7901 SW 34th Ave
Amarillo, TX 79121
Victor M. Taylor, MD, DABA
Board Certfied Pain Management
Physical Rehabilitation in Chronic Pain | Opioids and Chronic Pain | Approach to Treatment
The Role of Opioid Pain Medication
In The Treatment of Chronic Pain
A terrible mistake was made in the 1990s regarding the treatment of chronic pain. An influential doctor asked the question, “Why not treat people with non-cancer pain the same way we treat cancer pain?” Unfortunately, this doctor did not really look for an answer. He assumed that we should just give lots of opioids if a patient was in pain. This rhetorical question was the start of a terrible and destructive plague on the people of the United States. The flip and unthinking question has led to the death of tens of thousands of Americans. It has led to the sickness and increased pain and suffering of untold hundreds of thousands more. This question led to government policies that drove an epidemic that ruined the lives of many people that it was trying to help.
Why not treat people with non-cancer pain the same way we treat cancer pain?
What this doctor was really asking was, “Why not give people with chronic pain large doses of opioid pain medications?” The reason the question was so destructive? Because the doctor did not bother to answer it as a scientist and physician. His answer was held within his question. Let us answer this question now in the light of science and experience.
Why not give people with chronic pain large doses of opioid pain medications?
Let’s break down what opioid medications are. Opioids are drugs that bind to specific receptors on nerve cells. The receptors have various names such as Mu receptors, among others. When an opioid drug binds to the Mu receptor, it causes a change in the way the nerve works, making it harder to send a pain signal to the brain. That is a good thing! Unfortunately, like most everything in life, too much of a good thing can have really bad consequences.
So, opioids make it harder to send a pain signal to the brain? Fantastic! But what else do they do? Well, they also hit reward centers in the brain. What this means is that for many people these drugs trigger a response that is pleasurable. They can make the world seem like a nicer place, give you a feeling of well-being. Again, this doesn’t seem so bad; however, most human beings don’t want a fake sense of well-being. Unfortunately, this is a big part of why opioids are so dangerous.
Along with one really positive effect and one somewhat questionable effect, opioids possess many undesirable effects as well. First, these drugs lead to respiratory depression. The reason we breathe without having to think about it is because there is a group of nerves in our brainstem that makes us breathe automatically. When a strong opioid is taken, those nerves quit working, which leads to an overdose. Over 30,000 people in the United States died last year because they took an opioid and stopped breathing. That is more people than died in car wrecks or from guns combined. When Opioids are combined with alcohol or anti-anxiety medications like Xanax, the risk of death increases.
Now, many people are taking high doses of opioids, like fentanyl or oxycodone, and they are still breathing. When a person starts on a small dose and builds up over time, the body adapts to the drug, and the brain cells keep you breathing even at the high dose. What is really scary though is that if you stop taking the drug for even short time, your body may lose that adaptation. You could restart a drug you had been taking, and it could kill you. A child can get a single pill, overdose and die. A person lends a friend a drug, and the friend can overdose and die.
Another bad effect of opioids is they cause your bowels to lock up. Opioids block the nerves in the intestines that keep them moving waste through the body. Constipation is a side effect of all opioid medication.
More insidious yet less obvious side effects of opioids relate to the bad effect they have on health. Your body has a set point or balance point. When we are too hot, we sweat. When we exercise, our heart rate increases, and we breathe harder. When we take medications, the way our liver, glands and immune system adapt too. As a result, opioid drugs cause a decrease your body’s production of hormones, such as testosterone and others. Loss of hormones can make you feel weak, sluggish and just bad overall. Opioids can suppress your ability to fight infections and lead to thinning of your bones. At high doses, opioids can actually lead to changes in the DNA within your brain.
Probably one of the worst aspects of the way opioids work in the body is the dependency they cause. Your body becomes used to the drugs very quickly. If you miss a dose, your body goes into withdrawal, and you feel bad. Your muscles get tight, and you may feel anxious. At high doses, you may get nauseous and have a racing heart among other symptoms. When withdrawal begins, pain worsens as well. Taking the opioid drug makes the symptoms stop, so it seems like the drug helped. Of course, if it were not for the body’s dependence on the opioid drug, you never would have had the symptoms from missing the dose.
You may ask, “So what types of drugs are opioids?” The base drug and the one that the strength of all the others is compared to is Morphine. Other opioid drugs include: hydrocodone (Lortab, Vicodin), hydromorphone (Dilaudid), Demerol, Fentanyl, Oxycontin, Opana, Methadone, Codeine, Tramadol, Talwin, and Heroin, among others. The main thing these drugs have in common is they bind to Mu opioid receptors and other receptors in the body. As previously mentioned, these drugs decrease pain, but also decrease breathing, decrease gut motility(constipation), lower the immune response, suppress hormone production, cause bone thinning, increase depression, worsen memory, cause changes in personality and lead to addiction and aberrant behaviors. When taken for long periods of time, they can actually increase pain.
Initially, opioid medications can be great tools. With a broken bone, after surgery or having a tooth worked on, taking opioid drugs for a few days can be like a miracle. For most of the 20th century, we limited the use of opioid drugs to this type of setting, or a setting when a person was dying, and there was nothing else that could help ease their pain. Because of our failure as doctors, government, pharmaceutical companies and a society to answer the rhetorical question, ‘Why not give strong opioids to patients with chronic pain?’ our society has created an epidemic.
The saddest part of this, beyond the deaths, is the use of strong opioids has not proven useful in the treatment of chronic pain. When a person stays on these drugs, his or her body very quickly begins to adapt. It decreases its natural substances that normally stimulate the Mu receptors. The body also begins to destroy the Mu receptors themselves. Because of these changes, pretty soon it takes a higher dose of the Opioid drug to get the same effect as before. As the doses go up, the body continues to adapt. Eventually, the Mu receptors (and others), along with the hormones and other chemicals of the body, become so depleted that the amount of pain a person is feeling goes up. That’s right. Opioid medications can cause pain to be worse. It is called opioid-induced hyperalgesia.
To date, no good scientific study has shown that long term use of opioids improves the quality of life or function in patients with chronic pain. What we have found is that patients, who gradually wean off of high dose drugs and keep them out of their system for 2-3 months, feel better overall. They report they are happier, have more energy, feel better and have a greater sense of well-being. Patients, who get off high dose drugs, tell us there is not much difference in their pain and every other aspect of their life is better.
So, there is the answer the doctor should have looked for before he carelessly started an epidemic that has killed so many, ruined the lives of countless others and led to poorer pain control and worse outcomes for patients with chronic pain.
My staff and I want you to feel as good as you can. We want to help you get your pain controlled and have a better life than you are having right now. The vast majority of patients we see tell us that they feel better once they have become our patients than they did before. When we measure patients’ response to variables such as anxiety, pain and focusing on their pain, our patients score much better than the ‘average’ pain patient.
Our goal is to treat your pain in the most effective and safe manner possible. It takes more effort to treat a patient correctly than it does to just prescribe an opioid drug. It is hard in the beginning for a person to take that step to reducing the use of opioid drugs but it is worth it. You should not stop opioids suddenly, as it can be dangerous, and there is no need to go through the misery of sudden withdrawal. We will work with you to gradually wean off the high doses. It will be tough at times. We may still use lower dose opioids in the overall treatment of pain, but you will be healthier and feel better overall.
What one patient said to me after finally deciding to get off of high dose opioids sums up what we hear from 99% of patients, which was “I can’t believe I wasted 4 years of my life taking those drugs. I finally feel like I am living again!”
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