Prescription Opioids: Pain Relief Comes With Risks

Opioid painkillers -- addictive drugs such as hydrocodone (Vicodin, Lortab), oxycodone (OxyContin, Percocet) and methadone -- are being overprescribed, primary care physicians said in a JAMA Internal Medicine survey released last month. Most of those surveyed agreed prescription drug abuse and addiction are "big" or "moderate" problems in their communities. And nearly half of these doctors said they're less likely to prescribe opioids than they were just a year ago.

That awareness is a welcome sign, says study author Caleb Alexander, co-director of the Johns Hopkins Center for Drug Safety and Effectiveness. "There's an epidemic of abuse and addiction" of these drugs, he says, and "it would certainly be hard for this epidemic to get much worse."

As to why physicians overprescribe these drugs, Alexander says they may "overestimate their effectiveness and underestimate their risk." And, he says, physicians tend to "underestimate the widespread diversion of these drugs from the licit to the illicit market."

In the Community

One pill. For Cole Smoot, 16, an Ohio high school honor student, a single prescription opioid tablet, given to him by a friend, was enough to kill him. That was in February 2011. The drug was methadone, a powerful narcotic.

Drug diversion was the source. Danielle Smoot, Cole's mother, explains the circumstances that are known: Originally, the methadone was prescribed to a woman who had advanced cancer, along with other medication. When the woman died, Smoot says, the widowed husband "didn't know what to do with the pills. So he had taken them and stuck them in a box and put them in the back of a closet." Later, the pills went missing. What isn't certain is where the medications went next. However, they somehow ended up with a friend of Cole's, and the friend gave the methadone pill to Cole.

When Cole came home, Danielle, then a nursing student who'd completed pharmacology coursework, immediately picked up on signs of drug intoxication, including her son's pinpoint pupils. She and her husband took him to the emergency room, where he was treated for the intoxication and sent home. Shortly after, however, respiratory depression set in -- and this time when Danielle found him, it was too late.

Too-Popular Drugs

"Methadone is a really dangerous drug, primarily because of its extraordinarily long half-life," Alexander says, and it accounts for a disproportionate share of opioid overdoses and deaths. "It stays in an individual's system for a very long time and can lead to overdose." According to the Centers for Disease Control and Prevention, methadone contributed to nearly 1 in 3 deaths from prescription painkillers in 2009, and about 5,000 people die every year from methadone overdoses.

Drug diversion -- moving drugs from legal, medically necessary use toward illegal uses -- "is a problem with all opioids," he says.

One problem is the wide availability of these medications. Vicodin, for example, is among the top-selling drugs in the United States. Part of the issue is that "these products have been widely used beyond their evidence base," Alexander says. For instance, they're more appropriate for acute short-term pain, like right after surgery, or some cancer pain, than they are for chronic conditions such as lower back pain or arthritis.

According to CDC statistics, of the more than 22,000 deaths in 2012 related to a pharmaceutical overdose, 72 percent involved prescription painkillers. In an April 2014 statement, Food and Drug Administration Commissioner Margaret Hamburg noted that drug overdose deaths "driven largely by prescription overdose deaths" have surpassed motor vehicle accidents as the leading causes of injury death in the United States.

What Families Should Know

As parents, Danielle and Shane Smoot did everything they could to teach Cole and his younger brother Erik about the dangers of drugs. When Cole experimented with marijuana a year earlier, they took him to the sheriff's office to press charges, and Cole had to see a probation officer.

"We're very engaged parents," Danielle says, which included sitting down to a family dinner every night and keeping discussion lines open. "We didn't have a drug talk," she recalls. "We had a series of talks. So he was very well educated. We were very well educated."

But that wasn't enough. "My son was so incredibly bright," his mother says. "He was such a beautiful, beautiful young man. And he was just a little guy, but his personality was huge. And he made a decision -- just one bad decision."

Today, as founder and director of Cole's Warriors, a prescription drug abuse coalition named in her son's honor, and as a community outreach specialist for Ohio Attorney General Mike DeWine, Danielle Smoot is dedicated to educating families about the dangers of prescription drug abuse.

Whatever their age, she says, talk to your kids about drugs at the appropriate level.

Her other advice: "Always trust your instincts," she says. "You know your children better than anyone else. And if you feel that something is wrong, more than likely, something is. So investigate it. Search their room, search their car. Talk to them. And if you don't find something wrong at first, go back and do it again."

She wants to remove the stigma around drug abuse and the notion that it only happens to certain people or in certain areas. "There are a lot of drugs. Period," she says. "In every community. In every venue."

A Less-Casual Approach

In October 2014, in response to an FDA recommendation, combination drugs with hydrocodone -- like Vicodin -- were reclassified as Schedule II drugs. Now, patients must see a health care professional for new prescriptions, rather than having refills called in. Previously, patients could get up to five refills without being re-seen. (Methadone and oxycodone are also Schedule II drugs.)

Patients and families should store current prescription drugs in locked containers, and safely dispose unused drugs. Flushing is recommended for certain high-risk drugs, according to the FDA, and community drug take-back programs are good options.

Prescribers, patients and the public should recognize that opioids "are powerful medicines," Alexander says. "There's not a lot of evidence regarding their long-term safety or effectiveness. They have an appropriate use in treatment ... but they have to be taken at the lowest dose possible for the shortest time possible, and in most cases, only after having failed other treatments." The bottom line for these drugs: "They should be approached cautiously, not cavalierly."

Lisa Esposito is a Patient Advice reporter at U.S. News. You can follow her on Twitter, connect with her on LinkedIn or email her at lesposito@usnews.com.