benefits enable them to work, spend time with their children and grandchildren and other worthy goals. It’s not my experience that opioid-related problems are inevitable or that they don’t have any value under any circumstances.

I think addiction specialists and pain management specialists see a different spectrum of customers. Most of the patients I see would much rather be on less medication than more. They are poorly served by a system which facilitates prescriptions and over-the-counter solutions while making it hard to access pain education and interdisciplinary care. According to an old medical axiom, if all you have is a hammer, every problem starts to look like a nail. While we should strive to reduce preventable deaths from opioid poisoning, we would be foolish to think that was the only job that needed doing.

Well-informed consumers in partnership with smarter prescribers and allied practitioners could have better pain management with less of the carnage we currently see. Based on studies like this one, that doesn’t seem unrealistic. Most of the harm seems to come from drugs that are not particularly efficacious. It may well be that having a nationally consistent approach to persistent pain will solve several “intractable” problems at once.