Pain Control:

Opiates VS THE FIELD


2017 study from JAMA on the most effective medication for acute extremity pain (including fractures):

416 patients—> Large Study—>Check
Multiple Hospitals in the Study—> Check
Randomized—>Check
Double Blinded—>Check
Clinically Relevant Patient Population—>

This study looked at four combinations of medication to treat adult patients with acute extremity pain (defined as below the shoulder or the hip). Three of the medication combos included opiate medications and one combination was Ibuprofen and Tylenol. Below are the mixes of medications and the mean reduction in pain score on a 0-10 scale at 2 hours after the meds were given:


400 mg of ibuprofen and 1000 mg of acetaminophen—>     4.3 pain point decline
5 mg of oxycodone and 325 mg of acetaminophen—>     4.4 pain point decline
5 mg of hydrocodone and 300 mg of acetaminophen—>     3.5 pain point decline
30 mg of codeine and 300 mg of acetaminophen—>     3.9 pain point decline

***These are all clinically insignificant differences in pain control

You may say, “Wait a minute, extremity pain is a big bag of complaints. What about the patients with broken bones?” The authors of the study looked at patients with fractures as a separate group and found that the drug combos had similar effects in pain control in that cohort as well.

What?

Really?

Yeah really. There is also the argument that opiates don’t take away the pain, they just make you care less about the pain. Maybe that gives patients psychological relief, but you could make the same argument about alcohol or marijuana and there is no quick order button on our discharge instructions for a 5th of Jack Daniels or an ounce of super kush mindwarp. With studies like the one above, I think we need to step back and ask if we should be treating pain or getting patients high (admittedly there is a strong editorial tilt in that last paragraph).


The risk of creating an addict: this is the big question, because we, as medical providers, have culpability in giving people their first taste of addictive substances. There are a couple of studies that have looked at how many people keep on taking opiates at one year after they get their first opiate prescription when they leave the ER. The studies results revolve around a common figure: about

1 out of 8

patients we give opiates to will still be taking a prescribed opiate medication at the end of one year. There are probably a number of factors that go into why some people continue taking the opiates (new cancer diagnosis, bad arthritis, chronic abdominal pain), but the endgame is that we give people the tastes that can start the cycle of addiction.

Studies have also shown that around 4-6% of people who misuse prescription opiates will eventually switch to heroin and around 75% of heroin abusers started with prescription opiates.

To put these numbers together (a back of the envelope calculation that would admittedly make most statisticians turn red in the face and explode), if you write 200 prescriptions for an opiate to an opiate naive patient a year (that would be about one every shift) the data predict the following results:

25 people will still be using opiates at the end of 365 days (we will call these the people who misuse rx opiates)
and
1 of these people will start using heroin

Each heroin user has an estimated yearly cost to society of  $44,950, which goes up to $74,428 if they are incarcerated.  If we just look at the financial impact of that one non-incarcerated heroin addict (and not the patients who only abuse pills) and prorate the cost out to each prescription we write, each new opiate prescription has a societal costs of $225.

This may be a simplification, but some things need to be oversimplified.


Opiate: the badness of likability

There have been numerous studies that have looked at which opiates are favored by patients who abuse them.  One of the end points is the “likability” of the drug.  A literature review in the Journal of Medical Toxicology highlighted that oxycodone is the most likable and therefore the most abused of the opiate pain killers. Oxycodone has the least unpleasant side effects, which leads a to better cost/benefit of abuse for the user. The review also noted that the likability of oral morphine and hydrocodone were lower and close to equivalent to each other—this means that the risk of addiction goes down with PO morphine or hydrocodone compared to oxycodone.  If you think that someone really needs an opiate, consider Norco or PO morphine, instead of Percocet or oxycodone.

Finally, the story of how black-tar heroin took over the heroin market in Colorado, and a large part of the rest of the country is fascinating and complex. An LA Times reporter named Sam Quinones was one of the first people to unweave that web. He wrote a book about it called Dreamland. Or there is a great interview with Mr. Quinoes by Mark Maron (on his WTF podcast—which involves adult language) and a link to the interview on YouTube is here: https://www.youtube.com/watch?v=WEw-NOuMAUc

I am sitting in an airport in Tokyo and don’t have access to PubMed to explore the question of when do opiates actually give better pain relief, so I will get that out to you in an upcoming education nugget.

Chang AK, Bijur PE, Esses D, Barnaby DP, Baer J. Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial. JAMA. 2017;318(17):1661–1667. doi:10.1001/jama.2017.16190

https://www.washingtonpost.com/opinions/five-myths-about-heroin/2016/03/04/c5609b0e-d500-11e5-b195-2e29a4e13425_story.html

Wightman R, Perrone J, Portelli I, Nelson L. Likeability and abuse liability of commonly prescribed opioids. J Med Toxicol. 2012;8(4):335–340. doi:10.1007/s13181-012-0263-x

Jiang R, Lee I, Lee TA, Pickard AS. The societal cost of heroin use disorder in the United States. PLoS One. 2017;12(5):e0177323. Published 2017 May 30. doi:10.1371/journal.pone.0177323

https://www.drugabuse.gov/publications/drugfacts/heroin

Ann Emerg Med. 2015 May;65(5):493-499.e4. doi: 10.1016/j.annemergmed.2014.11.015. Epub 2014 Dec 18.
Association of emergency department opioid initiation with recurrent opioid use.
Hoppe JA1, Kim H2, Heard K3.