Information regarding opioids and the treatment of pain.
OPIOIDS FOR PAIN
Opioids for pain are safe apart from constipation which develops with consistent use.
Introduction
Some main points of relevance in regard to opioid therapy for pain are detailed below in a concise manner. An explanation of the political interference in opioid pain management is provided here. Much of the information is expanded upon in other pages of the site.
Opioids for pain
Opioids are unrivalled and are the 'gold standard' for the treatment of serious pain. They do not harm organ systems and are tolerable for most people if given correctly and their side effects treated effectively. They are safe and effective on a short or long-term basis, with constipation being the most troublesome consequence of use.
Opioids and breathing
Opioids do not stop breathing. There is no evidence to support the assertion that they are capable of stopping the autonomic breathing reflex. In fact, they are the accepted treatment for dyspnoea (shortness of breath), or as it is sometimes referred to as 'air hunger'.
They usually have the effect of slowing the rate and depth of respiration. Some take this a step further and assume that if an 'overdose' is administered, the rate of breathing will continue to slow and consequently cease. There is no evidence to support this assumption. There is only evidence that this does not occur.
The myth that morphine can stop breathing leading to death may have originated from the use of morphine to ease the suffering of those engaged in the dying process or with a life-threatening condition. Medical personnel may have worried that they had accidentally caused their patient's death due to administration of morphine, when the actual cause of death was always the underlying condition.
Morphine is associated with dying because it brings comfort and relieves pain, it is not associated with death.
Combinations of opioids and other drugs
Dangerous combinations of central nervous system depressant drugs including opioids can present a danger to breathing due to heavy sedation leading to airway obstruction. This means the person cannot breathe properly due to a blockage or restriction in their throat due to being sedated to the point that they cannot protect their airway. This can lead to a lack of oxygen causing injury or death.
People taking opioids in combination with other central nervous system depressant drugs must be careful to avoid combinations of drugs that have the potential to lead to dangerous sedation. These drugs include alcohol (in particular) and other substances such as benzodiazepines, anti-depressants and anti-histamines etc. The issue of dangerous sedation is not unique to combinations of drugs including opioids
The metabolism of morphine
Morphine is metabolised in an extraordinarily efficient manner by the body. In a clinically demonstrated example, (1) almost half a gram of heroin (a pro-drug for morphine) given as a single, fluent intravenous injection resulted in an extremely low, non-problematic blood-morphine level.
The maximum blood-morphine level in the subjects that received overdoses (maximum single I.V. heroin dose of 450mg) was 1.35 milligrams per litre of blood. (1:t2,p90) This is unequivocal evidence of the extraordinary efficiency with which morphine is metabolised and therefore, the safety of the drug in regards to overdose.
No maximum dose or ceiling level
Opioid agonist drugs have no maximum dose, meaning doses can be increased until desired results are achieved without regard to the size of the dose. They also have no ceiling level, meaning they do not reach a level at which they cease to impart a therapeutic effect. These two qualities are related to the rate at which they are metabolised and their benign nature in terms of toxicity.
The often-heard refrain from those intent on reducing opioid doses is that doses must be reduced for the patients own safety, in other words, to reduce the risk of overdose. This demand is not medically valid, is mischievous and irresponsible, and results in unnecessary suffering due to subsequent under-medication of patients.
The size of the total dose is irrelevant for opioids. People can take the required dose for effective pain control balanced with side effects such as nausea. Due to the rapidity of opioid metabolism and their personal level of pain, some people may need high doses to maintain a plasma level that is effective.
The need for escalating doses is sometimes claimed to be evidence of 'tolerance' or the decreasing efficacy of opioids in treating the patient's pain. The need for escalating doses is usually due to progression of the underlying disease or new pathology.
The risk for so-called 'overdose' is not the opioid dose, it is the combining of central nervous system depressant drugs, which carries with it a risk of dangerous sedation leading to asphyxiation.
Side effects and safety
There are two hallmark side effects of opioids: nausea and constipation. With regular use, tolerance to nausea can develop to a degree. Constipation however, can be severe and persistent, requiring aggressive treatment. Constipation is the side effect that makes regular and long-term use of opioids problematic for most people.
To illustrate the safety of opioids, a comparison can be made to a local anaesthetic that is being marketed with great fanfare by the manufacturer as an alternative to post-operative opioid use. Bupivacaine is routinely injected into the wound by surgeons to provide post-operative pain relief. A long-acting version of the substance is being promoted for its opioid-reducing potential in the post-operative setting.
Bupivacaine is cardio-toxic. If introduced intravenously by error, it can induce heart failure with extreme difficulty in resuscitation. This is a stark indication of the overall safety of opioids. If people are given the choice of post-operative pain relief that causes constipation and nausea versus pain relief that has the potential to cause heart failure, it is clear as to what the sensible and safer option is.
Physical dependency
If enough opioids are taken for long enough, physical dependency will occur. This involves the brain making an adjustment to counteract the slowing effect of opioids on the central nervous system. This will occur and is completely normal for many drugs that act at the neuronal level, including alcohol, nicotine, caffeine and anti-depressants.
Physical dependency is a reversible process. To cease or reduce the dose of the drug, the person gradually reduces (tapers) the dose to keep withdrawal symptoms at a minimum. The adjustment made by the brain in response to the substance will lessen on a gradual basis and cease as intake of the drug is brought to zero.
Opioid withdrawal brought about by sudden abstinence is often likened to a 'bad case of the flu'.
'Addiction'
Those offering potential for 'addiction' as a reason for reduction or cessation of opioid therapy for pain tend not to expand on the actual meaning of the term. It is generally used as a term having hostile and alarmist undertones towards those who use drugs other than alcohol, tobacco and caffeine.
It is true that a small number of people introduced to opioids via medical treatment will enjoy the psychoactive effects and will wish to continue use in a 'recreational' manner. The number of people doing this is extremely low due mainly to the undesirable nature of the side effects: nausea and constipation.
Those prepared to endure the side effects for what they find to be the positive effects of opioids are fundamentally doing nothing different to those who use other psychoactive substances such as alcohol, tobacco or caffeine.
Political interference
Chronic pain patients and others seeking to understand why there is political interference in the supply of opioid pain medications might like to consider the following. The groups listed here all benefit from the regulatory environment that gives rise to the restriction of medical opioids:
The Drug Enforcement Administration (U.S.) and 'enforcement agencies'
worldwide: The purpose of the DEA is to maintain the existence and value of the black market in drugs other than alcohol,
tobacco and caffeine. They are funded by government to do this. In the region of ten thousand people are employed by the agency.
The black market in drugs other than alcohol, tobacco and caffeine is intentionally created by criminalising the supply of these substances as determined by the Controlled Substances Act and its international variants.
The DEA maintains the existence and vibrancy of the black market by enforcing the law and thereby, restricting supply. It does this by investigating and prosecuting suppliers, confiscating the substances and seizing the assets of those convicted.
For those tending to be disbelieving of the above information, it is simply proved: the DEA does not investigate, apprehend and prosecute the manufacturers, distributors and retailers of the two most dangerous drugs in existence, alcohol and tobacco, or caffeine.
Obviously, their activities are not related in any way to the danger of any particular substance: their existence is solely related to the money, political advantage and employment resulting from intentionally-created crime. The crime is created by criminalising associations with drugs other than alcohol, tobacco and caffeine.
The DEA can only benefit from the restriction of medical opioids. Firstly, it is their job: they get paid to monitor supply, and investigate and prosecute those deemed to have been involved in diversion activities. Secondly, minimising diversion of medical opioids maintains the value of the black market by restricting supply and forcing recreational users to obtain substances from unregulated sources.
The legal fraternity: The so-called 'opioid crisis' and the
subsequent policing and restriction of opioid pain medication has resulted in a valuable stream of work for lawyers. Doctors,
manufacturers and pharmacists who have been prosecuted by government agencies and patients who are attempting to get medicated
properly, comprise a large and lucrative client base for the legal fraternity.
Academics: Academics and researchers are largely paid by
government and therefore will deliver research and advice that is sympathetic to the policy edicts of those governments. Many also
receive financial reward from industry and are therefore willing and obliged to deliver research that is beneficial to this source
of funding.
'Non-profit' organisations: Government money is liberally
distributed to organisations that purport to rally against 'drug-related' harm, often on the pretext of a child lost to
multiple-drug toxicity involving opioids. The money naturally comes with the expectation that the organisation has a narrative
conforming to that of the funding source.
Alternative treatment providers: The list of providers
purporting to provide 'alternatives' to medical opioids and who therefore profit from the restriction of the medication class is
long. These include pain psychologists, occupational therapists, massage therapists, chiropractors, acupuncturists and other
'allied health' practitioners.
Alternative treatment manufacturers: The restriction of opioid
pain medication is an obvious advantage for those providing non-opioid pharmacological treatments for pain. With their commercial
competition maligned and supply of the products restricted, a substantial commercial advantage for these businesses is
created.
The demonisation of medical opioids provides an apparent basis on which medical device companies can promote invasive and expensive treatment modalities such as 'pain pumps' and the like. As noted above, long-acting versions of bupivacaine are being promoted as methods to reduce the use of opioid pain medications.
The basic and fundamental relationship that the above bodies have with government is either a reliance on public money or the ability to donate to political parties.
Conclusion
Opioid pain medications are safe and effective and constipation is the primary undesirable consequence of use. The restriction of medical opioids is not related in any way to any perceived concern with the safety of the medication class.
The restriction of opioid pain medications is due solely to the financial and political advantage that comes from the intentional creation of crime. The crime is created by criminalising people as defined by an association with substances other than alcohol, tobacco and caffeine. The foundation of the situation with medical opioids is the criminalisation of associations with 'recreational' opioids.
The restriction of medical opioids creates a cohort of borderline criminals such as doctors, pharmaceutical companies, pharmacists and people with chronic and intractable pain. A plethora of commercial vested interests benefit from this virtual criminalisation founded on restriction of supply.
If the supply of 'recreational' opioids was not criminalised and therefore not restricted, there would be no intervention by governments in the supply of medical opioids apart from manufacturing standards.
REFERENCES
1. Pharmacokinetics and pharmacodynamics of high doses of pharmaceutically prepared heroin, by intravenous or by inhalation route in opioid-dependent patients. Elisabeth J. Rook et al. From Basic and Clinical Pharmacology and Toxicology, 98, 86-96. (2006)
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