Taken from Page 10 of the Summer 2018 Newsletter
By Adriane Fugh-Berman, MD, and Charlea T. Massion, MD
Adriane just had dental surgery and the surgeon provided a prescription for Tylenol with codeine. When she told him that opioids were not better than over-the-counter (OTC) painkillers for dental pain, the surgeon argued, “But it’s such a weak opioid.” And then he said, almost to himself, “Well, I guess it does turn to morphine in the gut.” That’s true: about 10 percent of codeine is metabolized to morphine and, while codeine is one of the weaker opioids, it’s still an opioid, and should not be prescribed unnecessarily.
Doctors and dentists regularly prescribe opioids when they are unnecessary, and they prescribe too many pills even when the drugs are useful. In 2016, one out of five Americans received an opioid prescription. That’s way too many pills!
Patients tend to save extra pills, often in their medicine cabinet, because they seem to be inherently valuable. But, here’s why you should always dispose of opioids rather than keeping them:
- You may be fostering addiction. Other people — friends, relatives, teenagers, visitors — can take them out of your medicine cabinet. You don’t want to be an inadvertent supplier of opioids to someone with an opioid use disorder or, worse, start someone down the road to addiction. Some people develop an opioid overuse disorder after taking just a week’s worth of opioids. And, 46 Americans die every day from an opioid overdose.
- You shouldn’t be dosing yourself, or anyone else, with opioids. While opioids are useful for acute pain or end-of-life care, consumers should not be dosing themselves. You should only take opioids while under a provider’s care. The risks are just too high.
Both patients and doctors tend to see opioids as “the good stuff.” But, in addition to being addictive, opioids also increase your risk of respiratory depression and heart rhythm problems, and suppress your immune system. Many opioid users also suffer from severe constipation, even with low-dose opioids.
And, other drugs do a better job than opioids at managing pain. A new study found that opioids were no more effective than non-opioid medications over 12 months for improving pain-related function in people with moderate to severe chronic back pain or pain from hip or knee osteoarthritis. And, opioids caused more side effects — mainly nausea, vomiting, and drowsiness.
Opioids are not the good stuff. The truth is that, for acute pain conditions, taking high doses of a nonsteroidal anti-inflammatory (NSAID) along with acetaminophen (i.e., Tylenol or generic) works just as well for most people. For the first few days after surgery or trauma, a painkiller should be taken regularly, even if the person is not experiencing bad pain. NSAIDs not only ratchet pain down, they also reduce inflammation, which prevents a cascade of pain chemicals. That can make a big difference in the weeks after an injury or surgery. It’s probably even a good idea to take NSAID before surgery, although that makes most surgeons nervous, because they believe it increases the patient’s bleeding risk. This risk is exaggerated; several studies have shown there is no increase in serious bleeding risk when NSAIDs are used before surgery.  
Acetaminophen (Tylenol and others) is a fairly weak painkiller on its own, but it reduces some pain chemicals and enhances the effect of anandamide, a cannabis-related mood-enhancing chemical made by our own bodies. When combined with an NSAID, acetaminophen packs a powerful punch. Over-the-counter NSAIDS include aspirin, ibuprofen (Advil, Motrin, and others), and naproxen (Naprosyn and others). Common prescription NSAIDs include ketorolac (Toradol and others), diclofenac (Voltaren and others), celecoxib (Celebrex), and indomethacin (Indocin).
Combining the opioid oxycodone with ibuprofen, on the other hand, doesn’t add much value. One study tested ibuprofen alone vs. ibuprofen in combination with 2.5 mg, 5.0 mg, or 10 mg of oxycodone. Only the 10 mg oxycodone combination was better than the others after 2 hours; at 3-6 hours, there was no difference in pain among any of the groups. Those who got oxycodone, though, did have more nausea, vomiting, and drowsiness.
Over-prescription of opioids is what has caused this opioid epidemic. If your doctor or dentist wants to give you an opioid prescription after surgery or injury, ask for a non-opioid alternative, and try that first. For acute pain, taking 400-600 mg of ibuprofen with 600 mg acetaminophen every 4-6 hours for 3 days or so is an excellent treatment.
And, get rid of those opioids in your medicine cabinet. The best way to do so is through a take-back program; most pharmacies and some doctors’ offices will dispose of opioids, and more and more communities offer take-back programs (see: https://takebackday.dea.gov/). Please don’t flush drugs down the toilet, as they go directly into the water supply; drugs cannot be filtered out.
While we’d rather people not throw pills into the garbage, because they end up in landfill and can poison wildlife or get washed into the water supply, disposing of drugs in the garbage is better than flushing them. If there is no convenient take-back program near you, it’s better to mix your pills with goopy garbage and throw them away, rather than keep them in your residence. (Don’t throw away fentanyl patches; these should always be folded in half so the adhesive sticks to itself, and taken to a pharmacy for proper disposal.)
Reducing the supply of opioids in people’s homes — both by not using opioids and by disposing of them properly — is a key contribution to ending the opioid epidemic!
BOX: Common opioid medications include
- Codeine with acetaminophen (Tylenol 3, Tylenol 4)
- Combunox (ibuprofen and oxycodone)
- Fentanyl (Duragesic, Actiq, Fentora, Subsys, Abstral)
- Hydromorphone (Dilaudid, Exalgo)
- Meperidine/pethidine (Demerol)
- Morphine sulphate, MS Contin
- Oxycontin (oxycodone)
- Oxymorphone (Opana)
- Percocet (oxycodone and acetaminophen)
- Ultracet (tramadol and acetaminophen)
- Ultram (tramadol)
- Vicodin (hydrocodone with acetaminophen)
- Vicoprofen (hydrocodone with abuprofen)
Adriane Fugh-Berman, MD, is a professor in the Georgetown University Medical Center (GUMC), and director of PharmedOut, a GUMC project that promotes rational prescribing.
Charlea T. Massion, MD, is a family physician and specialist in hospice and palliative care medicine. She is the Chief Medical Director of Hospice of Santa Cruz County and also teaches physicians about worklife balance and career development.
 Centers for Disease Control and Prevention (CDC), Prescription Opioid Overdose Data, Atlanta (GA): CDC, 2017. Available at: https://www.cdc.gov/drugoverdose/data/overdose.html
 Krebs EE, Gravely A, Nugent S, et. al., “Effect of opioid vs. nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: The SPACE randomized clinical trial,” JAMA 2018; 319(9):872-882.
 Aboul-Hassan SS, Stankowski T, Marczak J, et. al., “The use of preoperative aspirin in cardiac surgery: A systematic review and meta-analysis,” J Card Surg. 2017; 32(12):758-774. doi: 10.1111/jocs.13250.
 Liu XF, Wang XF, Yi YY, “Ibuprofen may not increase bleeding risk in plastic surgery: a systematic review and meta-Analysis,” Plast Reconstr Surg. 2018; 141(1):194e-195e.
 Zhang C, Wang G, Liu X, et. al., “Safety of continuing aspirin therapy during spinal surgery: A systematic review and meta-analysis,” Medicine (Baltimore) 2017; 96(46):e8603. Online at: https://www-ncbi-nlm-nih-gov.proxy.library.georgetown.edu/pmc/articles/PMC5704823/
 Dionne RA, “Additive analgesic effects of oxycodone and ibuprofen in the oral surgery model,” J Oral Maxillofac Surg. 1999; 57(6):673-8.