Healthy Skepticism Library item: 809

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Publication type: news

Szalavitz M.
Opioids could offer mass market pain relief
New Scientist 2005 Jan 29

Full text:

If you are one of the tens of millions of people who suffer from chronic pain, the last Christmas and New Year holiday was probably one you’d rather forget. In recent months, some of the latest, most promising painkillers have been pulled from the market because of safety concerns, and there are big questions over others.

It all started last September, when the drug company Merck withdrew Vioxx, one of a class of painkillers known as Cox-2 inhibitors. The drug was found to double the risk of heart disease and stroke. Then last month a study found similar problems with Celebrex, another popular drug of the same type. Now naproxen, an older drug from the larger class known as non-steroidal anti-inflammatory drugs (NSAIDs), which includes Cox-2 inhibitors, may also be unsafe.

What makes this all the more alarming is that Cox-2 inhibitors were supposed to save lives by reducing the risk of gastrointestinal disorders associated with other NSAIDs such as naproxen, ibuprofen and aspirin. Such side effects kill some 16,500 Americans each year, making these drugs the 15th largest cause of death in the US. But not only have the Cox-2 inhibitors failed to significantly reduce these problems, they have also introduced additional cardiovascular risks.

Where, then, should sufferers turn for relief? Remarkably, there is a reliable alternative that many patients may not even have considered. The opioid drugs, such as morphine and OxyContin, have for years had a bad press. Media hysteria and government paranoia over their addictive properties have frightened both doctors and patients alike. Yet the truth about opioids could not be more different.

Not only are they the most effective painkillers, they are also among the safest drugs on offer. Taken as directed, their most significant side effect is constipation, and possibly flu-like withdrawal symptoms if they are discontinued too abruptly. They are often billed as being irresistibly seductive and addictive, but although many patients feel sleepy or “spacey”
when they first take opioids, research shows that people taking a steady, regular dose do not suffer cognitive or physical impairment. And a series of studies funded by the US National Institute on Drug Abuse found that most healthy volunteers who were not drug abusers did not experience euphoria after taking them. “Paranoia over opioids’ addictive properties has frightened both doctors and patients”

Indeed, studies have found that only about 1 per cent of patients with no history of addiction become addicted to opioids taken for pain relief. This makes sense when you consider that most addicts become hooked on drugs in their youth, whereas most chronic pain occurs later in life. Even former addicts can take these drugs for pain relief with little risk of becoming addicted again.

So why do these drugs have such a poor reputation? The fears about using opioids for pain relief stem largely from the dangers of recreational use.
Yet even these have been overplayed. For example, while half of American soldiers in Vietnam tried heroin, only around 40 per cent of those who used it experienced any addiction, and just 1 to 3 per cent developed long-term addiction. In other words, at least 97 per cent of people in the highest-risk age group exposed to the scariest opioid under the most stressful circumstances did not become lifelong junkies.

The risk of overdose has been similarly exaggerated. For one thing, more than 80 per cent of deaths attributed to opioid overdoses are caused by taking a mixture of substances. Secondly, there is a harmless antidote that can neutralise an overdose, so when a patient starts using the drugs or needs to increase their dose, medical supervision can virtually eliminate any danger.

Despite this, the drugs continue to get a bad press. Last month, a prominent American pain specialist was convicted of 50 narcotics-related charges that could land him in jail for life. All federal prosecutors had to do was demonstrate that William Hurwitz prescribed more painkillers than the government believed was “medically necessary”. They convinced the jury that this was a crime, with testimony from an expert witness who claimed that the use of high doses of opioids to treat non-life-threatening chronic pain is itself drug abuse. That testimony has since been condemned as “factually wrong” by leading pain specialists.

So why are patients allowed to take inherently risky drugs, but have a hard time getting access to those that harm only when misused? It comes down to one word: politics. Entire government bureaucracies – from the US Drug Enforcement Administration and the drug tsar to state police and prosecutors – are devoted to demonising opioids. The truth about these drugs is politically inconvenient. It undermines a basic tenet of the multibillion-dollar war on drugs: that exposure to corrupting substances inevitably causes addiction or death.

As Siobhan Reynolds, founder of the advocacy group Pain Relief Network, puts it: “Opioids are the safest pain-relief drugs on the market, but patients are going to have to fight for them if they want to be able to take them.”