The Pits and Pearls of Prescription Pain Medication
By Katie E. Golden, MD
Most Americans are aware of the opioid crisis that has become a high priority public health concern. Over the last two decades, the alarming increase in fatal overdoses across the country has placed these medications under the microscope. The healthcare industry is learning more about the true addictive nature of opioids, and if they are truly an effective (and safe) long-term solution to chronic pain. This has led to a number of country and state-wide policies designed to protect the patients who are prescribed these medications. Given that emergency medicine doctors and PAs frequently treat pain-related conditions, we want to do our best to educate our patients on the safe use of opioids, and the new policies in place in our state to ensure they are prescribed safely.
What is an ‘opioid’?
Opiates and opioids are a class of substances used to treat pain. They are defined by their chemical structure, which allows them to bind to ‘opioid’ receptors, which are present on neurons throughout the body. When they bind to these nerve receptors, they suppress the part of our nervous system that is specifically responsible for the perception of pain. These medicines were first discovered from natural plants, namely the poppy plant. Morphine (and its recreational equivalent, heroin) contain this naturally derived molecule, and are technically called true ‘opiates.’ We have since replicated these molecules in labs, and named them ‘opioids’, which include medications like hydrocodone, oxycodone, dilaudid, and fentanyl (to list a few).
Why are these medications dangerous?
As with any medicine that performs a powerful job in the body – like taking away pain – the side effects of these drugs can be significant and potentially life-threatening. Before we review the guidelines for using these medications safely and effectively at home, we want to highlight some of the potential dangers that every patient needs to know before taking an opioid:
- One of the most common reactions to these medications is nausea and vomiting. While this is not particularly dangerous, these medicines can often make a patient feel unwell or ill, which can sometimes be more unpleasant than the pain itself.
- Patients often get drowsy with opioids. Older adults can have more severe changes in their mental state, and become very confused or even hallucinate. At the very least, this can be distressing to both the patient as well as caregivers. In more serious cases, this can lead to falls (and subsequent injury) or full loss of consciousness.
- An equally concerning side effect of these medicines is an associated drop in blood pressure, which can lead to many different complications. A low blood pressure can separately lead to symptoms of nausea, weakness, drowsiness, or again, full loss of consciousness. When a drop in blood pressure is combined with some of the other side effects listed above, it can sometimes lead to serious impairment of some of the body’s essential organs (like the brain, heart, and kidneys).
- The most well known, and dangerous immediate complication of these medicines is their effect on our breathing. At moderate to higher doses, they impair the part of the brain that subconsciously tells us to breathe. This means that as the medicine starts to take effect, a patient’s breathing can become slower and more shallow, or even stop completely. This is the most common way that opiates and opioids lead to unintentional death.
- A longer-term consideration and concern is, of course, the risk for dependence and addiction to these medications. This is a very real risk that should be taken into consideration any time these medications are prescribed, and therefore these medicines need to be taken with caution. We have outlined the ways to use these medicines effectively below, which provide concrete guidelines for the safest use of these medications at home.
What is the safest way to use these medications?
As patients often come to the ER in the setting of pain – kidney stones, fractures, infections – some patients may receive prescription pain medication for use after their visit. When this is the case, informed use of these medications is critical to ensure patient safety. If you or a loved one are prescribed an opioid for pain, please be sure to review the following guidelines:
- These medications are intended to be used only for SEVERE pain, when less-addictive pain medications are not providing relief. Please keep in mind that while over-the-counter options are often viewed as inadequate, ibuprofen (Advil) and acetaminophen (Tylenol) are surprisingly effective at treating pain, especially when used together. In fact, several research studies have shown them to be MORE effective than opioids, especially in treatment for muscle or skeletal pain, like fractures or lower back pain. So always try these medicines first when possible, and only take the prescription pain medication when absolutely necessary.
- It is most important to understand that opioids are rarely a long term solution for pain, and instead are intended to make a newly painful condition more manageable. We prescribe these medications so a patient can maintain daily functions despite their injury or condition, not to alleviate their pain completely. If you are prescribed hydrocodone for a fractured arm, for example, it should be used so you continue to care for yourself and engage in your daily activities (like work or school). If taking these medications leaves you more inclined to lay in bed, fall asleep, postpone an errand or a shower, etc, they are not being used effectively or the way they are intended.
- The patient (or caregiver) must be vigilant and disciplined in monitoring the use and response to the pain medication, and wean off the medicine as early and quickly as possible.
- Opioids can be very dangerous when combined with other substances or medications. This includes both recreational substances (like alcohol or other drugs), as well as other prescription medications (like anxiety medications, antidepressants, sleep medications, muscle relaxants, to name just a few). These combinations can sometimes lead to unpredictable, or even life-threatening effects on the body. Your doctor should discuss this with you before prescribing a new pain medication, but if you have any concern about the effect of combining two medications, please consult with a medical professional first.
- Please do not drive a car (or operate any heavy machinery or dangerous tool) while prescription pain medication is in your system. Even if the medication does not make you feel intoxicated, it can impair your reaction time and judgement in ways that can be difficult to predict.
What are the new policies in North Carolina regarding opioid prescriptions?
Since 1999, North Carolina has seen a 350% increase in deaths from opioid overdose. Our state is concerned about the escalating misuse of prescription opioid medications, and so the legislature has passed the ‘STOP Act’. The law follows guidelines released from the CDC in their nation-wide efforts to address opioid-related death:
- It places restrictions on prescription pain medication for non-chronic pain. Patients who take prescription pain medication for chronic conditions will not see new restrictions.
- For pain from a new condition and post-operative pain, prescribers are limited to providing a 5 and 7 day supply (respectively) of medication. This does not mean that additional pain medication cannot be prescribed, but a patient will need to be re-evaluated by their doctor to determine if this is necessary and in their best interest.
- As prescribers, we are mandated to review a patient’s prescription history (controlled substances are closely monitored in a protected database) to ensure they are not receiving too many prescriptions or pain medication from an alternate source.
As ER doctors, we are committed to ensuring our patients receive the appropriate treatment (and alleviation from their pain), while making their safety and health the number one priority.