Medicalization is the process in which a non-medical problem becomes defined and treated as a medical problem (Conrad, 1992). There are copious amounts of evidence suggesting that medicalization has increased and changed over the past couple decades with the emergence of new diagnoses, one being chronic pain (Møller & Gormsen, 2010). Chronic pain is defined as pain that persists for longer than three months and extends its expected healing process (Ling, 2017). When referring to the medicalization of chronic pain, it is the pain itself that is deemed a medical problem, not just a symptom, sign, or by-product of another diagnosis (Møller & Gormsen, 2010). As a result of recognizing chronic pain as a discrete medical condition, the focus has shifted from eliminating pain to managing it (Møller & Gormsen, 2010). One avenue for managing chronic pain that has gained popularity is the use of prescription opioids. Opioids are a class of medications that are known to help alleviate severe and/or chronic pain (Vowles et al., 2015). Today, opioid analgesics are widely being used to ease chronic pain in patients, however, heavy concerns have been raised in recent years regarding the addiction, abuse, and misuse of prescription opioids, particularly due to the opioid epidemic evident across the world (Vowles et al., 2015; see Figure 1). In the treatment of chronic pain, there may be no area of greater controversy than the use of opioids (Vowles et al., 2015).
Although there is much debate and conversation about the dangers of the illicit use of opioids, there is little about the dangers associated with use of prescription opioids. This paper is exploratory in nature, with the intent of exploring the relationship between chronic pain and prescription opioids, particularly opioid addiction, abuse, misuse, and overdose.
Scope Of The Problem
The rise of the global prescription opioid epidemic first began in the 1990s (“The Prescription Opioid,” 2015). During this time, pain specialists and advocacy organizations around the globe began to argue that the world faced an epidemic of untreated pain (“The Prescription Opioid,” 2015). As a result, an increasing number of professional and consumer groups pushed for the increased use of opioids for pain management (“The Prescription Opioid,” 2015). The shift towards opioids for pain management led to a dramatic upsurge in prescription opioid production, prescriptions written by medical professionals, sales, and consequently consumption (“The Prescription Opioid,” 2015; see Figure 2).
As a result of chronic opioid therapy increasing dramatically, there has been a parallel increase in the abuse, misuse, and addiction rates of prescribed opioids along with overdose rates (“The Prescription Opioid,” 2015). Although definitions vary, for the purpose of the paper, the terms are defined as following. Abuse refers to consumption of the drug in a way other than prescribed, usually by consuming more than directed or taking a higher dosage (Brady, McCauley, & Back, 2016). Misuse of opioids is a broad term including using the drug outside of prescription parameters, such as misunderstanding or ignoring instructions and using the medical for non-medical reasons (Brady et al., 2016). Addiction refers to a physiological dependence on the drug for purposes other than pain relief, using the drug despite it causing damage, inability to control drug intake, craving the drug for non-medical reasons, and deterioration in daily functioning due to obsessive preoccupation with the drug (Brady et al., 2016). And finally, overdose refers to death due to high levels of consumption of the drug (Brady et al., 2016).
The abuse, misuse, addiction, and overdose rates resulting from prescription opioids is vastly evident in society. For instance, in the documentary Understanding the Opioid Epidemic, several individuals spoke about personal encounters with prescription opioids, mainly about abusing such medication and overdosing on it due to its addictive nature (Grant, 2018). Recent data supports this statement. For example, one report estimated the rate of opioid abuse to be 26% amongst those taking chronic opioid therapy (Kata et al., 2018). Similarly, from 2015 to 2016, there was an increase of over 11,500 drug overdose deaths, and opioids accounted for 63.1% of these deaths, a number that has quadrupled since 1999 and made it more common than overdose from cocaine and heroin combined (Kata et al., 2018; see Figure 3). Contributing factors include more liberal prescribing methods, reports of undertreated pain, creation and availability of new opioids, and marketing techniques by drug manufacturers (Kata et al., 2018).
The Issue
This situation presents a conundrum. Opioid therapeutics are widely prescribed because they are the most effective analgesics in relieving many types of chronic pain, especially for those patients for whom no other treatment has been effective (Brady et al., 2016). However, with long-term use of prescription opioids, likelihoods of developing an addiction, abusing the medication, and/or misusing the medication are high and unfortunately not very uncommon (Vowles et al., 2015). The dilemma of treating chronic pain in patients by use of opioids versus the rising rates of opioid addiction, abuse, and misuse is an enduring and multifaceted issue that has no simple solution.
Prescribing Chronic Opioid Therapy
Why Are Opioid Analgesics Prescribed?
Opioid painkillers are prescribed by physicians to treat moderate to severe pain, be it the result of injury, surgery, a dental procedure, and/or a chronic health condition (Walwyn, Miotto, & Evans, 2010). They are prescribed due to their high effectiveness in relieving most types of pain and when used properly, opioids are successful in alleviating agony in both severe and long-term pain, making it a viable option for many (Walwyn et al., 2010).
After recognizing pain as a medical issue, physicians have been influenced and forced to put it into practice (Ling, 2017). Hospitals not following the mandate to address pain are in jeopardy of losing their accreditation (Ling, 2017). In fact, pain relief is viewed as a patient's right, and under-treatment of pain is considered a form of malpractice (Ling, 2017). For instance, a California court awarded $1.5 million dollars to a family who sued their physician for failing to adequately treat their 85-year-old father’s pain (Bergman v Wing Chin, MD and Eden Medical Center, No. H205732-1 Cal App Dept Super Ct 1999).
Thus, due to the complex nature of understanding and treating pain, along with the vicious consequences of under-treating pain, prescribing opioids as painkillers, medication that has proven time and time to be effective, has become an increasingly popular choice made by many medical professionals.
Prescribing Patterns
Opioid prescriptions increased from 47 to 62 million from 2006 to 2012 and opioid sales quadrupled from 2000 to 2010 (Kata et al., 2018). Correspondingly, the medical use of opioids increased by 240% from 2004 to 2011 in the United States alone (Kata et al., 2018). Data indicates that the majority of opioid prescriptions are provided by family practice providers (Kata et al., 2018). The most common prescribers of opioids include family practice, internal medicine, nurse practitioners, physician assistants, orthopedic surgeons, physical medicine, rehabilitation, and anesthesiology subspecialties (Kata et al., 2018). Pharmaceutical industries also benefit from prescriptions and sales of opioids for chronic pain as it brings them lots of income (Ling, 2017). It is thus not surprising that such industries are not against the prescribing practices of opioids for chronic pain (Ling, 2017).
Moreover, there are differences in prescribing patterns based on patient-provider interactions. Differences are based on multiple factors such as race, socioeconomic status (SES), and gender. More specifically, those that are non-white are less likely to have a physician treat their pain with opioids than those that are white (Hausmann, Gao, Lee, & Kwoh, 2013), and those that are females are less likely to have their pain perceived as being real by the physician (Frantsve & Kerns, 2007) and thus are less likely to be treated with prescription opioids, and lastly, those from a higher SES are more likely to not only have access to a physician but to also get better treatment (Frantsve & Kerns, 2007) and thus be prescribed opioids by their doctor.
Furthermore, there have been reported concerns among physicians about their confidence in prescribing opioids safely, their ability to detect misuse, addiction, and abuse of prescription opioid use in their patients, and their ability to discuss these issues with their patients (Kata et al., 2018). Nonetheless, there is still a demand for prescription opioids amongst pain sufferers. For example, a recent news article outlines the case of a women searching for a doctor that is willing to prescribe her opioids for her chronic back pain (Proctor, 2018). She states that she has seen three family physicians who have refused to bow to her demands of continuing her prescriptions due to the high risk associated with them and that doctors are not willing to accept her as a patient when learning that she desires opioids (Proctor, 2018). There are two important concepts here. One is that people are increasingly using the internet to research the prescriptions they want along with seeking the doctors they would like to see. Individuals use the internet to make sense of their illness, to find a solution to their illness, and to look for doctors who will meet their needs. For instance, in my journey to treating my chronic pain, I have turned to the internet several times to find treatments and doctors that can help me. Second, the opioid epidemic cannot be attributed to doctors. As specified in another recent new article, doctors are clearly not over-prescribing and many of them are not willing to prescribe opioids at all (Payne, 2018). Relating back to my journey, it took six years of failed attempts before my doctor was willing to prescribe me opioid painkillers, and even when he did, I was given an extremely low dose.
Consequences Of Chronic Opioid Therapy
Chronic opioid therapy entails many prevalent adverse effects. The list of negative side effects is never ending, with the most common being gastrointestinal and central nervous system related, specifically, constipation, nausea, somnolence, and respiratory depression (Kata et al., 2018). Other users report side effects such as fatigue, cognitive dysfunction, sweating, weight gain, and dry mouth (Kata et al., 2018). Some of the more serious effects include endocrine dysfunction, inadequate production of sex hormones, sexual dysfunction, muscle rigidity, pruritus, delayed gastric emptying, hyperalgesia, and adverse drug interaction (Kata et al., 2018).
However, the most substantial effects are those that include tolerance, addiction, dependence, abuse, and death, which are major risks when prescribing opioids (Kata et al., 2018). Thus, although the increase in the number of prescriptions and use of opioids has significantly improved the treatment of pain, this has been accompanied by an increased incidence of opioid abuse, addiction, and death (Ling, 2017). Overdose can be accidental but also a result of long-acting opioids contributing to cardiac-related deaths (Kata et al., 2018). For example, one study found that prescribing long-acting opioids for chronic pain compared to anticonvulsants and antidepressants was associated with a significant increased risk of mortality (Kata et al., 2018).
Additionally, supporting these findings and arguments is a short podcast from Dr. Daniel Alford where he expresses his opinions on prescription opioids and argues that the benefits of it prominent, but so are the side effects and consequences, the risks are just as pronounced (2018). He argues that the need for safer opioid prescribing programs are required in order to counteract rates of abuse, addiction, and overdose deaths (Alford, 2018).
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Furthermore, another consequence is the fear and stigma associated with chronic pain. As stated in one news article, because chronic pain is a contested and chronic illness, rates of stigma against the pain are high (Scanlon, 2019). In turn, these high rates of stigma against the pain may lead to high rates of stigma against using opioids for treating chronic pain which then leads to stigmatizing those individuals using prescribed opioids as contributing to the opioid epidemic (Scanlon, 2019).
Who Is At Risk For Prescription Opioid Abuse, Addiction, Misuse, And Overdose?
It is no secret that the dangers of prescription opioid abuse, addiction, misuse, and overdose are high. Thus, it is instrumental to recognize risk factors, in terms of those who are more vulnerable to these effects, so that society can collectively work towards safely decreasing the rates of prescription opioid abuse, addiction, and deaths. A wide range of variables, such as the user’s gender, age, race, SES, geographical area, and medical or clinical history all contribute to the progression of opioid abuse. However, it is vital to note that the risk factors are correlational, meaning they do not definitively predict that a person will develop an addiction, abuse, misuse, and/or overdose on opioids (Brande, 2018).
Gender
When it comes to gender, women are prescribed abuse-prone medications more often than men (Brande, 2018). It is thus not surprising that men are likely to die from a prescription drug overdose at higher rates than women and that men also report more problems associated with opioid use than women (Brande, 2018). Nonetheless, men and women are admitted to the emergency department at approximately equal rates for complications relating to opioid abuse (Brande, 2018).
Age
Moreover, younger individuals have a higher risk of abusing, misusing, overdosing, and becoming addicted to opioids (Brande, 2018). This is also reflected in a news article by the Vancouver Sun in which Dr. Gary Franklin highlights that prescription opioids are highly addictive, especially for teens (Harnett, 2018). However, rates among older users are on the rise with middle-aged users having the highest risk of overdose (Brande, 2018).
Race
Furthermore, there is a marked associated between race and prescription opioid problems with rates of opioid prescriptions being highest amongst White patients, followed by Black, Hispanic, Asian, and then other race patients, regardless of SES (Brande, 2018). Additionally, opioid overdose rates are nearly three times higher amongst American Indians/Alaska Natives and non-Hispanic Whites than among Blacks and Hispanic Whites (Brande, 2018). This may reflect larger societal issues regarding racial disparities and the effect of race in healthcare.
Socioeconomic Status
There is some preliminary evidence that SES may be related to prescription opioid problems (Brande, 2018). Specifically, people from high SES are prescribed more opioid medication than those from low SES neighborhoods (Brande, 2018). Also, those with higher education levels are three times more likely to be prescribed opioids than those with lower levels of education (Brande, 2018). SES can affect substance abuse by shaping drug use habits, influencing the availability of health resources, and affecting adherence to medication (Brande, 2018). Although the association is not yet complete, there is some evidence suggesting that SES and opioid medication prescribing and abuse are interwoven.
Geographical Area
Additionally, abuse of prescription opioids has been found to have a regional component, with rural regions having higher rates of prescriptions, abuse, misuse, addiction, and overdose than urban areas (Brande, 2018). Interestingly, these higher rates to do reflect higher incidences of injury, surgery, or chronic pain (Brande, 2018). Thus, this inconsistency may reflect a lack of consensus amongst healthcare professionals as to the appropriate guidelines of prescribing opioid medications.
Medical and Clinical History
Lastly, medical and clinical history are another risk factors. Those struggling with chronic pain along with coping with a substance use or mental health disorder simultaneously are at the highest risk for misusing prescription opioids (Brande, 2018). Also, long-term medical use of prescription opioids for chronic pain increases risk factors for overdose (Brande, 2018). Psychological disorders have shown to have a clear link with developing opioid abuse (Brande, 2018). Likewise, substance abuse of other substances is related to higher rates of abuse with opioid medication (Brande, 2018).
Reasons For Prescription Opioid Abuse, Addiction, Misuse, and Overdose
Prescription opioid abuse can result from a magnitude of different reasons. For instance, social acceptability may contribute towards structuring prescription opioid use norms and acceptability. Viewing prescription opioid use as a socially acceptable practice may have a potent impact on individuals as they will not only be more willing to try opioids but also consequently be at a higher risk of abusing and getting addicted to them (Brande, 2018). Additionally, social media has created a community connection in which individuals can engage and interact with other users, encouraging the use of opioids without properly assessing the risk factors (Brande, 2018). When individuals perceive others engaging in a particular behavior, such as opioid use, they come to normalize the behavior, which only serves to expand the problem (Brande, 2018). Therefore, rationalizing prescription opioids as socially acceptable has massive implications.
Moreover, because prescription opioids are prescribed by a physician, and because they are prescribed at higher rates today compared to the past (see Figure 4) many individuals view them as coming from a trusted authority source and thus believe that they are safe, overlooking the risks associated with them (Brande, 2018). Next, easy consumption, meaning that it is easy to take pills compared to smoking or injecting substances, and easy accessibility and availability, meaning that pills can easily be shared between individuals and that prescriptions can be obtained from a willing physician instead of a dealer, also contribute to the abuse of opioids (Brande, 2018). Furthermore, the staggering number of prescriptions being written sends the wrong message to consumers regarding the dangers of opioid abuse, a message that indicates that opioids are safe (Brande, 2018). Again, this leads to increased rates of opioid abuse, addiction, misuse, and overdose. Additionally, a major factor contributing to this issue is the aggressive marketing by major pharmaceutical companies. These companies have spent a lot of money creating and promoting prescription opioids and this direct marketing to consumers may communicate the message that opioid medications are good and safe to use (Brande, 2018). In turn, this may drive rates of demand for the medication from consumers, along with increase rates of abuse, addiction, misuse, and overdose (Brande, 2018).
Moreover, self-motivation to treat and manage pain may be a driver behind using opioids and ultimately contribute to the abuse and addiction to these medications to control pain (Brande, 2018). Also, there is a strong correlation found between prescription opioid abuse and mental health issues where those who struggle with mental health issues are more likely to underestimate the dangers of prescription opioid abuse, leading to higher rates of abuse amongst these individuals (Brande, 2018). Lastly, poly-substance abuse in association with the prescription opioids significantly increases the risk of overdose (Brande, 2018).
Alternative Pain Management Approaches
Given the severe consequences and risks of chronic opioid therapy, and because managing pain is still a necessary part of life, it is crucial to find alternative methods to cope with and treat chronic pain. There are many alternative methods that have been proposed recently. In a hearing held by the Senate Health Committee in the United States to examine pain management alternatives to opioids, alternatives presented include spinal cord stimulation, nerve blocks, injections, and non-opioid prescription drugs (Pain Management Alternatives, 2019). Other alternatives consist of acupuncture, stress reduction, exercise/physical therapy, psychological therapy, and hypnosis (Brande, 2018). Additionally, two alternatives that have received great news coverage recently include the use of medical marijuana and virtual reality in treating chronic pain (Bain, 2019; Desatoff, 2019). The next step is to test these alternatives and observe their effectiveness. Due to the nature of the high effectiveness of prescription opioids, and because there is no one size fits all, it will be hard to find alternatives with similar effects.
Conclusion
Opioid analgesics are considered to be the most effective pain relievers known to man (Walwyn et al., 2010). However, it is no longer feasible to simply continue previous practices of managing chronic pain with respect to opioids. The associated risks and rates of opioid abuse, addiction, misuse, and overdose demand change. Currently, society is facing the dilemma of treating chronic pain by use of opioids, a highly effective treatment, but also managing the high rates of abuse, addiction, misuse, and overdose in society. This issue is one that requires more attention because the treatment of chronic pain is vital for pain sufferers, yet society is still to develop a safe and effective treatment plan.
So how do we fix this? Future research needs to uncover precise ways to diagnose, prevent, and treat opioid abuse, addiction, misuse, and overdose. This is a multifaced issue that requires a comprehensive solution; the key is to focus on prevention, early intervention, and reversal of present cases. In turn, this will influence the rates of abuse, addiction, misuse, and overdose. Alternatively, substitute treatments with the same efficacy would also contribute to solve this issue and should be a primary concern for researchers. Although opioids may help us temporarily forget our troubles, they are in no way the solution to this problem in the long run. Continued determined efforts to find ways to treat chronic pain safely and effectively should be at the forefront of society’s future.
In the debate over opioid abuse, addiction, misuse, and overdose, many voices are being heard, including those of doctors, nurses, pain specialists, community workers, addiction support workers, government agencies, pharmaceutical industries, and even the voices of ordinary people in the society. However, there is one group whose voice is not being heard, the voice of those living with chronic pain who require opioids to manage their discomfort. As someone who has been living with chronic pain themselves for the past six years, I work hard to manage the pain and I want the medical system to be a respectful and cooperative partner, not a bully. I take opioids to treat my chronic pain and decisions about them will be decisions that harm me.
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