Opiates
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Criminal misuse of opiates by American chronic pain patients is extremely common with the best study putting it at 32%.  Diversion of medically prescribed opiates is rampant and addicting numerous American high school and college students.  FDA approved opiates have surpassed cocaine and heroin at the #1 drug problem in America.  The question of whether opiates should ever be used medically quickly comes to the fore.

Opiates are being promoted by drug manufacturers and the medical community as powerful pain relievers.  However, that is simply not true.  Opiates are not powerful pain relievers. They are no better than Tylenol, but much more dangerous.  Acetaminophen (Tylenol) causes several dozen deaths per year due to liver damage in overdose; opiates kill well over twenty thousand young Americans each year from overdose, AIDS, hepatitis B, hepatitis C, murder, auto crashes, fires, and suicide.  Tylenol and NSAIDs have never tore apart an American family, while opiates do it in massive numbers.  Many, if not most of the opiate deaths and harm are due directly or indirectly to prescription opiates.   No opiate is as good as the many of the more effect NSAID non-narcotic pain relievers.  The evidence is clear.  Even ibuprofen is stronger than any opiate pain pill or injection!  As you will read below, opiates are simply not medically justified for the relief of human pain, except in patients already addicted to them thanks to prior irresponsible treatment.  Even in the elderly where dangerous GI bleeding may occur from NSAIDs, many alternatives are available and better.

The facts are listed on the above webpages.  In 234 comparaisons in double-blind studies against non-narcotic pain treatments which I have been able to find so far, covering tens of thousands of patients, the track record for opiates by any route is 7 wins, 171 losses, and 58 ties.  Opiates are real losers.  Even the seven studies (3%) in which opiates were found better, the evidence is depressing.  Morphine did better than a seizure medicine with very weak pain relieving ability (gabapentin (Neurotin) for neuropathy), and was slightly better than the anti-depressant nortriptyline in one and IV acetaminophen (Tylenol) in yet another study.  Meperidine did better than low dose ketorolac in one study, but was inferior to full dose ketorolac in another.  Tramadol was better than low dose acetaminophen in two studies, but inferior to high dose in two others.  Tramadol was also better than low dose ketorolac in one study.  In four studies, the opiate did slightly better for pain, but caused significantly more side-effects, so I called each a tie (In the one where researchers made the inquiry, patients preferred the non-narcotic by a large margin).  In many other studies, acetaminophen did as well or better than opiates.  Of the 169 studies (73%) where opiates did more poorly, in 137 (60% of all studies) the non-narcotics were more effective pain relievers and in 32 (13%) non-narcotics did just as well at pain relieving and had significantly fewer side-effects.

For dental surgery, opiates were inferior in 97% of 35 studies and never better.  For surgery, opiates were inferior in 70% of 107 studies and better in only 1% (against IV Tylenol, the only study in which narcotics were ever better than full dose Tylenol).  For cancer, opiates were inferior in 88% of eight studies and never better.  For child surgery, opiates were inferior in 61% of 18 studies and never better.  For kidney stones, opiates were inferior in 71% of 17 studies and never better. 

Yet, opiate addiction is rapidily increasing and destroying the lives of millions of Americans.  At present, based on available studies, as many as 25% of all opiate addicts got started with a physician giving them an unsolicited prescription of an opiate for a legitimate pain condition.  Another huge number get started in high school or college with opiate pain pills obtained from someone with a prescription and used by the student to get high.  There is no doubt about it.  Most doctors treating pain are unwittingly drug pushers, plain and simple. Despite their claims to the contrary, they are not practicing evidence-based medicine.  However, the greatest blame rests not with the doctors, but with our highly corrupt Food and Drug Administration, the White House, and the U.S. Congress.

The FDA only requires that any highly addictive narcotic that a manufacturer wishes to get licensed be shown to be better than a placebo for any pain, no matter how minor in intensity or how brief the duration.  Even mild pain expected to last less than a day was treated with a highly addictive narcotic in at least one study with the approval of the FDA for a soon to be released drug (oxymorphone).  Congress has played a role making it easy for a drug manufacturer to resurrect an old and forgotten narcotic, slightly change the way it is delivered, and get a new 23-year patent to push a highly addictive narcotic with the massive profits protected by federal law, but the public footing most of the bill through Medicaid, Medicare, and corporate insurances where we all pay through the increased cost of the product.  George Bush and Congress also refuse to properly regulate the FDA.  Of course, behind the scenes, the big narcotic manufacturers are pulling the strings.  

At the moment, as Reseach Director of Doctors and Lawyers for a Drug Free Youth, I am working with others to attempt to force the FDA to halt the approval of any more narcotics until they conduct a rule-making to consider changing the current rules of placebo comparators to new rules requiring narcotics be shown to have some advantage over non-narcotic alternatives.

Recognition is growing that self-report of illicit narcotic use, prescribed or otherwise, by patients with chronic pain treated with opioids is very unreliable. This fact is well known to the addiction treatment community.  Patients often inaccurately report use of prescribed medications, fail to report use of nonprescribed medications or medications prescribed by other physicians, or fail to report use of illicit drugs. Shockingly, there are at present no accepted diagnostic criteria for addiction or other forms of medication misuse in the patient with chronic pain.  There appear to be no studies at all measuring the degree of uncomfortable drug craving experienced by medical patients on high doses of narcotics.  I sure see a lot of it in clinical practice. 

The use of external sources of information, such as urine testing, interviews with spouses, review of medical records, or input from prescription monitoring programs, may improve patient management.  Unfortunately, these are rarely used by physicians treating pain.  Of these methods, urine toxicology testing has by far the largest experience.  Urine toxicology testing may reveal the presence of illicit drugs, such as heroin or cocaine, or controlled substances not prescribed by the physician ordering the test (e.g., hydromorphone in a patient prescribed oxycodone).  Further research is urgently needed.  At this time, it should be mandatory to conduct routine urine toxicology testing in almost all out-patients with chronic pain treated with opioids.  In fact, in my opinion the use of opioids can and should be avoided in almost all cases. For patients already severely addicted, it may wise and humane in some cases to keep them on their narcotics.  However, no new patients should be started on narcotics.  If a patient has exhausted all other pain relief methods, an occasional person might benefit from opiates.  Research shows that narcotics add very little to effective pain control.  In fact, a small amount of research suggests that narcotics may even cause an increased sensitivity to pain (hyperalgesia), severe rebound headaches, and increased anxiety.

Shockingly, opiates are the most common pain relievers in surgery, and patients are almost never given any choice.  If they asked, they are given misinformation and pressured into accepting the narcotics.  There should be laws requiring all physicians wishing to prescribe a narcotic to obtain signed patient consent after fully informing the patient as to the research, i.e., the inferiority of narcotics as pain relievers, and after offering the patient various non-narcotic alternatives.  Narcotics may also increase the death rate at normal treatment levels.

79% of Chronic Pain Patients in Wisconsin Get Narcotics: In a chart audit of patients with chronic pain in 12 family practices in Wisconsin covering a sample of 209 adults, 67% were female with an average age of 53. The most common pain diagnoses included lumbar/low back (44%), joint disease/arthritis (33%), and headache/migraine (28%) pain. The most frequently prescribed opioids were oxycodone/acetaminophen (31%), morphine ERT (19%), Tylenol #3 (15%), and hydrocodone/acetaminophen (14%). Depression/affective disorders were reported in 36% of the patient charts, anxiety/panic disorders (15%), drug abuse (6%), and alcohol abuse (3%). Written drug contracts were utilized by 42% of the practitioners in 15% of all cases, pain scales 25% in 14% of cases, and urine toxicology screens 8% in just 3% of cases. Opioids and the treatment of chronic pain in a primary care sample. Adams NJ, et al. University of Wisconsin-Madison Medical School. J Pain Symptom Manage. 2001 Sep;22(3):791-6.  Ed: Presuming that patients were given only one narcotic each, the above study had 79% of chronic pain patients on narcotics. Since narcotics are highly addictive and relative poor pain relievers, it sounds like the over-prescribing of narcotics is rampant in Wisconsin.

Criminal Opiate Misuse Rampant (32%) in Chronic Pain Patients: In a prospective cohort study to determine the one-year incidence and predictors of opioid misuse patients enrolled in a chronic pain disease management program within an academic internal medicine practice, 196 opioid-treated chronic, non-cancer pain patients were monitored. Opioid misuse was defined as: 1. Negative urine toxicological screen (UTS) for prescribed opioids; 2. UTS positive for opioids or controlled substances not prescribed by the clinic; 3. Evidence of procurement of opioids from multiple providers; 4. Diversion of opioids; 5. Prescription forgery; or 6. Stimulants (cocaine or amphetamines) on UTS. The mean patient age was 52 years, 55% were male, and 75% were European-American. Sixty-two of 196 (32%) patients committed opioid misuse. Detection of cocaine (25% of all patients) or amphetamines (26%) on UTS was the most common form of misuse (40.3% of misusers). Misusers were more likely than non-misusers to be younger (48 years vs 54 years, p<0.001), male (59.6% vs. 38%; p=0.023), have past alcohol abuse (44% vs 23%; p=0.004), past cocaine abuse (68% vs 21%; p<0.001), or have a previous drug or DUI conviction (40% vs 11%; p<0.001%). In multivariate analyses, age, past cocaine abuse (OR, 4.3), drug or DUI conviction (OR, 2.6), and a past alcohol abuse (OR, 2.6) persisted as predictors of misuse. Race, income, education, depression score, disability score, pain score, and literacy were not associated with misuse. No relationship between pain scores and misuse emerged. Predictors of Opioid Misuse in Patients with Chronic Pain: A Prospective Cohort Study. Ives TJ, et al. University of North Carolina, Chapel Hill, BMC Health Serv Res 2006 Apr 4;6(1):46. Repeatedly negative urines occurred in 9%; multiple providers (9%)(not emergency rooms); unprescribed opioid (8%); 18% were positive for cannabinoids although this was not counted as misuse. It was, however, a powerful predictor of misuse (33% vs. 11%). All with negative urines for prescribed opioids claimed they were taking it as prescribed and none showed signs of withdrawal, which would be expected if patients ran out early. Several other studies find similar figures. Authors estimate national misuse by chronic pain patients at 25%. http://www.biomedcentral.com/content/pdf/1472-6963-6-46.pdf 

DAWN Documented Deaths from Opiate Pills Very High, But Current Data Hard to Find: 1014 oxycontin overdose deaths occurred in 23 states from August, 1999 to January, 2002, according to the government Drug Abuse Warning System (DAWN) system.  Hydrocodone-related deaths were 592 in 2001 and 618 in 2002 (DAWN). From 1998 to 2002, tramadol was involved in 382 deaths (DAWN).  Unfortunately, DAWN data has not been openly distributed by the government since 2003.  Despite the purpose of DAWN being to make rapid information available to the public about the course of America's drug epidemic, it appears that the Bush administration is keeping the information out of the public's eye, probably because the news is very bad news.  Finding current national data on-line is very hard.  King County, Washington (Seattle) reports 2004 cocaine deaths were at an all-time high of 92 and prescription opiates death were up 40% to 118 from only 28 in 1997. Heroin deaths were well below the record in 1998. The vast majority of Seattle IV drug users are infected with hepatitis B and C and many with HIV. In 2004, there were 849 methadone-related deaths in Florida alone (Palm Beach Post (Florida), Oct. 2, 2005, p. 1A). There were over 900 opiate-related deaths in New York City alone in 2004. (http://opiateaddictionrx.info/whatsnew.asp?id=881&Archive=True).

VA Orthopedic Clinic Patients: Two-Third Given Opiates; 25% on Long-term: In a 3-year retrospective chart review, a large majority of patients were being given a wide variety of opiates.  While the author sees no problem, this means that huge numbers of patients without any life-threatening or terminal disease and readily being dispensed extremely addictive drugs. While the author claims that his study showed that the opiates considerably reduced pain, in fact, such a retrospective chart review can never prove such a thing or even suggest it.  The author's claim is simply irresponsible. The average patient was taking the equivalent of over 20 mg. of morphine a day. Opioid use by patients in an orthopedics spine clinic. Mahowald ML, et al. Minneapolis VAMC. . Arthritis Rheum. 2005 Jan;52(1):312-21. 

450% Increase in Number of Office Visits in Which Highly Addictive Narcotics are Prescribed: Pain treatment has been promoted by national guidelines, the 'pain as the 5th vital sign' campaign and direct-to-consumer advertising. Using the National Ambulatory Medical Care Survey, a nationally representative survey of visits to office-based physicians, data from 1980-81 (n=89,000 visits) vs. 1999-2000 (n=45,000 visits) found that NSAID prescriptions increased 74% for acute (19% vs. 33%) and  16% for chronic (25 vs. 29%) musculoskeletal pain visits. In 2000, one-third of the NSAID prescriptions were for COX II agents. Opioids increased 38% for acute pain (8 vs. 11%) and 100% for chronic pain (8 vs. 16%). The use of more highly addictive opioids (hydrocodone, oxycodone, morphine) for chronic musculoskeletal pain increased 450% from 2 to 9% of visits. This means that there were 5.9 million visits where potent opioids were prescribed in 2000. The threshold for prescribing NSAIDS and opioids has clearly dropped. Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs. 2000. Caudill-Slosberg MA, et al. Dartmouth Medical School. . Pain. 2004 Jun;109(3):514-9. Ed: This is extremely frightening, especially since these drugs, at best, are of minor benefit for pain, acute or chronic. 

The Doping of Europe: 420% Increase in Opiate Use in Spain: Using the ECOM database from the Spanish Ministry of Health, researchers found that the consumption of opioid analgesics in Spain increased by 420% from 94.7 defined daily dose per 1,000,000 inhabitants in 1985 to 489.4 in 1994. The most consumed drug in 1994 was dihydrocodeine, followed by tramadol.

Prescription Opioid Abuse Often Leads to Heroin: In a chart review of 178 new admissions from 1997-1999, 83% had been using prescription opioids with or without heroin: 24% had used prescription opioids only; 24% used prescription opioids initially and heroin later; 35% used heroin first and prescription opioids later; and 17% heroin only (this group was significantly younger: mean age 26, P=0.0001). The 'prescription opioid only' group the reported mean number of codeine or oxycodone-containing tablets consumed daily was 23 tablets and 21 tablets, respectively. Those that used prescription opioids only or initially were more likely to have ongoing pain problems and to be involved in psychiatric treatment. Prescription opioid abuse in patients presenting for methadone maintenance treatment. Brands B, et al. University of Toronto. . Drug Alcohol Depend. 2004 Feb 7;73(2):199-207. Ed: This study found 30% of all heroin users in their program started with prescription opioids.  Remember, this study was before opioid prescribing really took off.

Many Drug Addicts Get Their Drugs from Physicians: In a study of 534 patients at the Sparrow/St. Lawrence Addiction Detoxification Unit in 2000, 27% were dependent on prescription opiate medications. The most frequently mentioned medication was Vicodin (hydrocodone) (53% of the users) followed by OxyContin (oxycodone) (19%). Physicians prescribed these medications in 75% of the cases. Predictors of dependence on opiate medications included substance-related diagnoses, positive drug screens for other opiates, and other medical diagnoses. Patient characteristics and risks factors for development of dependence on hydrocodone and oxycodone. Miller NS, et al. Michigan State University. . Am J Ther. 2004 Jan-Feb;11(1):26-32.

Drug Abuse Rampant Amount Medical Pain Patients: In a prospective, comparative evaluation of 200 patients from an interventional pain management setting, divided into two groups of 100 consecutive patients receiving either hydrocodone or methadone, drug testing was carried out by Rapid Drug Screen. Illicit drug use was detected in 22% of  hydrocodone and 24% of methadone patients. The misuse or abuse of a prescription opioid was seen in 3% of hydrocodone and 12% of methadone patients. In a significant proportion of patients in both groups, the drug prescribed for them was not detected on testing (probably selling their medications). The combined use of illicit drugs and misuse of prescription drugs was noted in 24% of hydrocodone and 33% of methadone patients.

Most Prescription Drug Abusers Hooked by Physicians: In a prospective survey of 109 prescription drug abusers entering a treatment facility in central Kentucky (69% men and 98% European-American), 84% stated that they had legitimately been given a prescription for opioids for pain at some point from a physician and 61% reported chronic pain concerns. The most commonly abused drugs were hydrocodone (78%) and oxycodone (69%), while methadone (23%) or fentanyl (7%) were abused much less frequently. Most respondents (91%) stated that they had purchased prescription opioids from a street dealer at least once and 80% had altered the delivery system of the prescription drug by chewing, snorting, or using i.v. administration. Psychiatric and pain characteristics of prescription drug abusers entering drug rehabilitation. Passik SD, et al. Memorial Sloan Kettering Cancer Center and Cornell University. J Pain Palliat Care Pharmacother 2006;20(2):5-13.

Misuse of Narcotics Very Common in Pain Clinic Patients:  This pain clinic uses a narcotic protocol which consists of a narcotic contract, consent, psychological evaluation, and random urinalysis. In a retrospective study of 186 patients at the center in 2001, there were 355 infractions of the narcotic contract. Products containing hydrocodone were found to be most frequently misused (20.3%), followed by oxycodone products (19.7%). Patients prescribed controlled substances should be repeatedly evaluated for medication misuse and the presence of addictive behaviors. Misuse of prescribed controlled substances defined by urinalysis. Vaglienti RM, et al. West Virginia Pain Treatment Center, West Virginia University School of Medicine, Morgantown. W V Med J. 2003 Mar-Apr;99(2):67-70. Ed: Prescribing potent narcotics is playing with fire.

Most Long-Acting Opioid Patients Exceed Manufacturer Guidelines: In a study of chronic nonmalignant pain management from 6 outpatient pain clinics of patients on either transdermal fentanyl (Duragesic) or oxycodone HCl controlled-release (Oxycontin) for at least 6 weeks. The manufacturer's package inserts say to use OxyContin every 12 hours and to change transdermal fentanyl patches every 72 hours. Of 690 patients, 63% received OxyContin and 37% transdermal fentanyl. The average interval between administrations of OxyContin was only 7.8 hours, not the planned 12 hours.  The average daily dose was 155.6 mg, i.e., quite high. Among OxyContin patients, only 17.5% had an average interval between administrations of 12 or more hours. Transdermal fentanyl patients reported wearing the patch, on average, for 2.5 days. Only 41% reported wearing the patch for at least 3 days, and only 14% reported the duration of pain relief as at least 3 days. The probability that OxyContin patients had higher oral morphine equivalents was 83%. Patient-reported utilization patterns of fentanyl transdermal system and oxycodone hydrochloride controlled-release among patients with chronic nonmalignant pain. Ackerman SJ, et al. Gaithersburg, MD. . J Manag Care Pharm. 2003 May-Jun;9(3):223-31.

31% Oxycontin Addicts in Treatment Started on Opiates with an OxyContin Prescription:  Of 48 patients admitted for in-patient detox for abusing OxyContin, 31% first obtained their OxyContin from a physician for a real medical aliment. None of these had a history of prior opioid misuse. They were more likely than illicit CR oxycodone users to report prior detoxifications (P<0.03) as well as a lower mean age of first alcohol use (11.7 versus 14.7, P<0.05) and first illicit drug use (12.8 versus 15.8, P<0.05). Substance use histories in patients seeking treatment for controlled-release oxycodone dependence. Potter JS, et al. McLean-Harvard. . Drug Alcohol Depend. 2004 Nov 11;76(2):213-5. Ed: Obviously, doctors in Massachusetts aren't being very careful to whom they prescribe OxyContin. At the University of Kentucky, 187 OxyContin addicts admitted for detox used an average dose of 184 milligrams of OxyContin per day. They made up 31% of all Addictive Disease Unit admission and 61% of opiate admissions. The OxyContin dependent individuals tended to show a progression from p.o. use to either snorting or i.v. use. J Addict Dis. 2004;23(4):1-9.

Medical Use Pushing Up Non-Medical Abuse: Fentanyl, hydromorphone, morphine, and oxycodone usage have markedly increased in medical usage between 1997 and 2002.  in the same time period, opioid analgesics increased from 5.75% to 9.85% of all drug abuse (J Pain Symptom Manage. 2004 Aug;28(2):176-88).  While pain clinics blossom and rake in the money, insurance costs skyrocket, pain doesn't decrease, and junkies, legal and illegal, are multiplying rapidly.

Morphine Kills Patients: Morphine is an independent risk factor for death from sepsis in burn and critically ill patients. It may increase the virulence of Pseudomonas bacteria (Alverdy et al. Science 2005;309:774-7).  The same is probably true of most other narcotic opiates. 

Numerous studies show that the use of non-narcotic pain medications before and after surgery can reduce the use of narcotics, e.g. diclofenac in Can J Anaesth. 2001 Jul-Aug;48(7):661-4; rectal indomethacin Am J Obstet Gynecol. 2001 Jun;184(7):1544-7; Chin Med J 1996; 58: 404; Can J Anaesth 1993; 40: 4068; Acta Anaesthesiol Scand 1995; 39: 969; Eur J Anaesth 1995; 12: 54953; Clin Otolaryngol 1991; 16: 5548; Eur J Clin Pharm 1987; 32: 24952 (a smaller number did not find an added benefit).  Narcotics add only a minor benefit if any in studies using them as add-on pain treatments.  Numerous surgical and non-surgical studies suggest that narcotics are of minor benefit at most and the harm of addiction far outweighs any benefit. Doctors almost never give patients a choice.

Government Approved Worldwide Use of Narcotics Skyrockets: Even before the massive increase in narcotics sales since 1995, narcotic use had already increased massively since 1983.  Morphine consumption worldwide had been stable around 2.0 metric tons per year. However, from 1983 through 1995, a steady and rapid increase brought the total of 15.6 tons, an increase of over 600%. Methadone also jumped massively from 1980 to 1995 going from 1.6 to 6.3 tons, a 300% jump. Eur J Palliative Care 1997:4:194-8. Based on these figures, compared to 1980, government sanctioned narcotic sales in the U.S. and world have gone up over 1000%!  

Researchers working on drug company-funded studies of narcotics seem to be very careful not to compared their new medication to a non-narcotic pain reliever so as to prevent their medication being proven no better or even not as good. (e.g. Tramadol hydrochloride (Ultram): analgesic efficacy compared with codeine, aspirin with codeine, and placebo after dental extraction. Moore PA, et al. University of Pittsburgh, School of Dental Medicine. J Clin Pharmacol. 1998 Jun;38(6):554-60.)

World Health Organization Ladder is Bogus and Not Supported by Research

In 1986, the World Health Organization (WHO), heavily influenced by the pharmaceutical industry, published guidelines for cancer pain management based on the three-step analgesic ladder (Cancer Pain Relief and Palliative Care. Geneva, Switzerland; World Health Organization; 1990). These steps comprise a sequential approach according to the individual pain intensity, which begins with non-opioid analgesics and progresses to opioids for moderate pain and then for severe pain. Step I includes the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and other non-opioid drugs for mild and moderate pain. The WHO claims that an opioid should be added to the NSAID if pain persists or increases, if intolerable adverse effects are encountered, or if pain is moderate to severe at the outset. However, many other non-addictive pain alternatives are available.  Opioids are then recommended for moderate pain in the second analgesic ladder, although there is a huge amount of research proving beyond any doubt that opiates are not better pain relievers than many non-opiates for moderate and severe pain.  If pain continues unrelieved or is severe at the outset, opioids of higher potency are then advocated by the WHO.

The quality of WHO analgesic ladder studies has been recently questioned due to their methodologic limitations, including the circumstances during which assessment were made, small sample size, high rate of exclusions and dropout, inadequate follow-up, and lack of comparison with levels of analgesia before the introduction of the analgesic ladder (Jadad AR, Browman GP. The WHO analgesic ladder for cancer pain management: stepping up the quality of its evaluation. JAMA. 1995;274:1870-1873).  In fact, there is very little research in comparing non-opiates to opiates for cancer pain and the research that exists actually favors the non-opiates!  Also, the large majority of opiates are not used for cancer pain, but for all sorts of other chronic or acute pain and are even given before anyone knows whether pain is even going to occur.

However, on the use of Step II of the WHO analgesic ladder, research shows that there are no significant differences in pain relief between non-opioids alone and non-opioids plus opioids for moderate pain (Eisenberg E, Berkey CS, Carr DB, et al. Efficacy and safety of nonsteroidal anti-inflammatory drugs for cancer pain: a meta-analysis. J Clin Oncol. 1994;12:2756-2765).  Some analgesics of the analgesic ladder may be more useful for particular pain conditions. A mechanistic approach based on a selective drug administration sequence according to the pain mechanism has been proposed rather than a step-wise fashion based on the overall severity of pain and potency of drugs (Ashby MA, Fleming BG, Brooksbank M, et al. Description of a mechanistic approach to pain management in advanced cancer: preliminary report. Pain. 1992;51: 153-161). 

Equally effective pain relief occurs in all three steps of the analgesic ladder, with over 80% of patients rating their pain as less than moderate. Equally effective pain relief could be obtained in all three steps of the analgesic ladder, with over 80% of patients rating their pain as less than moderate regardless of the pain mechanism (Zech DF, Grond S, Lynch J, et al. Validation of World Health Organization Guidelines for cancer pain relief: a 10-year prospective study. Pain. 1995;63:65-76; Mercadante S. Pain treatment and outcome in advanced cancer patients followed at home. Cancer. 1999).  Only 20% of patients were still taking NSAIDs in the last week of life, despite these being at least equal in efficacy to opiates and, in combination with opiates, always better than opiates alone.  The opiates add very little to pain relief, but force millions of pain patients to suffer the pains of drug craving addictions.  

The extensive use of NSAIDs explains the lower use of opioids in some countries such as Italy and Germany (Mercadante S. Pain treatment and outcome in advanced cancer patients followed at home. Cancer. 1999). While NSAIDS are prescribed in only 35% of patients on Step I of the WHO ladder (the official recommendation is adding the opiate, not stopping the non-narcotic pain relievers), still fewer maintained non-narcotic pain relievers on Step III.  Very little controlled research has ever studied the effectiveness of opiates compared to non-narcotics in cancer pain (Cancer Control 6(2):191-7, 1999. Lee Moffitt Cancer Center).

NSAIDs are considered be effective in some specific cancer pain syndromes such as bony metastases, although data to support this do not exist (Mercadante S. Malignant bone pain: pathophysiology and treatment. Pain. 1997;69:1-18). Of course, there is also no evidence that opiates help this type of pain either.  However, other non-narcotics have been shown effective for bone pain and clearly superior to opiates.  

Recent studies have shown that NSAIDs are equally effective in both visceral and somatic pain syndromes (Mercadante S, Casuccio A, Agnello A, et al. The analgesic effect of non steroidal anti-inflammatory drugs (NSAIDs) in cancer pain due to somatic and visceral mechanism. J Pain Symptom Manage. 1999). Different problems are unresolved due to a lack of controlled studies. These problems include the role of NSAIDs, the prolonged use of NSAIDs in cancer pain, and the utility of Step II.  Moreover, indications for using different strong opioids and alternate routes of administration to improve pain relief in difficult pain situations are not well established. The proportion of patients who do not benefit from these treatments remains unclear, and whether opioids are even necessary and, if necessary, how the opioid response may be improved with the use of adjuvants is also uncertain.

Substance Abuse Markedly Increases Anxiety in Affective Disorders: In a study of 260 adults in a supported socialization program, multivariate logistic regression analyses were used to determine the relationship between anxiety disorders and alcohol and substance use disorders among patients with severe and persistent affective disorders (i.e., major depression and bipolar disorder). Among patients with severe and persistent affective disorders, cocaine (odds ratio [OR] = 5.9), stimulant (OR = 5.1), sedative (OR = 5.4), and opioid use disorders (OR = 13.9) were all significantly more common among those with, compared with those without, anxiety disorders. This association persisted after adjusting for differences in sociodemographic characteristics and comorbid psychotic disorders. Significant associations between panic attacks, social phobia, specific phobia, and obsessive-compulsive disorder and specific substance use disorders were also evident. The relationship between anxiety and substance use disorders among individuals with severe affective disorders. Goodwin RD, et al. Columbia University. Compr Psychiatry. 2002 Jul-Aug;43(4):245-52.

I have found very little protest against the massive promotion of narcotics by physicians despite massive amounts of evidence showing that narcotics add little to effective pain relief and that abuse appears common and growing. 

One DB study showed that even acetaminophen improved pain control in patients already on high doses of opioids. University of Sydney. J Clin Oncol. 2004 Aug 15;22(16):3389-94.

Strengths: IM: morphine 10 = hydromorphone 1.5 = methadone 10= oxycodone 15 = oxymorphone 1 = meperidine 75 = codeine 130; P.O.: morphine 60 = hydromorphone 6.5 = methadone 20= oxycodone 30 = oxymorphone 10 = meperidine 75 = codeine 200 = fentanyl (patch) 15; Ed: It is easy to see why addicts shoot up.  It makes a small amount stretch farther.