Talk:Opioid

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Revised lead for review[edit]

I want to offer this for review before posting. This grew from revising the lead paragraph. I placed the modern definition of opioid at the beginning while noting opiate in that definition. It simply isn't appropriate to not place the primary there. Even sources such as D'Arcy call morphine an opioid in the cited sources. After review of multiple reliable sources I made this more comprehensive and repositioned existing sentences more logically. This is also cited heavily which will serve the review but can be moved or removed in the article space.

The citations may not yet follow the date style in the article, if one exists.

I can't imagine any major issues with this. The lead follows minus the layout markers:

(signed here and at bottom) Box73 (talk) 11:41, 13 February 2016 (UTC)


Opioids are substances that act on opioid receptors to produce morphine-like effects.[1] Opioids include opiates, an older term that refers to such drugs derived from opium, including morphine itself.[2] Other opioids are semi-synthetic and synthetic drugs such as hydrocodone, oxycodone and fentanyl; antagonist drugs such as naloxone and endogenous peptides such as the endorphins.[3] Opioid drugs are predominantly central nervous system agents, most often used medically to relieve pain.[4]

The side effects of opioids may include pruritus, sedation, nausea, respiratory depression, constipation, and euphoria. Tolerance and dependence will develop with continuous use, requiring increasing doses and leading to a withdrawal syndrome with upon abrupt discontinuation. The profound euphoria attracts recreational use; frequent and escalating recreational use of opioids typically results in addiction. Accidental overdose or concurrent use with other depressant drugs commonly results in death from respiratory depression. Because of opioid drugs' reputation for addiction and fatal overdose, most are highly controlled substances.

Primarily used for pain relief, including anesthesia, opioids are also approved to suppress cough, suppress diarrhea, treat addiction, reverse opioid overdose, and suppress opioid induced constipation,.[5] Extremely potent opioids are used to only approved for veterinary use such as immobilize immobilizing large mammals.[6] Opioids act by binding to opioid receptors, which are found principally in the central and peripheral nervous system and the gastrointestinal tract. These receptors mediate both the psychoactive and the somatic effects of opioids. Opioid drugs include partial agonists and antagonists, which produce moderate or no effect (respectively) but displace other opioids from binding in those receptors.

Opioids are among the world's oldest known drugs. The medical use of the opium poppy predates recorded history; recreational and religious use likewise precedes the common era. In the 19th century morphine was isolated and marketed, and the hypodermic needle invented, introducing rapid, metered administration of the primary active compound. Synthetic opioids were invented, and biological mechanisms discovered in the 20th century. Illicit production, smuggling, and addiction to opioids, prompted treaties, laws and policing which have realized limited success. In 2013 between 28 and 38 million people used opioids recreationally (0.6% to 0.8% of the global population between the ages of 15 and 65).[7] In 2011 an estimated 4 million people the United States used opioids recreationally or were dependent on them.[8] Current recreational use and addiction are attributed to over-prescription of opioid medications and inexpensive illicit heroin.[9][10][11] Conversely, fears about over-prescribing, exaggerated side effects and addiction from opioids are similarly blamed for under-treatment of pain.[12][13]

The terms opiate and narcotic are sometimes encountered as synonyms for opioid. Opiate is properly limited to the natural alkaloids found in the resin of the Papaver somniferum (opium poppy) although some authorities include semi-synthetic derivatives.[14][2] Narcotic, derived from numbness or sleep, is now a legal term that refers to cocaine and opioids, and their source materials; it is also loosely applied to any illegal or controlled psychoactive drug.[15][16] The term has pejorative connotations and its use is generally discouraged.[17][18]

  1. ^ Hemmings, Hugh C.; Egan, Talmage D. (2013). Pharmacology and Physiology for Anesthesia: Foundations and Clinical Application: Expert Consult - Online and Print. Elsevier Health Sciences. p. 253. ISBN 1437716792. Opiate is the older term classically used in pharmacology to mean a drug derived from opium. Opioid, a more modern term, is used to designate all substances, both natural and synthetic, that bind to opioid receptors (including antagonists). 
  2. ^ a b Offermanns, Stefan (2008). Encyclopedia of Molecular Pharmacology. 1 (2 ed.). Springer Science & Business Media. p. 903. ISBN 9783540389163. In the strict sense, opiates are drugs derived from opium and include the natural products morphine, codeine, thebaine and many semi-synthetic congeners derived from them. In the wider sense, opiates are morphine-like drugs with non peptidic structures. The older term opiates is now more and more replaced by the term opioids which applies to any substance, whether endogenous or synthetic, peptidic or non-peptidic, that produces morphine-like effects through action on opioid receptors. 
  3. ^ Freye, Enno (2008). "Part II. Mechanism of action of opioids and clinical effects". Opioids in Medicine: A Comprehensive Review on the Mode of Action and the Use of Analgesics in Different Clinical Pain States. Springer Science & Business Media. p. 85. ISBN 9781402059476. Opiate is a specific term that is used to describe drugs (natural and semi-synthetic) derived from the juice of the opium poppy. For example morphine is an opiate but methadone (a completely synthetic drug) is not. Opioid is a general term that includes naturally occurring, semi-synthetic, and synthetic drugs, which produce their effects by combining with opioid receptors and are competively antagonized by nalaxone. In this context the term opioid refers to opioid agonists, opioid antagonist, opioid peptides, and opioid receptors. 
  4. ^ Benzon, Honorio; Raja, Srinivasa N.; Fishman, Scott E.; Liu, Spencer; Cohen, Steven P. (2011). Essentials of Pain Medicine. Elsevier Health Sciences. p. 85. ISBN 1437735932. 
  5. ^ Stromgaard, Kristian; Krogsgaard-Larsen, Povl; Madsen, Ulf (2009). Textbook of Drug Design and Discovery, Fourth Edition. CRC Press. ISBN 9781439882405. 
  6. ^ Sterken, Joeri; Troubleyn, Joris; Gasthuys, Frank; Maes, Viviane; Diltoer, Mark; Verborgh, Christian (2004-10-01). "Intentional overdose of Large Animal Immobilon". European Journal of Emergency Medicine: Official Journal of the European Society for Emergency Medicine. 11 (5): 298–301. ISSN 0969-9546. PMID 15359207. 
  7. ^ "Status and Trend Analysis of Illict [sic] Drug Markets". World Drug Report 2015 (PDF). Retrieved 26 June 2015. 
  8. ^ "Report III: FDA Approved Medications for the Treatment of Opiate Dependence: Literature Reviews on Effectiveness & Cost- Effectiveness, Treatment Research Institute". Advancing Access to Addiction Medications: Implications for Opioid Addiction Treatment. p. 41. 
  9. ^ Tetrault, Jeanette M.; Butner, Jenna L. (2015-09-03). "Non-Medical Prescription Opioid Use and Prescription Opioid Use Disorder: A Review". The Yale Journal of Biology and Medicine. 88 (3): 227–233. ISSN 0044-0086. PMC 4553642free to read. PMID 26339205. 
  10. ^ Tarabar, Asim F.; Nelson, Lewis S. (2003-04-01). "The resurgence and abuse of heroin by children in the United States". Current Opinion in Pediatrics. 15 (2): 210–215. ISSN 1040-8703. PMID 12640281. 
  11. ^ Gray, Eliza (2014-02-04). "Heroin Gains Popularity as Cheap Doses Flood the U.S.". TIME.com. Retrieved 2016-02-12. 
  12. ^ Maltoni, M. (2008-01-01). "Opioids, pain, and fear". Annals of Oncology. 19 (1): 5–7. doi:10.1093/annonc/mdm555. ISSN 0923-7534. PMID 18073220. [A] number of studies, however, have also reported inadequate pain control in 40%–70% of patients, resulting in the emergence of a new type of epidemiology, that of ‘failed pain control’, caused by a series of obstacles preventing adequate cancer pain management.... The cancer patient runs the risk of becoming an innocent victim of a war waged against opioid abuse and addiction if the norms regarding the two kinds of use (therapeutic or nontherapeutic) are not clearly distinct. Furthermore, health professionals may be worried about regulatory scrutiny and may opt not to use opioid therapy for this reason. 
  13. ^ McCarberg, Bill H. (2011-03-01). "Pain management in primary care: strategies to mitigate opioid misuse, abuse, and diversion". Postgraduate Medicine. 123 (2): 119–130. doi:10.3810/pgm.2011.03.2270. ISSN 1941-9260. PMID 21474900. 
  14. ^ ARNP, Pamela Davies MS; CNS, Yvonne D'Arcy MS, CRNP (2012-09-26). Compact Clinical Guide to Cancer Pain Management: An Evidence-Based Approach for Nurses. Springer Publishing Company. ISBN 9780826109743. 
  15. ^ "21 U.S. Code § 802 - Definitions". LII / Legal Information Institute. Retrieved 2016-02-12. 
  16. ^ "Definition of NARCOTIC". www.merriam-webster.com. Retrieved 2016-02-12. 
  17. ^ Satoskar, R. S.; Rege, Nirmala; Bhandarkar, S. D. (2015). Pharmacology and Pharmacotherapeutics. Elsevier Health Sciences. ISBN 9788131243718. 
  18. ^ Ebert, Michael H.; Kerns, Robert D. (2010). Behavioral and Psychopharmacologic Pain Management. Cambridge University Press. ISBN 9781139493543. 

(sign is repeated from above revised lead) — Box73 (talk) 11:41, 13 February 2016 (UTC)

minor revisions to above lead — Box73 (talk) 12:12, 13 February 2016 (UTC)

Changes needed due to new guidelines?[edit]

Content on the new CDC guidelines was added only to the lead in this dif, and i moved that to the appropriate part of the body in this dif. I don't think this rises to the importance of being included in the lead of this article. Others may differ of course.

bigger question - do these new guidelines need to be incorporated elsewhere in the article? I kind of don't think so, as they are more about how to prescribe them, and we follow WP:NOTHOWTO. But am interested in what others think. Jytdog (talk) 18:52, 18 March 2016 (UTC)

Please, refine first para in lede[edit]

Tolgraven made some good faith edits to the lede's first paragraph which seemed reasonable but suffered from too many prepositional phrases. I pruned them for readability while attempting to keep his changes. I also moved the opioid drugs are CNS pain agents sentence to 2nd place which might benefit from fine tuning. The "American legal term" isn't quite right, but the thing gets choppy with many prepositional phrases. My time and energy are short so I'd appreciate someone helping tweak things. Thanks. — Box73 (talk) 11:45, 12 April 2016 (UTC)

re revert:
  1. The lead would make one believe opioids are utilized equally for CNS, PNS and GI effects. There is a reason morphine is C-II and Imodium is OTC, most opioids are given for pain, and recreational use involves reward.
  2. Since morphine is called strong and fentanyl very strong, etorphine etal need more emphasis, hence extremely potent.
I do appreciate the campaign of simplification but oversimplification cuts essential information and breeds confusion. If such info is cut it should reappear elsewhere in the lead or the ideas somehow preserved. Now I did request tweaking for readability but respectfully, I think our audience can grasp material/complexity a bit above the level of My Weekly Reader. — Box73 (talk) 11:00, 15 April 2016 (UTC)
What does this mean "reverse opioid overdose, and suppress opioid induced constipation" Opioids are not used for opioid overdoses or to treat constipation. Ref does not have a page number. Doc James (talk · contribs · email) 15:43, 15 April 2016 (UTC)
Re my last post... First, the CNS inclusion comes down to the lede later saying CNS, PNS and GI. Opioid drugs (desired actions) are predominantly central. This issue is also important because opioids are also endogenous, not simply drugs, and these are distributed in those areas+. Second, the drug sufentanil is described as very potent but vet only opioids are much stronger/more potent than this very strong/potent, which should qualify as extremely potent. Sufentanil is approved for medical (human) use. — Box73 (talk) 16:18, 15 April 2016 (UTC)
Doc: Respectfully, based on a current definition of opioid, I am not wrong. An antagonist is used to reverse an agonist overdose; a peripheral antagonist is used to suppress peripheral effects (constipation) of an agonist permitting central effects. Opioids are agonists, partial & mixed agonists and antagonists. This is ref'd in lede. Give me a few minutes to look at the ref in question. — Box73 (talk) 16:18, 15 April 2016 (UTC)
@Doc James: First, re opioids including antagonists, see Hemmings, "Opioid, a more modern term, is used to designate all substances, both natural and synthetic, that bind to opioid receptors (including antagonists)." and Freye, "...the term opioid refers to opioid agonists, opioid antagonists, opioid peptides, and opioid receptors." Since these are cited you should revert those changes. Second, what reference above are you talking about? Third, would you prefer to talk about changes or instigate warring? You're putting me in a position where I am forced into warring. Should we seek an outside opinion? — Box73 (talk) 16:36, 15 April 2016 (UTC) fix typos above. Box73 (talk) 16:44, 15 April 2016 (UTC)
Yes agree you are correct and have returned the other uses to the lead. We should keep discussion of the mechanism in the second paragraph though IMO. We have "Opioids act by binding to opioid receptors, which are found principally in the central and peripheral nervous system and the gastrointestinal tract." in the next paragraph so not convinced we need to mention CNS effects in the paragraph above.
This ref is missing a page number "Stromgaard, Kristian; Krogsgaard-Larsen, Povl; Madsen, Ulf (2009). Textbook of Drug Design and Discovery, Fourth Edition. CRC Press. ISBN 9781439882405. " Doc James (talk · contribs · email) 17:16, 15 April 2016 (UTC)
  • If we are going to include antagonists here the first sentence is now wrong. the article was formerly limited to opioids with agonist effects. my sense is that we should have this article focus on opioids with agonist-like effects as we have Opioid antagonist already and opioid agonist redirects here. Jytdog (talk) 17:45, 15 April 2016 (UTC)
Yes I do not typically consider opioid antagonists to be opioids. I think common usage is for opioids to mean agonists. But do agree that some sources support that this is the case. Doc James (talk · contribs · email) 18:48, 15 April 2016 (UTC)
Editors decide the scope of Wikipedia articles; they do need to be a reasonable fit with the literature and common use and the limitation to opioid agonist-like compounds was and is both, regardless of whether some sources use the term more broadly. Jytdog (talk) 18:54, 15 April 2016 (UTC)
I guess the question is do we redirect opioid to opioid agonist. Than have an opioid (disambig) page that mentioned the wider meaning and links to opioid antagonist. So we result in this article being split into two. Doc James (talk · contribs · email) 19:22, 15 April 2016 (UTC)
  1. We certainly don't need to do that. (If so then we should separate endogenous opioids from opioid drugs.) I'm cool with excluding antagonists and this issue can be simply noted in the first section for clarity. What follows was already written...
  2. Common use and medical literature also generally limits opioids to drugs yet inclusion of antagonists is not limited to two sources (for example, see: Opioid Guidelines in the Management of Chronic Non-Cancer Pain and also Mehdi B (2008). "Opioid analgesics and antagonists". In Seth SD, Seth V. Textbook Of Pharmacology.). Having said that, excluding antagonists is a reasonable compromise and remaining wording easily tweaked. IMO the distribution of receptors is appropriate and well written. Yet it misses the fact that opioids' utility is by CNS action.
  3. re the missing page number: I don't know the page offhand but this refers to naloxegol.
  4. This has bothered me: Does the 5th and 6th paras under addiction belong there?
  5. Doc James, I appreciate your efforts to simplify as too many articles make readers trudge through technical details to get to the meat and also benefit from common language. Thank you and Jytdog for responding here. — Box73 (talk) 22:18, 15 April 2016 (UTC)
Great, so we can resolve the dispute with which this section began and all move on. thx for compromosing, box73 Jytdog (talk) 03:53, 16 April 2016 (UTC)

Removed content - consumer information[edit]

I work for Consumer Reports, and I am paid to add my organization's health information to Wikipedia. Paid editing is a touchy subject on Wikipedia. If anyone wants to comment on what I am doing, WikiProject Medicine would one of the appropriate forums to discuss paid editing in medicine with others.

I do not have any question or request here. I just wanted to talk through an experience in this article so that I can reflect on it and state the issue.

I couple of years ago I added the below information to this article, and the article looked this way in June 2014. Mostly I cited this report.

A user removed a lot of what I added, saying "Consumer's reports is not a reliable source for medical information, see WP:MEDRS". That user since left Wikipedia. I agree with them, though - the report that I cited is not the kind of medical source which Wikipedia usually accepts, because it is not peer reviewed academic literature. Still, I feel that the report is an expert response to the academic literature and written in a way that presents evidence-based medicine to a layman audience, along with insights for that demographic, and is a good source for the information it presents.

Here is most of the text I originally added, and which was either removed or kept but with the citation to Consumer Reports replaced with academic sources. A lot of this is still in the article, and I am glad for that. It stayed in the article because I used multiple citations, so the citation to my organization's layman source was deleted while the academic sources remained.

Extended content

Opioids for pain relief are also used when nondrug pain treatment options including cognitive behavioral therapy, exercise, spinal manipulation, and physical medicine and rehabilitation programs are insufficient to meet therapy goals.[1] Patients taking opioids talk with their health care provider to develop a personal health plan which includes a combination of therapies, perhaps including drug and nondrug treatments, to relieve pain.[1]

In treating chronic pain, opioids are an option to be tried after other less risky pain relievers have been considered, including paracetamol/acetaminophen or NSAIDs like ibuprofen or naproxen.[1][2] Some types of chronic pain, including the pain caused by fibromyalgia or migraine, are preferentially treated with drugs other than opioids.[1][3][4] The efficacy of using opioids to lessen chronic neuropathic pain is uncertain.[5]


There are gaps in available research describing the safe use of opioids long-term or comparing the relative safety of the long-term use of various opioids to each other.[1] The research also does not have information about the extent to which opioids differ in terms of the risk they bring for causing addiction.[1]

Research suggests that when methadone is used long-term use it can build-up unpredictably in the body and lead to potentially deadly slowed breathing.[1][6][7] Regular physician monitoring reduces the likelihood of problems.[1][6]


When prescribing an opioid, physicians have a process to recommend the correct one, find the right dosage for the patient, and then minimize the side effects.[1]


People who take opioids long term have increased likelihood of being unemployed.[8] Taking opioids further disrupts the patient's life and the adverse effects of opioids themselves can become a significant barrier to patients having an active life, gaining employment, and sustaining a career.[1]

'from bluerasberry in this case, the Consumer Reports citation was removed, but the sentence was left without a citation. I do not think this information is of greater value when it is presented without a citation.
  1. ^ a b c d e f g h i j Consumer Reports Health Best Buy Drugs (21 August 2012), "Using Opioids to Treat: Chronic Pain - Comparing Effectiveness, Safety, and Price" (PDF), Opioids, Yonkers, New York: Consumer Reports, retrieved 28 October 2013 
  2. ^ McNicol E, Strassels SA, Goudas L, Lau J, Carr DB (2005). "NSAIDS or paracetamol, alone or combined with opioids, for cancer pain". Cochrane Database Syst Rev (1): CD005180. doi:10.1002/14651858.CD005180. PMID 15654708. 
  3. ^ Regarding using opioids to treat migraine, see American Academy of Neurology (February 2013), "Five Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation, American Academy of Neurology, retrieved August 1, 2013 , which cites
      • Silberstein SD (2000). "Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology". Neurology. 55 (6): 754–762. doi:10.1212/WNL.55.6.754. PMID 10993991. 
      • Evers S, Afra J, Frese A, Goadsby PJ, Linde M, May A, Sándor PS (2009). "EFNS guideline on the drug treatment of migraine - revised report of an EFNS task force". European Journal of Neurology. 16 (9): 968–981. doi:10.1111/j.1468-1331.2009.02748.x. PMID 19708964. 
      • Institute for Clinical Systems Improvement (2011), Headache, Diagnosis and Treatment of, Institute for Clinical Systems Improvement 
  4. ^ Painter JT, Crofford LJ (2013). "Chronic Opioid Use in Fibromyalgia Syndrome". Journal of Clinical Rheumatology. 19 (2): 72–77. doi:10.1097/RHU.0b013e3182863447. PMID 23364665. 
  5. ^ McNicol ED, Midbari A, Eisenberg E (2013). "Opioids for neuropathic pain". Cochrane Database Syst Rev. 8: CD006146. doi:10.1002/14651858.CD006146.pub2. PMID 23986501. 
  6. ^ a b Wolff K (2002). "Characterization of methadone overdose: Clinical considerations and the scientific evidence". Therapeutic drug monitoring. 24 (4): 457–70. doi:10.1097/00007691-200208000-00001. PMID 12142628. 
  7. ^ Teichtahl H, Wang D (2007). "Sleep-disordered breathing with chronic opioid use". Expert Opinion on Drug Safety. 6 (6): 641–9. doi:10.1517/14740338.6.6.641. PMID 17967153. 
  8. ^ Cherubino P, Sarzi-Puttini P, Zuccaro SM, Labianca R (2012). "The management of chronic pain in important patient subgroups". Clin Drug Investig. 32 Suppl 1: 35–44. doi:10.2165/11630060-000000000-00000. PMID 23389874. 

Some information was removed and not re-added in any form. Here is that information -

  1. Opioids for pain relief are also used when nondrug pain treatment options including cognitive behavioral therapy, exercise, spinal manipulation, and physical medicine and rehabilitation programs are insufficient to meet therapy goals.[1] Patients taking opioids talk with their health care provider to develop a personal health plan which includes a combination of therapies, perhaps including drug and nondrug treatments, to relieve pain.[1]
  2. There are gaps in available research describing the safe use of opioids long-term or comparing the relative safety of the long-term use of various opioids to each other.[1] The research also does not have information about the extent to which opioids differ in terms of the risk they bring for causing addiction.[1]
  3. When prescribing an opioid, physicians have a process to recommend the correct one, find the right dosage for the patient, and then minimize the side effects.[1]
  4. For this statement, the information was kept, but left without any citation at all:
Taking opioids further disrupts the patient's life and the adverse effects of opioids themselves can become a significant barrier to patients having an active life, gaining employment, and sustaining a career.[1]

As an organization, Consumer Reports advocates that patients consider treatments with fewer side effects whenever such treatments are backed by evidence based medicine. Biases that Consumer Reports has include favoring evidence-based medicine (just like Wikipedia) and then within evidence-based medicine, encouraging health care providers and patients to consider safer treatment options when possible. I do not think the information above is heavy science, but rather, it a social perspective of the field of consumer studies derived from the original academic papers.

I think that I might be able to find academic sources which say all of the above things, but I doubt that I would find any academic source which emphasizes drug safety in the way that a nonprofit advocacy group would. I do not know whether this information has a place in the article, because I do not know if it is worthwhile to seek academic sources for consumer issues. I am also biased because this is from my organization, and I am encouraged to share whatever content I like from my organization. I do not think that I want to think this through right now, but in the future, I do hope that more nonprofit educational groups with special interests can come to Wikipedia and share expert interpretations of health information. Social issues are never likely to be covered well in academic articles presenting reviews of drugs. Not every social issue has a place in Wikipedia's medical content, and I am not sure where to seek a balance.

Blue Rasberry (talk) 16:17, 20 May 2016 (UTC)

Unsourced[edit]

No source is actually provided and some of this is dubious. Is opium actually used clinically?? This subsection was in the "Society and culture' section but includes content that should be in the "Medical use" section, if it were sourced.

United States approval

The sole clinical indications for opioids in the United States, according to Drug Facts and Comparisons, 2005, are:

Evidence supports the use of low dose, regular oral opioids for the safe relief of breathlessness that is not responsive to disease-modifying treatments. This action appears to be a result of the effect on opioid receptors in the limbic system.

Opioids are not used for psychological relief.

Opioids are often used in combination with adjuvant analgesics (drugs which have an indirect effect on the pain). In palliative care, opioids are not recommended for sedation or anxiety because experience has found them to be ineffective agents in these roles. Some opioids are relatively contraindicated in renal failure because of the accumulation of the parent drug or their active metabolites (e.g. codeine and oxycodone). Age (young or old) is not a contraindication to strong opioids. Some synthetic opioids such as pethidine have metabolites which are actually neurotoxic and should therefore be used only in acute situations.

-- Jytdog (talk) 21:00, 31 May 2016 (UTC)