Opioid Analgesics: The Myths-and the Facts

During the past several years, there has been increasing focus on opioid analgesics. Opioid use disorder related to prescription opioid analgesics is considered to be at epidemic proportions in the US. Moreover, it has been widely asserted that the overprescription of these drugs has resulted in the growing use of heroin.

In fact, we know relatively little about the causes of this crisis-and even less about the patients who run into problems with prescription opioids that were originally prescribed for legitimate pain complaints. The following questions seek to separate what we actually know about opioid analgesics and their use and misuse from what we don’t.

1.True or false? A significant number of patients treated with prescription opioid analgesics for pain turn to heroin when their opioid analgesics are discontinued.

A. True

B. False

Discussion: Although there are frequent reports that any limits on the prescribing of opioid analgesics to patients with pain will result in their using heroin if these drugs are discontinued, virtually no research supports this. Even among people who use prescription opioids for nonmedical reasons, only a small minority also use heroin.¹

Answer: B. False

2. True or false? The recent increase in heroin use in the US has resulted from increasing restrictions on the prescribing ofopioid analgesics.

A. True

B. False

Discussion: Research shows that the increasing use of heroin in the US began before the newer restrictions on the prescribing of opioid analgesics were instituted.¹

Answer: B. False

3. Which of the following is the best treatment for patients who received opioid analgesics for a legitimate pain complaint and who went on to have an opioid use disorder?

A. Methadone

B. Buprenorphine

C. Cognitive-behavioral therapy (CBT)

D. None of the above

Discussion: Although there have been calls for increased treatment ofpatients with opioid use disorder with methadone and buprenorphine, there is little evidence that these medications or CBT are beneficial for patients for whom opioids were prescribed for legitimate pain complaints.²

Answer: D. None of the above

4. True or false? Urine drug testing (UDT) is sufficient to identify those patients who take opioids prescribed for legitimate pain complaints and who have or who are at risk for opioid use disorder.

A. True

B. False

Discussion: Although UDT is widely recommended for all patients who take prescription opioids, there is little evidence that it has value in identifying patients in whom an opioid use disorder will develop.² At best it can identify patients whose opioids have been discontinued, but who continue to use one of these drugs or who use medications different from those prescribed by the physician.

Answer: B. False

5. What is the best way to determine whether opioid analgesics are beneficial for an individual patient with chronic pain?

A. Ask the patient if the medication is reducing the pain

B. Determine whether the medication is increasing the patient’s level of functioning

C. Ask if the medication makes the patient less depressed

D. Ask if the medication makes the patient less anxious

Discussion: Although reducing the levels of pain, depression, and anxiety in patients with chronic pain is important, measuring the impact of any treatment modality for chronic pain is best done by determining its effect on the level of functioning. If there is no improvement in functioning, the benefits of the treatment should be questioned.³

Answer: B. Determine whether the medication is increasing the patient’s level of functioning

6. Which of the following has been identified as a risk factor for the development of an opioid use disorder in patients who take opioids prescribed for legitimate pain complaints?

A. Past history of substance abuse

B. Major depression

C. Younger age

D. The use of psychotropic medications

E. All of the above

Discussion: All of these have been identified as risk factors for the development of opioid use disorder.² However, even patients without any of these factors are still at risk for a substance use disorder, and it is unclear how many patients who develop the disorder have these risk factors.

Answer: E. All of the above

7. True or false? The Opioid Risk Tool (ORT) and the Screener and Opioid Assessment for Patients With Pain–Revised (SOAPP-R) are useful instruments for predicting the likelihood that opioid use disorder will develop in patients with no identified risk factors who take opioid analgesics prescribed for legitimate pain complaints.

A. True

B. False

Discussion: Both ORT and SOAPP-R self-identify past and current history that indicates substance abuse, but neither has been found to have any predictive value for substance use disorder.

Answer: B. False

8. Which class of medications is contraindicated in patients with chronic pain who are taking opioid analgesics?

A. NSAIDs

B. Tricyclic antidepressants

C. Benzodiazepines

D. All of the above

Discussion: Use of a benzodiazepine with an opioid analgesic significantly increases the risk of death from overdose. Furthermore, extended use of a benzodiazepine can cause hyperalgesia.² There is evidence that taking a tricyclic antidepressant with an opioid analgesic may actually have a beneficial synergistic effect.⁴

Answer: C. Benzodiazepines

9. True or false? It is well established that opioid analgesics are beneficial for most cases of chronic pain.

A. True

B. False

Discussion: No controlled studies demonstrate that opioid analgesics are beneficial for most cases of chronic pain.²

Answer: B. False

10. The CDC guideline for prescribing opioids for chronic pain specifically states that the recommendations do not apply to patients with cancer who are undergoing active treatment and have pain.

True or false?For patients with cancer pain, opioids arealways the most efficacious analgesics.

A. True

B. False

Discussion: Although opioid analgesics can be beneficial for many types of cancer pain, there are also many common forms of this pain that respond better to other analgesics.⁵ Neuropathic pain usually responds better to tricyclic antidepressants and other SNRIs, such as duloxetine and venlafaxine, and anticonvulsants. Bone pain related to metastases often responds best to NSAIDs.

Answer: B. False

References:

1. Compton WM, Jones CM, Baldwin GT. Relationship between nonmedical prescription-opioid use and heroin use. N Engl J Med. 2016;374:154-163.

2. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain: United States, 2016. MMWR. 2016;65:1-150.

3. Sullivan MD, Ballantyne JC. Must we reduce pain intensity to treat chronic pain? Pain. 2016;157:65-69.

4. Gilron I, Tu D, Holden RR, et al. Combination of morphine with nortriptyline for neuropathic pain. Pain. 2015;156:1440-1448.

5. Smith TJ, Saiki CB. Cancer pain management. Mayo Clin Proc. 2015;90:1428-1439.