What we need to understand about opioids (Transcript)

Dr. Jen Gunter:
Hi everyone, I wanted to give you a heads up that we mention substance abuse and suicide in this episode. Please keep that in mind as you’re listening, and think about who might be listening with you. I was 40 miles into a 60 mile bike ride, and feeling GREAT, representing the 55-year-old ladies!…and then…my wheel got caught in some tram tracks. Before I could think or react, I was crashing into the pavement. HARD. Lots of things hurt, and I was scraped up pretty badly. I did the thing we doctors do so often… pretend it was nothing… but the pain in my chest was something I hadn’t experienced before. Every breath was agony and it was getting worse. I was sure something was broken. It got so hard to breathe that I started worrying a broken rib might have punctured my lung…At the ER, I waited…and waited and waited. I finally got an exam and after diagnosing 2 broken ribs – no punctured lung – the doctor offered me opioids for the pain. I wanted to try Tylenol first, because I know it’s a really effective pain reliever. But my request was so unusual, it took what felt like ages to get the Tylenol and by that time, the pain was nearly unbearable. And I was getting really anxious. I felt I had no other choice, so I took the opioids. Eventually I left the hospital with 7 days worth of opioids…medications that can have big consequences…and I left with not much guidance about how to take them…and NO guidance about how to STOP taking them.

I’m Dr. Jen Gunter and from the TED Audio Collective, this is Body Stuff… Chances are, at some point, you or someone in your life will take opioids: they’re a common pain medication.

So, what are all the risks of opioids? And are they as effective as many of us think they are?

In this episode…what you need to know about your options for treating pain, and what to do if you’re prescribed opioids…

[AD BREAK]
Dr. David Juurlink:
I get branded a little bit as an anti opioid zealot because I think that doctors should prescribe opioids in a different way than we currently do. And certainly differently than we did say 10 or 15 years ago.

This is Dr. David Juurlink. He started his career as a pharmacist. Now he’s an internist, a pharmacologist, and a toxicologist.

Dr. David Juurlink:
I deal with drug related problems pretty much every day. And I spend a fair bit of time doing research in the field of drug safety as well.

Dr. Jen Gunter:
So before we talk about opioids, I want to talk a little bit about pain. I was hoping maybe you could, could give me a definition of what you think pain is.

Dr. David Juurlink:
The international association for the study of pain has a formal definition. And in their definition it's an unpleasant sensory and emotional experience associated with actual or potential tissue damage.

Dr. Jen Gunter:
Though we’re usually focused on making pain go away, it’s actually something we need to survive...Pain tells you something is wrong…You stubbed your toe! You burned your hand on the stove! You fell off a bike and broke a rib! Pain gives you a message that it’s time to rest, recover, and treat the damage. It warns you not to re-injure yourself. That’s the sensory component. But pain is emotional and psychological too. Worrying about pain can amplify it…the longer I waited in the ER, the more worried I got… and the more pain I felt. Think of pain as a fire, and anxiety as gasoline on that fire.

Dr. David Juurlink:
I think a lot of pain is about worrying about the future, thinking about, you know, five minutes from now or five days from now, or five weeks or five months from now, whether you're going to be still grappling with the same problem.

Dr. Jen Gunter:
Usually, once we treat the pain, our brain essentially shuts off the pain message. But sometimes, that whole system goes awry. With chronic pain, we think the pain signal might be firing even when nothing is causing it. It’s like a computer virus has changed your brain’s wiring. That means your brain is sending pain signals when it doesn’t need to. Whether pain is acute or chronic, we want to avoid it! For doctors, like me, relieving pain is a big part of our job. Pain can be created by different chemical signals and receptors. Medications like Acetaminophen (Tylenol) or NSAIDs like Ibuprofen, Aspirin, and naproxen primarily treat pain by affecting enzymes that produce prostaglandins. Those are chemicals that generate inflammation…and pain. OPIOIDS treat pain by targeting your opioid receptor system.

Dr. David Juurlink:
This opioid receptor system is very sophisticated. Very sort of highly evolved and it's not just about pain relief. It plays a role in mood and bonding and a whole host of other factors.

Dr. Jen Gunter:
Our body actually makes hormones that bind to opioid receptors — you’ve probably heard of them… endorphins.

Dr. David Juurlink:
You can view them as natural pain relievers.

Dr. Jen Gunter:
Opioids are made from the opium poppy plant or synthesized in a lab... Either way, they bind to our body’s receptors too.

Dr. David Juurlink:
And this is part of how these drugs work. I mean, in terms of their ability to reduce pain. And so well-intentioned doctors like you and me, we come along and we give people morphine or oxycodone or hydromorphone and the goal there is to make the patient feel better by tickling these same receptors. What we're really doing is we are flooding these receptors with concentrations of chemicals at massively higher concentrations than our endorphins.

Dr. Jen Gunter:
Opioids can provide more pain relief than our endorphins can on their own. BUT, here’s the big myth about opioids… probably part of the reason why everyone in the hospital was confused when I asked for Tylenol instead of opioids…

Dr. David Juurlink:
There's this mythical perception that they're our best, strongest pain pain relievers. And there’s just nothing to back that up. There have been dozens,
if not more than a hundred studies, randomized trials, comparing opioids to antiinflammatories for acute pain. In no study are they shown to be better. I mean, in almost every study when you compare opioids to anti inflammatories in a proper rigorous design, anti-inflammatories win from a safety or effectiveness perspective or both.

Dr. Jen Gunter:
You heard that right…Dr. Juurlink has not come across a single, well-designed study that shows opioids are more effective at treating acute pain — from sprains and strains all the way to broken bones that don’t require surgery. But the myth that opioids are our best pain relievers has HUGE effects on how we prescribe and use them...People are often sent home after surgeries with more opioids than they report needing — sometimes TWICE as many! And some people who are prescribed opioids after a procedure STAY ON THEM….

Dr. David Juurlink:
If you look at people who aren't on opioids, they come to the hospital. They have their gallbladder removed or their appendix removed, or they have a whole litany of different kinds of surgeries. If you then look down the road and say, okay, how many of these people who went home on an opioid are still using an opioid 90 or 180 days later? It varies, but somewhere between five and 10 or 12%, that's just an astonishing, astonishing figure that you, that you go in for an appendectomy or a vasectomy there's vasectomy at 7% of men who get a vasectomy and who get an opioid are still on opioids, you know, three months later, that's just mind-boggling.

Dr. Jen Gunter:
One study on opioid prescribing really shocked me. It found that young people between 13 and 30 who get an opioid prescription for their wisdom teeth removal were nearly three times as likely as their peers to be using opioids weeks or months later. So, why have doctors turned to opioids so often over the last few decades? Dr. Juurlink points to a couple things. First medications like Tylenol or Aleve have a clear dose ceiling…a point where giving a patient more, will NOT improve their pain. Opioids do NOT have a natural dose ceiling…And there are some situations where medications with a dose ceiling simply can’t provide enough pain relief. When someone’s in extreme pain, like after a big surgery, or maybe even a couple of broken ribs, opioids might be the best option for pain relief, because you can increase the dose if needed. But not all pain requires that approach… and yet, opioids often became the default treatment. And some of this was caused by the World Health Organization’s pain ladder.

Dr. David Juurlink:
You know, It had at the apex of the pain ladder, strong opiates, like morphine and hydromorphone, but below that, you know, weak opioids and below that anti inflammatories and so on. And what it really means is you should be going to opioids last, but there's this perception that maybe they're actually better. Cause we're at the top of the pyramid. Maybe they work better than the things below it.

Dr. Jen Gunter:
Dr. Juurlink says doctors also turn to opioids because of another common misconception…that they have limited side effects.

Dr. David Juurlink:
If I have a good medical student with me and I say to him or her, hey, you know, you want to put a patient on pain medicine. You know, let's think about some of the options and first they’ll float Acetaminophen as one option and they'll float anti-inflammatories as another. And when I ask them to tell me what the potential side effects of those drugs are, a reasonably capable medical student will identify liver problems with acetaminophen and they'll identify gastrointestinal and kidney problems with anti-inflammatory meds. And then you go to opioids and you ask them, okay, what are the side effects of opioids? And most capable medical students will say constipation and sedation. And if you take too much, you can fall into a coma, respiratory depression and you can even die. But for many docs, I think that's kind of where it ends.

Dr. Jen Gunter:
BUT there is a pretty long list of other side effects: sleep apnea...osteoporosis...suppressed testosterone levels...increased risk of car accidents…falls and fractures... depression, and…hyperalgesia… where opioids can actually worsen pain. People can also develop TOLERANCE, where they need increasing doses to achieve the same effect. Which, in turn, increases their risk of side effects. And one other very important and misunderstood side effect is one you’ve probably heard about…physical dependence. Dependence and addiction are different. Opioid addiction is a complex medical disease, where people often continue to use opioids, despite harmful consequences. When someone is physically dependent on opioids, they might not even know they’re dependent! But their brain and spinal cord – their opioid receptor system – has adapted over time to expect opioids. And when they don’t take them, they have symptoms of withdrawal. What a lot of people don’t know – and what a lot of people NEED TO KNOW — is how quickly you can develop opioid dependence…

Dr. David Juurlink:
I polled doctors some years ago on Twitter. I said, how long has it taken before dependence happens? And I think the, I think the average was kind of seven or 14 days, right? And that's not true. It happens within, a couple of days. I've had, I have some colleagues here at my hospital and after three measly days of taking hydromorphone pretty much around the clock, they said, I should probably stop it. And they had obvious…They saw it in themselves, obvious opioid withdrawal. They had GI cramping and diarrhea and irritability and their hair standing on end. We would call it dope sickness in a person who is injecting heroin or fentanyl. It's physiologically no different when you're given a prescribed opioid by a doctor.

Dr. Jen Gunter:
Like addiction, opioid dependence can be devastating. Dr. Juurlink remembers reading the story of a bioethicist, Travis Rieder, who got a few surgeries after a bad motorcycle accident…

Dr. David Juurlink:
At the two month mark, he goes to see his orthopedic surgeon. And the orthopedic surgeon says, oh, you're doing pretty well. You probably should come down on the pills there. By this time he's on 120 milligrams of oxycodone a day, which is quite a lot. He's not addicted. He's not, he's not crushing his pills up or injecting them. He's not going to different doctors. He's just doing what the doctor told him to do. So he goes, okay, I'll just, I'll just taper myself. He recounts, being unable to sleep spontaneous crying, he near the end of his taper thought of ending his life. It is a testament to just how pernicious a problem dependence is. He wasn't addicted at all. He had just been on opioids for two months and went through hell trying to come off them.

Dr. Jen Gunter:
Dr. Juurlink says dependence is tricky because it can make it look like opioids are doing a lot to relieve pain. In reality, your body has become physically dependent on opioids. So when you stop taking them, there are changes in the brain that produce symptoms…like nausea, vomiting, and…PAIN.

Dr. David Juurlink:
It comes to masquerade as ongoing benefit, But when you step back to 35,000 feet, you realize that those effects, they're largely in part because the patient's been on opioids.

Dr. Jen Gunter:
In other words, pain during withdrawal can be a result of the dependence itself, not a sign that the opioids were successfully treating pain. But imagine how hard it is to untangle those things when someone is suffering and just wants to stop hurting. It gets even harder to do that when so many people, including doctors, believe the myth that opioids are the best painkillers! The whole picture of whether opioids are helping — and how much damage they’re doing — gets muddled. It took time for all of these misconceptions about opioids to evolve…When Dr. Juurlink was working as a pharmacist in the mid-1990s, he remembers most opioid prescriptions were for end-of-life or cancer care…and they were pretty rare.

Dr. David Juurlink:
Fast forward to say 2000, just another five years. And I was an internist practicing at this hospital in Toronto where I still am. And it was very common to see people coming in on Oxycontin in particular, because that was the main drug that led the charge, on much higher doses than we would ever have seen. And I look back and kind of cringe in hindsight, in hindsight at how I practiced say 20 years ago.

Dr. Jen Gunter:
But doctors and patients were in a situation created by decades of decisions and policies…

Dr. Keith Wailoo:
American society is defined by this capacity for commercial enthusiasm. And we often find ourselves kind of confronting and dealing with the consequences 10, 15, or in the case of the opioid crisis, 20 or so years down the line.More about that after the break…

[AD BREAK]

Dr. Keith Wailoo:
God's own medicine is how some 18th and 19th century physicians referred to it.

Dr. Jen Gunter:
Dr. Keith Wailoo is a medical historian at Princeton and the author of Pain: A Political History. He says for centuries…opium was used to treat all kinds of pain, and diseases…

Dr. Keith Wailoo:
Let me give you an example, you know, in an atmosphere where you have diseases associated with diarrhea, dysentery, and the loss of fluids, opium is incredibly powerful, not only as a painkiller, but as an astringent, it binds the bowels. So opium is very crucial in a cholera epidemic. It's absolutely vital medicine, right? For treating children, for treating young adults, and for treating adults as well.

Dr. Jen Gunter:
As we developed ways to break opium down into different products, opioids became more and more widespread…and commercialized. Dr. Wailoo says…you can follow that commercialization…right up to today’s opioid crisis. One of the biggest opioid pushes started around World War II. There was a lot of national pride in the pharmaceutical industry — they had just produced penicillin to treat infections on the battlefield! So when drug companies rolled out new painkillers like Demerol and Percodan, doctors were interested.

Dr. Keith Wailoo:
Modern medicine has always been looking for the perfect alternative to Morphine, the non-addictive painkiller. Right? And so there's a lot of enthusiasm for the powers of synthetic chemistry and pharmaceutical production to produce that.

Dr. Jen Gunter:
These new opioids were especially enticing because at the time, options for treating pain were…limited.

Dr. Keith Wailoo:
One of them might be to call in a neurosurgeon, who might conduct a lobotomy, and the weird kind of logic here was that what you were doing was removing not the pain center of the brain, but you were removing a part of the brain that reduced the likelihood that the patient would complain.

Dr. Jen Gunter:
Drug companies also worked hard to get more doctors prescribing these painkillers…

Dr. Keith Wailoo:
They were employing drug representatives to meet with physicians, uh, you know, the kinds of things that we consider today to be undue influence on medical practice.This was the heyday of that spectrum of activities.

Dr. Jen Gunter:
Right. Yeah. So let's take you all out for golfing and, buy you whatever. And hey, by the way, let me detail you on my, on the Percodan.

Dr. Keith Wailoo:
That's right.

Dr. Jen Gunter:
By the 1960s, it was becoming clear that these new drugs could be addictive. Meanwhile, a new theory of pain became popular — that pain is subjective, experienced differently by all of us…and that treating it might require a range of options. Not just a single pill or surgery…

Dr. Keith Wailoo:
John Bonica, who is seen as one of the founders of pain medicine in the post-war era he helped to create something that became a model for many decades, which is the multidisciplinary pain clinic. The idea that to be really effective at that holistic vision of understanding pain and treating it, you might need a psychologist. You might need a social worker, you might need a surgeon.

Dr. Jen Gunter:
The pain clinic model was very forward-thinking, but it started to disappear…I’ve read some of the studies from these clinics. Even though they showed good outcomes, they kind of vanish from the record over time…

Dr. Keith Wailoo:
What does it cost to maintain this multi-disciplinary orientation towards pain? It became increasingly difficult to sustain in an era of cost containment so increasingly what you have is to be frank, a kind of search for the quickest fix and this story coincides in the 1980s with another set of trends. And that is the emergence at the federal level with a sense that, you know, the market could solve our problems far better than government could. And that what we needed was to relax regulations and controls and allow the market to flourish.

Dr. Jen Gunter:
This led to mind-boggling new policies…policies that released some new opioids into the market before we could learn much about their effects…

Dr. Keith Wailoo:
What you have are new phenomenon, like direct to consumer drug advertising, and you have this sense that, the FDA's role was not to stand in the way of drug production, but to let drugs like come onto the market to solve the problems of American society. and we'll figure out in the aftermath how much of a problem it is.

Dr. Jen Gunter:
Take OxyContin, for example. It’s one of the most prescribed opioids on the market. When it first came out, regulators didn’t follow due diligence regarding the manufacturer’s claim that it was less likely to be addictive.

Dr. Keith Wailoo:
Well that was naive from the outset and a different regulatory environment, might've looked askance at that.

Dr. Jen Gunter:
But once again, companies marketed these new opioids, especially OxContin, aggressively to doctors. I remember it. So does Dr. Juurlink….

Dr. David Juurlink:
The big messaging that was out there, was that the risk of addiction was less than 1% with chronic opiate therapy. I still don't know why I didn't ask the pain thought leaders at the time. How do you know that? As it turns out the evidence for it was abysmal. It was, it was, it was actually largely based on a single five sentence letter to the editor in the back issues of a 1980 New England journal of medicine. That single 100 word letter to the editor was cited as evidence that addiction was a rare consequence of opioid therapy. So it's kind of amazing in hindsight that they were approved, but they were, and, we now had, effectively authorization and lots of expert endorsements to go ahead and prescribe opioids in a way that we had never really done before.

Dr. Jen Gunter:
This big push to let drugs onto the market without much oversight, led to what Dr. Juurlink calls a decades-long experiment on the North American population…

A disastrous experiment. From 1999 to 2019, HALF A MILLION people in the US died from opioid overdoses.

Dr. Keith Wailoo:
It's a story of this unseemly and disturbing mix of how capitalism and the desire for profit could flood communities with this substance and how long it takes to kind of recognize what's been going on and then try to hold the actors accountable.

Dr. Jen Gunter:
Dr. Wailoo says the blame for the opioid crisis kept shifting, from “bad patients” to “bad doctors”…and then finally, to drug companies and consultants who helped them turbocharge sales…Attorney generals across the country are trying to hold the drug companies accountable… and getting big settlements out of some of the lawsuits…Unfortunately, I haven’t seen much of a push to use this money to fund multidisciplinary pain clinics… even though we know they work well.

Dr. Keith Wailoo:
Yeah. So this is one of the most unfortunate things I think about the opioid crisis. I do think that the era of the sixties into the 1970s, in which you see this broad embrace of multi-disciplinary ways of thinking about pain, there's a lot to be learned by reflecting on the fact that the reason why that path was not followed was because we allowed increasingly narrow economic concerns to really inhibit and undermine a true, truly expansive understanding of what pain is. And how we might create a system that serves people in pain far better than we do today.

Dr. Jen Gunter:
We need an approach to pain that considers the bigger picture. That means taking a step back from opioid receptors and looking at pain holistically. Because pain is highly individual. Our experience of it is affected by many factors — genetics, pain in other areas of the body, stress, anxiety, and past trauma to name a few. And we all respond differently to pain treatments. For instance, some people feel achy, groggy, and nauseated when they take opioids — and others find opioids really help with their pain. So where do we go from here? Dr. Juurlink says the first step is understanding that opioid use is a spectrum.

Dr. David Juurlink:
There are people on, on the one end of the spectrum who have opioid addiction. And they need access to things like buprenorphine and methadone
and supports in employment and housing and stuff like that.

Dr. Jen Gunter:
In the middle of the spectrum, there are people who have been on opioids for a while and are dependent on them. Cutting them off suddenly would create horrible withdrawal symptoms.

Dr. David Juurlink:
When I have those patients in hospital, it's not a five minute visit. I pull up a chair, I sit down at the bedside and we talk for maybe an hour or sometimes more about the potential benefits of a very, very gradual patient centered opioid taper. And we'll engage in a taper over the span of months, or sometimes even years and it's amazing how often their pain and quality of life will actually improve when it's done in a thoughtful way.

Dr. Jen Gunter:
The last part of the spectrum is people who aren’t on opioids but might be one day. That’s a lot of us! If you’re offered opioids, there are a few things you can do to make sure you’re getting responsible care. First, ask about alternatives to opioids, like Tylenol, NSAIDs, muscle relaxants and physical therapy. There may be more effective, safer ways of treating your pain. Second, if opioids ARE the best option for your pain, make sure your doctor has a plan to taper you off them. You shouldn’t just be handed a prescription like I was and sent away to manage it on your own…

Dr. David Juurlink:
I like to say that it's like flying a plane, right? You wouldn't take off if you didn't know how to land.

Dr. Jen Gunter:
I knew about the risks of dependence, so I made my own plan for tapering. And I asked my partner to keep me on track — it’s easy to be forgetful or confused when you’re in pain. But, I only knew to do that because I’m a doctor! You shouldn’t have to figure it out on your own.Third, if you or a loved one are prescribed opioids, ask for naloxone too. Naloxone can reverse an opioid overdose. Like I said, it can be easy to forget if you’ve taken a dose and you never know who in your household could take your medicine. So naloxone can literally save a life. When I asked for naloxone, the ER doctor looked at me like I was asking for a ticket to Mars. But it should be standard practice. Understanding what opioids can and can’t do…and their risks…is as important as knowing what your car can and can’t do, and the risks of driving. And we’ve got to do a better job of giving everyone the rules of the road…the information they need to make informed decisions and get responsible pain treatment. If you or someone you know is struggling with substance abuse or thoughts of suicide, the Substance Abuse and Mental Health Services Administration’s helpline is free, confidential, and available 24/7 at 1-800-662-4357. That’s 1-800-662-4357.

Next time, on Body Stuff, we take on a particularly debilitating kind of pain…

Guest:
So excruciating, I couldn't get out of bed.

Dr. Jen Gunter:
What to do if your BACK hurts. And how to avoid back treatment scams. Body Stuff is brought to you by the TED Audio Collective. It’s hosted and developed by me, Dr. Jen Gunter. The show is produced by TED with Transmitter Media. Our team includes Mitchell Johnson, Poncie Rutsch, Gretta Cohn, Michelle Quint, Banban Cheng, Sammy Case and Roxanne Hai Lash. Phoebe Wang is our sound designer and mix engineer.

This episode was written and produced by Camille Petersen and edited by Sara Nics.
Fact checking by the TED fact checking team.

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