Nothing to Fear but Pain Itself

Are You Opio-Phobic?

Aug. 13, 2001 -- Oncology nurse specialist Carol Blecher, RN, MS, AOCN, knows the face of pain and the face of fear.

Cancer, says Blecher, is not a gentle, silent enemy but rather a painful, raging foe, which must be fought with powerful weapons that often cause their own unremitting pain. So easing or eliminating a patient's pain is often Blecher's primary concern.

"But every day patients and families come to me filled with fear about taking opioids," she says -- narcotic drugs like methadone, morphine, and OxyContin. That fear, called "opio-phobia," can stand in the way of relief for many patients.

At her office at Valley Hospital System in Ridgewood, N.J., Blecher says the media frenzy surrounding abuse of the long-acting painkiller called OxyContin has fueled patients' fears. "Now patients and families are asking: Does this drug make you an addict? I have to just tell them over and over that they are taking the drug for pain, not for addictive reasons," says Blecher, a spokesperson for the Oncology Nursing Society.

Drug a 'Lifeline' for Cancer Patients

The furor surrounding use of opioid painkillers is very frustrating for pain management specialists like Syed Nasir, MD. "I take care of people who have cancer, and for these people [OxyContin] is a lifeline," says Nasir, a neuro-oncologist at the Culichia Neurological Clinic in New Orleans.

Both patients and physicians have traditionally been wary about the use of narcotics for pain relief, he says, because of fears it could trigger addiction. It makes for a great movie-of-the-week plot -- traumatic injury leads to unrelenting pain that can only be eased with morphine, turning an unsuspecting housewife or grandmother into a raving junkie -- but such tales have little basis in medical reality, says Nasir. In fact, he says, only about 1% of people who take drugs such as OxyContin for treatment of chronic pain will become addicted.

How It's Abused

Johns Hopkins University cancer expert Michael Carducci, MD, tells WebMD that some cases of OxyContin abuse may be related to confusion about how the drug should be given. Doses of older long-acting opioids, such as MS-Contin, could be increased from two times a day to three, four, or more times a day. OxyContin, on the other hand, is "a twice-a-day drug, not three times, not four times a day," he says.

The drug's special formulation allows for an immediate release into the bloodstream followed by "12 hours of slow release, so each pill lasts for 12 hours," says Carducci.

Abusers of the drug discovered that if extended-release OxyContin pills were ground up and snorted or injected, the user could, in effect, get the entire 12 hours' worth of drug at one time, resulting in a much more intense high. Such use has been blamed for around 100 deaths nationwide and prompted the FDA last month to strengthen warnings on the drug's label, likening it to morphine. The agency also mailed letters to doctors, pharmacists, and other healthcare providers alerting them of its potential for abuse.

And just last week, manufacturer Purdue Pharma announced its plans to reformulate the drug in an effort to discourage such abuse. The new form of OxyContin -- available in three to five years -- will come mixed with tiny beads of naltrexone, a drug that counteracts the effects of narcotics and is used to treat heroin addiction. The naltrexone is designed to be inactive as long as the pill is intact -- crush it, however, and the high-busting naltrexone is released.

Media Overkill?

While the torrent of news stories about OxyContin abuse has certainly raised public awareness of this deadly new drug trend, it's also fanned the flames of opio-phobia, say critics.

As the point man in implementing new federally mandated pain-control measures at Johns Hopkins, Carducci says he deals daily with the results of painkiller paranoia.

"I am implementing this plan in which all patients are asked if they have pain, and then a pain care plan is started," he says. "Now it makes that job even harder because people are afraid to take drugs for pain."

New Drug, Old Fears

Many pain experts are concerned that scary headlines are making opio-phobia worse, says Daniel Bennett, MD, a Denver-based pain management specialist. Bennett, co-founder of the National Pain Foundation, recently joined other pain specialists for an international symposium on the problem of irrational fear of opioid drugs.

Much of the attention being paid to OxyContin abuse is silly because very similar drugs like "MS-Contin have been around for 10 years or longer," he says, with no attendant bad media.

The U.S. has a history of opio-phobia that stretches back to legendary newspaper publisher William Randolph Hearst, says Bennett, who used his newspapers to campaign against the dangers of opium almost 100 years ago.

In the current environment, opio-phobia is flourishing because both physicians and patients are uneducated about pain and pain treatment.

"The average physician has less than two hours of formal training in the treatment of pain," says Bennett, assistant clinical professor at the University of Colorado Health Sciences Center in Denver. "Yet, the number one reason for visiting a doctor is because of some painful problem."

Dependence Doesn't Equal Addiction

Even though pain leads people to seek medical help, too many patients suffer needlessly because they have misplaced fears about the use of opioid medicines, says Akshay Vakharia, MD, a pain management specialist at the University of Texas Southwestern Medical Center in Dallas. Those fears often stem from confusion about the difference between dependence and addiction.

Patients who are treated for long periods with opioid medicines like OxyContin -- meaning more than two weeks -- will experience physiological dependence on the drug. That means, simply put, that if the patients abruptly stopped the drug they would have symptoms of withdrawal, such as tremors, nausea, diarrhea, and sweating. In many cases the symptoms are mild and not like Diana Ross' bathroom histrionics in "Mahogany." And if the patient is gradually tapered off the drug, there are no symptoms and, most importantly, there "is no relapse, no drug-seeking behavior," says Vakharia.

Bennett says he and other pain experts want to get the message out that addiction is not a significant risk when drugs like OxyContin are used to treat pain. Moreover, he says that the whole concept of tolerance, meaning that patients get used to the drug at a low dose and then need higher and higher doses to overcome pain, is flat-out wrong.

"If the patient is started on an opioid and the dose is adjusted to a level where pain is adequately treated, the patient can be maintained on that same dose for the long-term," says Bennett. When a patient complains that pain has returned "it usually means that either the disease has progressed or there is something else, another condition," he says.

Moreover, Bennett says, even after years on opioids, patients can be taken off the drugs without fear of relapse. He points to one of his patients who took methadone for a painful hip defect. After many years the patient had hip replacement surgery, which freed him from the pain.

"We weaned him off the methadone and he has been methadone free for two years, no problem. Taking the drug did not make him an addict," says Bennett.

Why such a low risk of addiction with such powerful narcotics? It seems the body processes drugs differently when they're taken for genuine pain and when they're taken for recreational purposes.

"Patients without a history of addiction who actually have bona fide pain don't get high when they take these drugs for pain," says psychiatrist and addiction specialist Elizabeth Wallace, MD. For most pain patients OxyContin "relieves the pain but doesn't give the buzz," says Wallace, director of professional services at Professional Renewal Center, a drug treatment center in Lawrence, Kan.

It's yet another of the missing pieces of information that contributes to the opio-phobia phenomenon. Yet until both physicians and patients are educated about the real opioid story, such misinformation and fear will continue to stand in the way of "getting the job done: treating patients and their pain," says Bennett.