The Opioid Pendulum: Balancing Risks and Benefits

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Vital Signs are 4 medical measurements that are used by healthcare providers to assess a patient's essential bodily functions. These measurements are blood pressure, heart rate, breathing rate, and temperature. The idea of pain as the 5th vital sign was first proposed in 1995, and it is now common for healthcare providers to include it as part of their initial evaluations. The sensation of pain is unique to every person, and pain tolerance can vary even within the same person depending on the situation. Genetic, environmental, psychological, and cognitive differences all affect the way in which we deal with pain, making it unlikely that 2 people will experience the same level of pain given the same pain stimulus. This makes it very difficult for healthcare providers to accurately assess pain, but at least pain is being more frequently addressed and treated.

Actively assessing patients' pain has helped to reduce the undertreatment of pain, but it might have led to overuse of opioids and contributed to the present opioid epidemic. Currently, we are at a point where opioid prescribing is being discouraged. This oscillation between overprescribing and under-prescribing is known as the opioid pendulum.

The opioid pendulum presents a dilemma. Concerns about overuse of opioids are valid. According to the CDC, unintentional poisoning is the leading cause of death due to injury for all age groups. It has surpassed motor vehicle traffic fatalities as the leading cause of injury death in the US. About two-thirds of the 64,070 drug overdose deaths in 2016 involved an opioid. While limiting access to opioids might seem like an appropriate reaction, it could leave people with legitimate pain or those with altered pain tolerance without adequate relief. Lack of access to opioids could cause these people to self-treat their pain through illegal and unsafe options.

A good example of the swing of the opioid pendulum comes from the Veterans Administration (VA) healthcare system. From 2001 to 2009, the percentage of veterans receiving an opioid prescription increased from 17% of veterans to 24% of veterans. Further, the number of pain medication prescriptions written by military physicians quadrupled during that same time period. Veterans with mental health disorders like posttraumatic stress disorder were more likely to be prescribed an opioid. In response, the VA cut opioid prescribing by 41% from 2012 to 2017. The VA's Opioid Safety Initiative resulted in mixed responses from advocacy groups and patients. While some have hailed the movement as a step in the right direction, others are concerned that the VA might have gone too far. The US Pain Foundation's national director of policy advocacy stated that the new recommendations put veterans at risk for unnecessary harm if they are withdrawn from therapies that have proven effective in managing their pain. This issue is further discussed in our podcast, Poison!.

Patients who have pain that has been adequately controlled by opioid medications can face suspicion, accusations, and push-back when asking their providers for opioids. Some patients suffering from chronic, painful diseases like sickle cell disease have few pain relieving options other than opioids. Because these patients can require frequent pain medication, they are often assumed to be drug abusers and are undertreated as a result.

Data have shown that many patients with severe pain can be adequately managed on non-opioid medications, and this led to the treatment recommendations by the CDC in their 2016 guidelines. Additionally, a study published in 2017 found no difference in arm and leg pain relief when comparing the effect of single doses of opioids to a combination ibuprofen/acetaminophen dose.

If the opioid pendulum swings too far in one direction, we have overprescribing and the potential for developing opioid dependence with each new prescription. If it swings too far in the other direction, data favoring non-opioid pain treatment might be used to justify aggressive tapering or immediately discontinuing opioids, resulting in inadequate pain control or withdrawal symptoms. In patients who have been taking opioids for long-term conditions, gradual tapering under healthcare provider supervision should reduce the risk of withdrawal while adequately managing symptoms of pain.

Lindsy Liu, PharmD
Certified Specialist in Poison Information

Diana N. Pei, PharmD
Certified Specialist in Poison Information

Pela Soto, PharmD, BSHS, BS
Certified Specialist in Poison Information