Should I Take Opioids?
When my second child was born by cesarean section last year, I came home from the hospital with a half-moon of stitches across my belly, a stash of oh-so-elegant mesh underwear, and a bottle of oxycodone.
And, of course, a wondrously sweet baby girl.
A couple of days later, I was lying in bed, nuzzling her soft head as she snoozed on my chest, when my husband came in the room and announced the baby was awake and needed to be fed.
“What do you mean? She’s right here sleeping on me,” I said.
“Ummm, no,” my husband said. “I’m holding her.”
“Oh, wow! We must have gotten an extra baby,” I said.
Then I opened my eyes. Wait a minute. Had I been asleep and dreaming? Was I hallucinating from days of little sleep? Or was the oxycodone, a prescription opioid painkiller, messing with my mind?
It seemed like a good time to stop taking the drug. Although I had been sent home with a three-week supply and the option for a refill, the pain was subsiding and I figured extra strength ibuprofen would do the trick. Frankly, I was nervous about continuing to take oxycodone. I had read so many stories of people’s lives spiraling out of control from opioid addiction that each tiny white tablet felt like an invitation to trouble.
According to the Centers for Disease Control and Prevention, some 2.6 million Americans have been diagnosed with an opioid use disorder, the technical term for being addicted to or chronically abusing the drug. And that figure may be underreported, according to Caleb Alexander, co-director of the Johns Hopkins Center for Drug Safety and Effectiveness. Another 2 or 3 million people likely have an undiagnosed opioid use disorder, he says. In 2014, 28,000 people died from an opioid overdose, the most since the CDC began keeping records.
Opioids are a class of drugs that includes opium, morphine, heroin, OxyContin, Fentanyl, and others. Many people who become addicted start with a legitimate prescription. “We see a fair number of patients coming in addicted to painkillers from an accident or an injury,” says Beth Kane Davidson, director of Addiction Services at Suburban Hospital in Bethesda, Maryland, a member of Johns Hopkins Medicine.
“Patients have to go into this with their eyes wide open, realizing that these products are highly habit-forming. Don’t be afraid to question your provider as to whether opioids are needed.”
Until recently, some doctors didn’t hesitate to dash off a prescription for an opioid painkiller. In 2012, clinicians wrote prescriptions for 259 million bottles of opioids, more than the total number of adults in the country. To put that in perspective, pharmacists dispensed only 13 million more bottles of antibiotics than opioids that year. “Historically, we have vastly underestimated the addictive potential of these products,” says Alexander. Prescription opioids can be just as addictive as heroin, he says; in fact, the drugs are very similar on the molecular level.
While the opioid crisis raises sobering questions for public health officials and policymakers, it also prompts concerns from patients. What should you do when the doctor recommends an opioid? Are there better ways to treat pain? And if you do need to take an opioid, how can you avoid developing a problem? What are the warning signs of opioid dependence?
To understand the drugs’ powerful appeal, we must first peer into our brain. When we feel an intense wave of pain mixed with pleasure—such as from exercising, giving birth, or, in our evolutionary past, escaping from a tiger—endorphins flood the brain, producing waves of euphoria. Opioids fit into the same receptors on brain cells as these natural endorphins, but their effects are exponentially stronger and longer lasting. When the drugs wear off, people crave more. In time, they become habituated to the drugs and feel depressed and ill without them.
Since the dawn of recorded history, people have cultivated the opium poppy and used the sticky fluid from its seed pods to get high. Opium became more widely used in the 1700s and 1800s, as new trade routes swept the drug across the world. Morphine, a derivative of opium, became used as a painkiller during the 1800s, easing the suffering of soldiers wounded in the Civil War. Heroin, another opium derivative, was introduced later in the century as a treatment for morphine addiction. Both drugs were routinely marketed as medicines to treat everything from anxiety to teething. But the U.S. government took steps to curb the sale of opioids in the 1920s, and, with few exceptions, the drugs became tightly controlled.
For decades, doctors reserved opioids for patients in acute pain or with terminal illnesses. But that changed with the introduction of OxyContin in the mid-1990s. The drug’s maker, Purdue Pharma, said that it did not pose the same risks for abuse and addiction as other opioids. Purdue said that OxyContin’s time-release coating would eliminate the highs and lows that people experience on traditional opioid painkillers, making it less likely to be abused. It was a promising moment to introduce a new painkiller—patients and advocacy groups were calling for better understanding of and treatment for pain. The drug’s makers, and many physicians, pointed to what were, in fact, flawed and inaccurate studies showing that OxyContin posed few risks for dependence or abuse. Soon clinicians began routinely writing prescriptions for OxyContin for migraines, back pain, and other common complaints. Many patients became addicted, turning to sham pain clinics, known as “pill mills,” for quick prescriptions. Some even turned to street heroin dealers to feed the craving. The number of heroin users soared from 2002 to 2013, according to the CDC. Three-quarters of new heroin users said they had first become hooked on prescription drugs.
“Health professionals and patients have made the mistake of turning to opioids when there are many alternatives that have a better risk-benefit balance, treatments that are more effective and more safe.”
In 2007, Purdue and three of its current and former executives pleaded guilty to misrepresenting the drug’s dangers and agreed to pay $600 million in fines. But the damage had already been done.
Today many clinicians are keenly aware of the dangers of opioids. But others remain locked in the practice of prescribing the drugs for routine pain, Alexander says. It’s important for patients to be vigilant when offered an opioid painkiller. “Patients have to go into this with their eyes wide open, realizing that these products are highly habit-forming. Don’t be afraid to question your provider as to whether opioids are needed,” he says.
It’s important to have frank conversations with your doctor before you start taking an opioid. Let your doctor know if you have struggled with substance abuse in the past, whether with alcohol or drugs, says Eric Strain, director of the Johns Hopkins Center for Substance Abuse Treatment and Research. Ask how long pain typically lasts for your condition, and see how soon you can switch from an opioid, he says.
Davidson recommends drawing up a treatment plan with your doctor. Set goals for treatment and follow-up visits, she says. “We’re not typically thinking this way if we’re injured or in pain,” she says. “But we really should step back and make it a priority to review the risks and discuss them with our physicians.”
One key question is whether another therapy could relieve your pain. Steven Cohen, the director of the Johns Hopkins Blaustein Pain Treatment Center, finds that physical therapy, yoga, acupuncture, and massage can help his patients. Antidepressants and anti-seizure medications can effectively treat some types of chronic pain. Targeted treatments, such as a steroid injection or radio waves that can wipe out a pain neuron, are also important tools, he says.
“There are lots of things that doctors and other health professionals can use to treat pain,” says Alexander. “We—health professionals and patients—have made the mistake of turning to opioids when there are many alternatives that have a better risk-benefit balance, treatments that are more effective and more safe.”
Of course, that’s not to say that opioids don’t provide crucial relief for some conditions. These drugs are best for acute pain, such as that experienced after a surgery or an injury, Alexander says. They can also ease severe pain suffered by those with cancer or facing the end of life. But for chronic, noncancer pain, there are usually better, safer treatments.
If you do need an opioid prescription, it’s important to follow your doctor’s orders carefully. Never double up doses or take it more frequently than prescribed. And be alert for signs that you might be developing dependence. “If you take the medication and you find it feels good, I would be concerned,” says Strain. That pleasant buzz could be a warning sign that a patient is particularly susceptible to the drug’s addictive properties, he says. “When patients say, ‘The pain was no longer an issue, but I kept taking the medication because I liked how it made me feel,’ that’s a red flag,” he says.
Alexander recommends that patients discuss the risks with their doctors when requesting a refill or second refill of opioids. “Your likelihood of developing an opioid use disorder increases exponentially when you get a second prescription or a third prescription,” he says. Refilling an opioid is an opportunity to consider whether dependence is forming, and whether nonopioid alternatives have been adequately pursued.
Sometimes it may be necessary to recalibrate your expectations around pain, Alexander says. If your pain is mild, it may be better to live with it than run the risk of developing an opioid addiction. The goal is to manage pain so that you can continue to do things you enjoy, not to totally alleviate pain, he says. “Pain is often like an unwanted roommate that you can’t necessarily get rid of entirely,” he says.
Opioid use disorder is a complex but treatable medical condition. A physician can help find the right program to manage withdrawal and to treat the medical and psychological effects of addiction.
It’s particularly important to keep a close watch on teenagers who are prescribed opioids, says Davidson, who treats many adolescent patients. Talk to them about the drugs’ potential for abuse and addiction. Keep the medication locked away, and dispense one dose at a time, Davidson says. Many teens report obtaining the drugs from friends who had legitimate prescriptions.
It’s also a good idea to discuss the risks of opioids with elderly loved ones. While the opioid addiction crisis in younger adults is well-publicized, opioid dependence among the elderly is often overlooked, Alexander says. He believes that many elderly people with chronic medical conditions may be dying prematurely owing to complications of an opioid use disorder. The symptoms are often confused with the normal signs of aging—drowsiness, susceptibility to falls, mental impairment. “The elderly are also at tremendous risk from opioids,” he says. “I think we have underestimated societally the harms or the risks that the elderly have been exposed to.”
Whether you, or a family member, or a friend is taking an opioid, be alert to the signs of addiction. Mood swings, memory problems, nausea, dry mouth, constipation, or changes in sleeping habits could all be symptoms of a problem, Davidson says. If people are spending their days looking forward to the next dose, that’s a big warning, she says, and “there’s a decrease in overall well-being.”
As an addiction deepens, people may lose interest in hobbies and recreational activities, have trouble maintaining a job or relationships, and repeatedly and unsuccessfully vow to stop taking the drug. Withdrawal can bring flulike symptoms, gastrointestinal upset, and anxiety.
If you are concerned that you or someone close to you has a problem with opioids, talk to the doctor who prescribed the drugs, a primary care doctor, or another trusted physician as soon as possible. Opioid use disorder is a complex but treatable medical condition. A physician can help find the right program to manage withdrawal and to treat the medical and psychological effects of addiction.
One way we can all help stem the crisis is to promptly discard any unused pills. I wish I could say I did this when I stopped taking the oxycodone after my surgery. Instead, I pushed the bottle to the back of my bathroom closet. As my belly healed and my baby began to smile and coo, I occasionally thought of the bottle with a twinge of guilt: What should I do with those pills?
It’s a common dilemma, the experts say. “Many, many patients who are prescribed opioids are prescribed more than they need,” Alexander says. “There are millions of bottles of prescription opioids sitting around on patients’ bedroom nightstands, bathroom cabinets, and kitchen counters that are inadvertently contributing to the epidemic.”
These leftover drugs fall into the hands of curious teens or those already struggling with an addiction. And the well-meaning friend who gives you some of her pain pills for your hurt back could be setting you on the road to addiction. “Whether you’re an 18-year-old or a 45-year-old, if you take a prescription that is not prescribed for you, you are gambling with your health,” Davidson says. “You can’t get addicted to something that you never try.”
The best thing to do with unused opioids is to get rid of them. The federal Drug Enforcement Administration has designated numerous pharmacies as safe drop-off spots. You can go online to the DEA’s website where, under its Diversion Control Division, there is a searchable database of controlled substance public disposal locations. Simply input your ZIP code and state, and the site pulls up safe drop-off spots near you. The DEA also sponsors periodic drug takeback days when people can drop off drugs at police stations and other locations. They collected nearly 450 tons of drugs across the country at one of these events last year. And, though there are valid concerns about drugs contaminating water sources, the DEA has declared that it is safer to flush the drugs than to run the risk that they are ingested by children or pets.
For months, I let the bottle of oxycodone linger in the medicine cabinet. I felt a twinge of guilt and anxiety each time I saw it. Then, after I researched how to safely dispose of opioids, I got rid of them. And finally I breathed a sigh of relief.
Talking to Your Doctor About Opioids
1. Tell your doctor if you or a close relative has a history of substance abuse.
2. Ask if there are alternative treatments or therapies.
3. Find out how long most people with your condition experience severe pain.
4. Make a plan to re-evaluate your symptoms and the opioid regimen.
5. Book a follow-up appointment.
6. Ask about safe ways near you to dispose of opioids.