Opioids. We all know what they are and that there are a lot of them going around, but it wasn’t until I was asked to write this blog on the information overloading review by Manchikanti and friends (2010) that I realised quite the extent. And to tell you the truth, it’s painfully scary!
In a nutshell, well over half of the review pumped out national statistics about the escalating use and abuse of psychotherapeutics (defined here as prescription-type pain relievers) in the United States. Those statistics were often given in parallel to overall illicit drug use; which also includes marijuana, cocaine, heroin, hallucinogens and inhalants. The authors then brought it back more specifically to the use of opioids in chronic non-cancer pain patients, where the evidence for its efficacy is limited. But the statistics they gave were alarming!
Did you know that Americans (4.6% of the world’s population) consume 80% of the global opioid supply, and 99% of the global hydrocodone supply? And it’s not all for medical use. In 2008, 15.2 million people aged 12 and over used psychotherapeutics for nonmedical use within the past year. That’s a 163% increase from ten years earlier. What I found even more alarming, was that 55.9% of people aged 12 years or more, who used pain-relievers non-medically in the past month, reported they received the drug for FREE from a FRIEND or RELATIVE! And 18% reported that they got the drug from just ONE doctor! Further to this, in 2008, apparently the Drug Abuse Warning Network estimated that the non-medical use of prescription drugs were involved in 1 million emergency department visits. That’s the same number of visits as for illicit drugs. And over the past 40 years, the rates of unintentional drug overdose deaths have been rising steadily.
In regards to chronic pain, Manchikanti and friends discussed some fairly recent systematic reviews by Chou et al (2009 x4- there’s four of them) and Noble et al (2010). Apparently, Noble and friends reported some fairly weak evidence to suggest that patients (well selected with no history of substance abuse or addiction) could use opioids long-term and have clinically significant pain relief, with a small risk of developing addiction, abuse or serious effects. But they also reported that several patients discontinued the opioids due to adverse events or not getting sufficient pain relief. Quality of life and functional improvement were inconclusive. Chou and friends apparently came to similar conclusions in regards to opioids being an effective therapy for a carefully selected group of patients, but reported that it’s also associated with serious opioid related adverse effects or abuse.
My impressions from reading this review were that the evidence for opioid use in chronic pain patients is a bit wishy washy, but what does stand out, are the staggering statistics on the growing abundance of opioids, and their therapeutic use, abuse, and non-medical use.
On another note, and perhaps I woke up with a particularly critical eye this morning, but I was somewhat confused and then bemused whilst reading this article. For starters, there were a few discrepancies between the text and tables (which at the time confused the heebie-jeebies out of me), and then to find that 51/59 of the references (total of 301 references) that had Manchikanti (main author) as either a main or contributing author, were all published in the same journal that this review was published in! Apparently he is not an editor, but this last statistic is worth a raised eyebrow or two too…
About Sarah Wallwork
Sarah is a part-time physio and part-time research-assistant-soon-to-start-PhD with the BiM group in Adelaide. As suspected, her enquiring spirit has sent her back to the dark side, after finishing an Honours thesis in normative left/right neck rotation judgments in 2010. She absolutely loves anything outdoorsy, from rock climbing to kayaking, and cops a lot from her fellow BiMers about her outdoor gear and habits.
Reference
Manchikanti L, Fellows B, Ailinani H, & Pampati V (2010). Therapeutic use, abuse, and nonmedical use of opioids: a ten-year perspective. Pain physician, 13 (5), 401-35 PMID: 20859312