INTRODUCTION
Both “opiate” and “opioid” have commonly been used interchangeably in the past, but current accepted practice is to specifically use the term opioids to refer to all natural, semisynthetic, and synthetic forms of this centuries old agent of pain control. Fentanyl, the most prevalent synthetic opioid today, is included in this category along with naturally occurring opioid formulations such as heroin, morphine, and codeine. The popularity of this drug class stems from its powerful ability to control pain and induce euphoria. Naturally occurring forms can be referred to as “opiates” and these drugs are derived from the opium extracted from the Poppy plant and dried to form a power. Some of the most famous people in history have been associated with the use
of this drug. Hippocrates prescribed poppy for the treatment of pain. 1 Roman emperor Marcus Aurelius, Benjamin Franklin and Thomas Jefferson all used opiates for various conditions. Opioids have a unique ability to treat pain from almost any source because of their effect on the brain’s ability to process signals related to noxious stimuli. It has been observed that “Though it could cure little, it could relieve anything,” and “Doctors and patients alike were tempted to overuse.” 2 The potential benefits related to the action of opioids are matched only by its significant risk when used improperly. It is vital that all who use opioids in any capacity understand these effects to allow for responsible use.
HISTORY OF OPIODS IN MODERN MEDICINE AND SOCIETY
Modern medicine’s journey with opioids began with German pharmacist F.W. Serturner's "discovery" of morphine in 1805. Serturner was the first to successfully isolate and extract crystals from the tarry poppy seed juice. Serturner named the sleep inducing agent morphium (in English, morphine), after Morpheus, the god of dreams in ancient Greece. 3 Parenteral Morphine treatments began in the mid 1800s following the development of the hypodermic needle in 1856. Morphine played an even greater role after the use increased significantly in the United States during the Civil War as a treatment for the pain associated with the injuries of war. Heroin was then synthesized in the late 1800s and marketed as a "heroic", non-addictive cough medicine by the Friedrich Bayer & Co. in 1898. 4 During this time opium was one of the main ingredients in many elixirs sold as a remedy for pain, cough, and colic. Laudanum, an alcoholic herbal mixture containing 10% opium, was a common preparation during the Victorian era. The public's use of these elixirs increased in popularity and resulted in an epidemic of overuse that necessitated government action to attempt to limit the availability of these agents. In 1914 the US Congress passed the Harrison Narcotics Act, which ultimately did little to control the availability of these agents. Morphine was widely used medically to treat injuries during both world wars. During World War II, U.S. soldiers were even issued medical kits with morphine syringes to self-administer to treat the pain of combat wounds while waiting for the medics. At the time, it was known that morphine could be habit forming and warning labels were placed on the packaging. 5 Despite the known risks, the illicit use of opioids continued steadily after the war and through the 1960s, when use increased and heroin addiction became to be understood as a psychiatric illness that required treatment. 6 During most of the late 20th century, accepted medical opioid therapy was limited to the treatment of acute traumatic pain and cancer. It was the widely held perception among professionals in the United States that the long- term use of opioid therapy to treat chronic pain was
contraindicated by the risk of addiction, increased disability and lack of efficacy over time. 7 The use of opioid use by health providers did not significantly expand past those narrow indications until the late 1970s in response to published literature, including the 1973 manuscript from Marks and Sachar in the Annals of Internal Medicine. This report described the failure of physicians to treat patients in severe pain with adequate doses of opioid analgesics and claimed that many physicians overestimated the dangers of addiction. 8 This report, along with a much-referenced letter in the New England Journal of Medicine in 1980, was used by those supporting expanded use of opioids. The NEJM letter claimed that the addiction rates related to the treatment of patients with acute pain using opioids was extraordinarily low in patients without a history of addition. The authors claimed review of almost 40,000 hospitalized patients with an addiction rate of 0.03%. This claim was made in the context of a letter to the editor, but notably without detailed scientific evidence to allow for peer review. 9 Support for the medical use of opioid medication continued to expand through the 1990s. At that time, multiple agencies, including the Joint Commission, advocated for the improved treatment of acute and chronic pain in patients. This campaign of increasing focus on the importance of pain control coincided with Purdue Pharma’s introduction of a long-acting oral opioid pill, Oxycontin, in 1996. This company, along with others, spent millions of dollars promoting the notion of sustained pain control. 10 The widespread marketing and use of oral opioid medication, including Oxycontin, helped fuel the current opioid epidemic. The early part of this century saw significant increases in the complications related to liberal opioid use and prescribing, leading to public policy changes by health organizations to appropriately address the risk-benefit paradigm for the use of opioids for pain. 11 Currently, recommendations related to the use of opiate medications are closely regulated as a result of that analysis.
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Book Code: CT24CME
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