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New Risks From Tylenol Raise Question About Chronic Pain Treatment
August 18, 2005
Maia Szalavitz
What about opioids?

First, COX-2 drugs like Vioxx and Celebrex were linked with an increased risk for heart attack and stroke. Then, research expanded that risk (albeit to a smaller degree) to the overall class of drugs to which they belong -- NSAID’s (non-steroidal anti-inflammatory drugs), with the exception of aspirin. NSAID’s also include Advil (ibruprofen) and Aleve (naproxen). And now, the last hold-out, Tylenol (acetominephen) has been linked with kidney problems and with a significantly increased risk for high blood pressure in women in an analysis of the Nurses’ Health Study.

The risk is especially high for younger women who take it regularly: for these women, it doubled, and that’s the level of risk at which experts say that observational studies should give us cause for serious concern. The study also found an increased risk for high blood pressure amongst users of NSAIDS (except aspirin), though that risk was smaller.

While the study does rely on self reports of both drug doses and of blood pressure readings — the subjects are nurses who presumably know how to record such measures.

The question is, what are the 10-20 million Americans who suffer chronic pain to do?

The only non-narcotic painkiller left, aspirin, remains an option. However, long-term use of painkilling doses can lead to potentially fatal gastrointestinal bleeding. Some 16,000 people die each year from bleeding related to aspirin and other NSAIDs.

All of this leaves chronic pain patients with just one safe and effective option: opioid pain medication. Except that doctors have become far more cautious about prescribing opioids due to increased pressure from law enforcement.

Unfortunately, the National Institute on Drug Abuse has recently gotten into the anti-opioid act, with director Nora Volkow claiming that medical education misleads doctors into believing that there is little risk of addiction when prescribing chronic opioids for pain because it teaches that there’s little risk for acute pain treatment.

In an interview with Psychiatric Times (7/05), Volkow said that "5-7%" of chronic pain patients given opioids become addicts. That means, of course, that over 93% do not, which many would see as a low risk. But other studies have found the risk to be lower than that claimed by Volkow. The risk for people without a prior history of drug problems, for example, has been found to be less than 1%. Furthermore, the risk of accidental addiction declines with age, which, given that many pain patients are middle aged or older, is an important consideration in considering any potential risk for accidental addiction. None of that, however, is mentioned in the Psychiatric Times piece.

Nor is it mentioned that 50% of dying patients in the U.S. are still under-treated for pain, according to research reviewed by the World Health Organization’s Health Evidence Network.

Volkow also claims that opioids are "toxic," noting the potential for overdose; but she fails to mention that over 80% of opioid overdoses are overdoses of opioids mixed with alcohol or benzodiazepines during drug abuse and also fails to note that there’s an antidote which instantly reverses overdose if given quickly enough.

The article implies that Volkow sees the development of new, non-opioid medications as the only answer to the problem. But look what’s happened to those drugs — they aren’t as strong and can kill you if taken as directed. The only recently approved non-narcotic, non-NSAID drug, Prialt, made from the venom of a poisonous snail, can cause psychotic symptoms and must be injected into the spine.

As we’ve mentioned before, the only risks associated with opioids used as directed in a steady dose are constipation and physical dependence. Addiction doesn’t just "happen" to you—this "risk" requires a conscious choice to take more of the drug, more frequently than prescribed as a way to alter your emotional state on a regular basis.

But stroke, heart attack, gastrointestinal bleeding and high blood pressure are, for some people, the unavoidable pharmacological consequences of taking non-narcotic pain killers. Which leaves us wondering: why are the risks a patient can control so much worse than those which are inevitable? Why can’t patients be allowed to make an informed choice, as they do with other medical treatments?