When Pain Kills
46 Americans overdose on painkillers each day — and the numbers are rising for those over 55
En español | After years of suffering from a degenerative back condition, Betty Tully worried that she was already taking too many pills. But when her doctor reassured her that a long-acting opioid medication called OxyContin would fight her pain without any negative repercussions, she decided to try it. At first the pills helped. As their effectiveness diminished, though, she had to take more and more pills to get any relief at all. "Within seven months I was taking 280 milligrams a day," says Tully, 68, who lives in Chicago. "That's the equivalent of 56 Percocets a day. I was completely addicted." When a new doctor balked at refilling her prescription, she discovered what heroin addicts go through when they can't get a fix. "My body was screaming for the drug. My brain was screaming for it."
Health experts have long warned of a growing epidemic of addiction and overdose related to opioid prescription pain meds (morphine, oxycodone and hydrocodone are the most common). Every day, 46 Americans die from using prescription painkillers. In recent years, older Americans like Tully have increasingly fallen victim. Between 1993 and 2012, the rate of hospitalizations for prescription pain-pill overdoses increased fivefold among people 45 to 85 — much faster than for younger adults, according to data from the Agency for Healthcare Research and Quality. The rate of overdose deaths for adults ages 55 to 64 soared sevenfold. The group with the highest death rate was the 45-to-54 age group — more than four times the rate for teenagers and young adults.
And those statistics probably underestimate the true toll the epidemic of pain pills is taking on older Americans. "If a young or middle-aged person doesn't wake up in the morning, the death immediately looks suspicious and the medical examiner is called in," says psychiatrist Andrew Kolodny, chief medical officer for Phoenix House, a national nonprofit addiction treatment agency, and a leading expert on opioid addiction. "But when an older person with multiple medical problems doesn't wake up, death is more often attributed to natural causes, even when the true cause is an accidental opioid overdose."
Older Americans are at high risk of running into trouble for several reasons, explains David J. Tauben, M.D., clinical professor and chief of the University of Washington's Division of Pain in Seattle. "For one, they're more likely to suffer chronic pain and to be prescribed an opioid drug for it. Second, the body's ability to clear drugs from the system declines with age, so a safe dose for younger people can be an overdose for older patients." The danger is compounded when people are taking several different drugs that have to be cleared through the liver or kidneys — such as medications for heart disease or diabetes — as many older people do. "Adding opioid pain medications to a stew of other drugs is a very risky venture," Tauben says.
Opioid pain medications can also prove deadly for older patients who have trouble keeping track of their pills. "If someone on an 80-milligram dose of oxycodone forgets they took it and takes another, there's a good chance of a fatal overdose," Kolodny says.
Good intentions gone bad
Opioid pain medications can help for acute pain — following an injury or surgery, for example, when they provide relief while the body heals. They can also control pain at the end of life. But because of the risk of addiction and overdose, opioids traditionally were rarely prescribed for cases of chronic pain.
That changed in the late 1990s with new campaigns that encouraged doctors to take chronic pain more seriously. Backed by the American Pain Society, the American Academy of Pain Medicine and other professional groups, the campaigns had the laudable goal of encouraging doctors to be more aggressive in relieving chronic pain, which afflicts an estimated 100 million Americans. One campaign, called "Pain is the Fifth Vital Sign," suggested that pain should be considered as important an indicator of health as blood pressure or pulse.
But the push for wider use of painkillers was largely financed by drugmakers with a vested interest in making money, Kolodny says, "and they vastly understated the risks of addiction and greatly overstated the effectiveness of these drugs. Physicians were given the impression that the drugs are far safer and more effective for chronic pain than they actually are."
Between 1996 and 2002, Purdue Pharma, the maker of OxyContin, funded more than 20,000 educational programs for doctors, many of them promoting long-term use of opioids for chronic pain.
"For more than a decade, we were told that these medications are safe and effective," says Jason Hoppe, an emergency room physician who has studied how opiates are prescribed by ER doctors.
The campaigns worked. Over the next 15 years, the rate of opioid pain reliever use more than doubled in the U.S. Consumption of oxycodone — the drug Tully was given — increased nearly fivefold. By 2012, 8 percent of adults 40 and over reported taking an opioid painkiller in the past 30 days.
The irony, say experts, is that despite decades of prescribing, researchers still know little about the actual risks and benefits of taking these powerful drugs long-term. In 2014, Roger Chou, a professor of medicine at Oregon Health and Science University, and his colleagues searched the medical literature and found almost no studies that looked at the long-term use of opioids. Do the drugs enable people beset by chronic pain to function better? No one really knows.
"Most trials followed patients for about six weeks," said Chou — certainly not long enough to see what happens when people take them for months or even years, the way chronic pain patients typically do. "We know that people develop tolerance over time, which means you need a bigger and bigger dose. That's something we see with very few other drugs, and don't see with other non-opioid pain medications. And we know that people who take an opioid drug for three to six months are highly likely to still be taking it years later."
While Chou and his team found little evidence that long-term opiate use helps, they did find compelling evidence of potential harm, including risk of overdose, abuse, heart attacks, falls, fractures, constipation and sexual dysfunction.
A delicate balance
In response to this runaway painkiller epidemic, federal officials in recent years have launched educational programs for physicians, designed to halt the overuse of opioid drugs. The Centers for Medicare & Medicaid Services have established a monitoring system to spot patients who may be overusing opioids. And the FDA has issued separate guidelines on the safe use of opioid painkillers.
Those efforts are beginning to work. The rising curve of opioid prescriptions has begun to level off. But while most experts agree that opioids should be used much more cautiously, there's less agreement about exactly who should take them, and for how long.
"Based on everything we know, daily use of strong opioid pain medications is a lousy option for most patients with chronic pain," Kolodny says. "These are drugs that become less effective at controlling pain over time, and ultimately may even make people more sensitive to pain. And once people have been taking them daily for a few weeks, it can become very, very difficult to stop."
At many major pain clinics around the country, in fact, including the Mayo Clinic, one of the first goals is often to get chronic pain sufferers off opioid medications.
But some experts say opiates still have a role in treating chronic pain, as long as they are very carefully prescribed. "We take some patients off opiates. But we also leave some patients on them," says James W. Atchison, medical director of the Rehabilitation Institute of Chicago's Center for Pain Management. "Everything comes down to how you are functioning. If your pain medication helps you function, great. If it's making you groggy and you're still in a lot of pain, you need to come off the medication."
One challenge with opioid painkillers is the exceedingly narrow line between benefit and harm, according to Joseph W. Shega, M.D., an expert in geriatric medicine who is regional medical director for VITAS Healthcare. "Doctors need a lot of expertise in prescribing and monitoring patients on these drugs." Still, he says, some chronic pain patients can benefit from low doses of opioids. He describes an older patient with severe neck and shoulder pain who was referred to him when her physician became concerned that she was addicted to opioids. Shega kept the patient on the medication but strictly limited how much she could take a day. He also treated her pain in other ways.
No magic bullets for pain
"What we've learned is that throwing medication at chronic pain isn't going to make it go away," Chou says. "And there are clear risks to using these drugs." Even nonsteroidal anti-inflammatory drugs, or NSAIDs, can be hazardous. In July the FDA issued new alerts about the risk of heart attack and stroke associated with drugs such as ibuprofen and naproxen.
If opioid pain medications are used at all, they need to be carefully prescribed and closely monitored. Patients need to be better informed about the limitations and hazards of pain medications. "Opiates and other pain medications are not a panacea," Tauben says. "Studies suggest they can reduce chronic pain intensity by at most 30 percent."
Fortunately, other approaches to pain relief — physical therapy, stress management, yoga — can help.
Betty Tully eventually turned to physical therapy and weight loss to help control her pain — but not before she checked herself into a detox program to wean herself off the opioids. "No one told me that what I was on was comparable to heroin," she says. "If I'd known, I would have never started taking it." To spare other patients the anguish she experienced, she joined Kolodny to form the nonprofit Physicians for Responsible Opioid Prescribing, to inform others about the risks and benefits of pain medications. "Mostly I've learned to live with a certain amount of pain. I accept it and try to live as full a life as I can."
How to Stay Safe
If you're currently taking an opioid pain medication, here's what you need to know to use it safely and effectively:
Start low and go slow
"Older adults should start with half or even one-quarter of a standard dose," says Joseph W. Shega, M.D., a pain expert at VITAS Healthcare.
Tell your doc about other meds you take
One of the biggest risk factors for overdose and death from opiates is mixing them with alcohol or other medications. The combination of benzodiazepines (sometimes prescribed for anxiety or insomnia) and opioids is especially hazardous.
Follow up frequently
To monitor how you’re doing, your doctor may need to see you frequently, in some cases monthly. Your doctor may also order a urine test to measure opiate levels in your system.
Don’t expect any pain medication to be a magic bullet. Most only ease pain, and all of them have risks. “Often we can’t eliminate the pain,” says James W. Atchison of the Rehabilitation Institute of Chicago’s Center for Pain Management. “But we can help people with chronic pain live their lives as fully as possible.”
Keep medications safe
Opioid pain relievers are a frequent target of thieves, who then sell them on the street. Store painkillers in their original packaging in a locked cabinet or lockbox, and keep track of how many you’ve taken.
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