Prescription painkillers: 10 things you need to know

By Ruben Halperin, M.D., internal medicine, Providence Medical Group-Northeast in Portland, Oregon, and Linda Cruz, M.D., area medical director for Providence Medical Group-West in Portland

The death of musician Prince from an accidental overdose of prescription pain medication calls attention to the only recently understood dangers of opioid painkillers and the toll they have been taking on millions of people.

In 2014, according to the Centers for Disease Control and Prevention, nearly 2 million Americans abused or were dependent on prescription opioids such as morphine, oxycodone (OxyContin®), hydrocodone (Vicodin®) and methadone, and more than 14,000 died from overdoses. Every day, more than 1,000 people land in emergency departments because of opioid misuse.

Over the last few years, research has shown that opioid medications are not particularly effective for chronic pain and carry significant risks. In light of what we are learning about these medications, physicians across the country are working to help patients reduce their dependence on opioids and transition to safer, more effective treatment for their pain.

If you take opioids, here are 10 things you need to know.

1. There are other ways to treat pain that can make your life better.
   Safer, non-opioid alternatives can return many people to a more active, more enjoyable life. We’ll say more about that, but wanted to make that clear up front.
2. Opioids may harm more than they help.
   Opioids are very useful for acute injuries and post-surgical pain, but studies are finding no evidence that they benefit people who use them long term – in fact, they might make you worse off. In addition to the potential for addiction and overdose, opioids can cause problems with breathing and sleep, severe constipation, nausea, sexual dysfunction, itchy skin, confusion, depression, falls, broken bones and loss of independence.
3. Painkillers may increase your pain.
   Paradoxically, long-term use of pain medicine may actually make pain worse for many people. This condition, called opioid-induced hyperalgesia, causes more pain by amplifying pain messages in the brain.
4. Anyone can become addicted to opioids.
   Opioids are highly addictive. You may be at higher risk of addiction if you’ve had a history of substance abuse or psychological trauma, but anyone can become addicted. Even people who don’t become addicted grow dependent and are likely to build tolerance to the medication. That means you’ll need higher and higher doses to maintain the effects and to prevent withdrawal symptoms, eventually getting up to levels that are very unsafe.
5. Know your dose.
   We now have clear evidence that higher dosages of opioids increase your risk of overdosing. At a high dosage, even a small medication change or minor shift in your metabolism could tip the scales. That’s why we call it accidental overdose. Taking other medications – particularly benzodiazepines (Valium, Xanax, Ativan) – can increase the risk of accidently overdosing.
   
   What is a high dosage? That can be confusing, because some medications are stronger than others at similar dosages. To compare different opioid medications, we use a term called “morphine-equivalent dose” (MED) – that is, how much morphine would your current medications equal? You can learn yours by using this MED calculator. The CDC recommends caution with an MED over 50, and strong caution over 90. In Washington state, new legislation requires a pain specialist to sign off on any prescription with an MED over 120. In Oregon, Providence Medical Group physicians are working closely with patients who are over 120 toward the goal of tapering down to safer levels.
6. Patients who taper to lower doses usually feel better.
   Once we help patients get past the fear of reducing their medication, it’s amazing to see how they improve. They feel less mentally foggy, they become more physically active, and many have less pain. In a recent recorded interview, one patient told us, “It’s the best thing I did – I was falling asleep, I didn’t have a life, and now I can do things that I want to do.”
7. The goal of treating pain is to improve your function.
   With persistent pain syndromes, pain may never go away completely. Most people have good days and bad days. The goal of treatment isn’t to eliminate all pain, but to improve your ability to function and live a good life. We ask patients: What are your goals? What would you like to do if your pain were better? How can we help you work toward that in a way that helps you have more control?
8. There are other ways to turn down your pain.
   When pain persists long after an injury or surgery, the problem is probably not tissue damage, as most tissues usually heal within about three months. Often, the problem is that the nerves have become hypersensitive, causing the brain to continue sending out pain messages. Depression, anxiety, poor sleep, poor nutrition, inactivity, obesity, relationship problems or general life chaos can all contribute to the way your brain processes pain. We can turn down the sensitivity of the brain and the nerves by identifying and dealing with the whole realm of experiences contributing to it.
9. Taking an active role gives you back control.
   Every situation is different, and some people may still need to take opioids to function well. But people who can taper down and take a more active role in managing their pain tend to feel less isolated, less frustrated and more in control of their pain. Taking an active role involves working closely with your primary care provider, and possibly with physical and behavioral therapists, to understand your pain, ease your fears, deal with underlying conditions, learn “physiologic quieting” techniques for anxiety and stress, and get under-used muscles moving again.
   
   At “full” effectiveness, opioids generally relieve only about 30 percent of pain. Physical therapy and behavioral techniques have been found to relieve pain just as well, if not better, with none of the life-impairing side effects.
10. Your health care team is here to help.
    If you have any questions about your pain medications, or you feel ready to explore alternatives, have a talk with your health care provider about what might work for you. A good doctor-patient relationship will be key. If you choose to taper your dosage and try other approaches, you’ll want to have the guidance, monitoring and support of a good partner who understands your overall health and is looking out for you.

Don’t have a health care provider? You can find a Providence provider find a Providence provider here.

Dr. Halperin practices in Portland, Oregon, and speaks to physicians nationwide about opioid risks and pain management. Dr. Cruz is the medical director of Providence Medical Group-West in Portland, and has helped develop opioid prescribing guidelines for Providence physicians in Oregon.