Is an opioid really the best medication for my pain?

David Boyce, MD

Contributor

As physicians, many of our daily practices involve administration of substances that are shrouded in mystery. Certain medications, specifically opioids, have been part of tragic news stories, and have turned young children into orphans, happy spouses into widows and widowers, and once-aspirational youth into memories. The CDC reports that on average, 130 people die each day from an opioid overdose.

With such harrowing statistics, why take opioids in the first place? Well, if used appropriately, opioids can significantly improve pain with relatively tolerable side effects. A short-term course of opioids (typically three to seven days) prescribed following an injury, like a broken bone, or after a surgical procedure, is usually quite safe. It’s long-term use that can lead to problems, including the risk of addiction and overdose.

National guidelines for physicians recommend the shortest duration of opioids possible for acute pain, as a person’s chances of unintentional long-term use increase with the degree of exposure. One large study found that in first-time opioid users, one in seven people who received a refill or had a second opioid prescribed were on opioids one year later.

While widespread overuse of opioids has contributed to increased scrutiny regarding their administration, careful consideration of a variety of factors can help physicians and patients determine whether opioids are the right medication.

Here are several important things you may want to discuss with your doctor when considering taking opioids for the first time.

What kind of pain am I having?

Classification: This can be tricky, since many conditions include a wide variety of pain signals that can overlap. Two of the main types are:

  • Nociceptive: This is the most common form of pain. It occurs when some sort of stimulus (i.e., inflammatory, chemical, or physical) causes your skin, muscles, bones, joints, or organs to send a message by way of your nerves to your brain.
  • Neuropathic: This is a type of pain that is caused by a direct injury to the nerve itself. This type of pain is commonly seen in people with diabetes, neurologic issues, or prior amputations. Opioids are not effective in treating this type of pain.

Time course:

  • Acute: Pain lasting less than three to six months (often much less). It typically goes away when the underlying cause of pain is resolved. Classic examples include surgery, broken bones, and labor during childbirth.
  • Chronic: Pain lasting for more than three to six months. This tends to be more difficult to treat than acute pain, since the pain signals adapt over time, which can change the way the brain perceives painful sensations. Common conditions that may cause chronic pain include arthritis, some types of back injury (such as a bulging disc), and fibromyalgia.

What are some of the most common side effects?

Many of the side effects of opioids are due to their effects on your brain and gastrointestinal tract, so you are most likely to experience constipation, nausea, sleepiness, and confusion. Some ways for you to minimize your chances of experiencing these include using the smallest dose possible and treating the side effects directly. For instance, constipation can be initially treated with a high-fiber diet and increasing fluids, though you may be directed to prophylactically start taking treatment medication like stool softeners and/or stimulant laxatives. At times, adequate treatment of any underlying constipation may resolve any nausea you might be experiencing, though this will not help if your nausea is caused by direct activity of opioids on the part of your brain that induces nausea. When this is the case, your doctor may prescribe anti-nausea medications.

What’s my risk for tolerance, dependence, and addiction?

  • Tolerance occurs when a person’s response to a medication changes over time, in that they require a higher amount of a medication to achieve the same effect, such as pain control or euphoria. In the context of opioids and addiction (more below), with time the brain adjusts to the excess of the reward hormone, dopamine. As the brain adapts, it requires more opioid in order to feel the same effects or benefits. Tolerance is a gradual process that is highly dependent on the specific opioid being used, the dose of the medication, and a person’s biology. To some degree, everyone would eventually develop tolerance to opioids if taken long enough.
  • Dependence happens when a person requires a substance in order to feel normal and to prevent withdrawal. Many of us have experienced this on a much smaller scale on days we are deprived of coffee. With opioids, once a person is physically dependent, abrupt cessation of the medication can lead to gastrointestinal symptoms, anxiety, and agitation. Everyone exposed to a drug long enough will become dependent, though only a small percentage of people truly become addicted.
  • Addiction is a disease state that is seen when a person continues to use a drug despite harmful health, social, and/or economic consequences. Assessing individualized risk of becoming addicted is complex and involves many factors: biological, developmental, and environmental factors combine to influence a patient’s individual predisposition. Ultimately, a fatal overdose can happen when too much of the drug is taken or combined with other dangerous drugs, which may cause a person to stop breathing.

What other medications am I taking that may pose safety concerns?

As mentioned earlier, opioids affect your brain and can make you sleepy and slow your breathing. Certain medications or substances, when combined with opioids, can increase this effect. Medications commonly considered are those used to treat seizures, sleeping problems, psychiatric disorders, and muscle spasms. There are many things you can do to avoid drug interactions.

In our era of controversy related to excessive opioid use, there is a well-deserved focus on judicious prescribing. Procedural techniques, like injections and non-opioid medications, are being used more often as effective treatments for people in pain, as these interventions don’t carry the risk of serious side effects such as overdose. But there are times when an opioid is the right choice; it’s a matter of thoughtful discussion and understanding your risks.

If you find yourself on a course of treatment requiring opioids for chronic pain and are concerned about your likelihood of opioid misuse, discuss this with your doctor, along with a plan for addressing side effects of these medications. Together you can weigh the pros and cons of taking opioids and work to manage your particular type of pain.

Resources

CDC Injury Prevention & Control: Opioid Education Resources for Patients

Harvard Medical School Longwood Seminars: The Science of Pain

 

Comments:

  1. Peter V Recchia

    The ignorance or and DENIAL of the painkilling and anti inflammatitory properties of THC is staggering ,If the Medical Community would see the light ,We would have no use many current Pharmacy Drugs ,But Profits speak louder than common sense to many physicians ,This is very sad .

  2. David J. Littleboy

    Hmm. I’m surprised at this article. You wrote: ” But there are times when an opioid is the right choice;”

    My understanding of the current scientific knowledge is that other than cancer and a few other truly serious conditions, there really aren’t any times when an opioid is the right choice.

    My understanding is that the current best science is that for chronic pain, patients are in better shape (less pain, less disability, fewer problems with side effects) a year later without opioids (with NSAIDs and other OTC painkillers.)

    Is this correct?

    Similarly, my understanding is that the current best science is that the number of addicts in a doctor’s patient population is directly proportional to the number of opioid pills prescribed.

    Is this correct?

    Given the above, my personal preference would be for a recommendation that opioids only be prescribed for acute pain if that pain is truly unbearable with other treatments, and for a strong statement recommending that opioids not be prescribed for chronic pain.

    Have I misunderstood the current science?

    Sorry about being grumpy, but your opening statement put me off. I’m a bit of an older bloke, and in my generation (Vietnam era) we learned the hard way that heroin was a bad idea. Returning Vietnam veterans and musicians in those days were the victims. There isn’t any mystery around opioids: 7% of people given opioids get addicted. We knew this from returning vets; most of whom were able to just stop using, but a horrifically large number couldn’t. How this knowledge get lost so quickly is an interesting sociology question. The results of that forgetting aren’t so interesting.

    • Glen

      You are Not correct. Even the CDC said that .02% of all Legally prescribed opiod patients ever became addicted. Less than 2% ever abused the opiod meds Period. If that’s your Opinion for only yourself that’s fine, but Not for anyone else because you obviously do Not know their experience. What you wrote shows a lot of ignorance in this subject, probably just repeating the First information that was published. Both the FDA and CDC admitted that they Grossly skewed and outright Lied about all their original information published in late 2017 to! If you want to actually Know the Truth, do research with nonbiased places now and you will be able to see what I’m saying.

  3. Lawrence Feldman

    Have these doctors ever heard of CRPS? Nucynta, after years of alternative therapies, is the best I’ve found; with medical research out there if they bothered to look.

  4. Lawrence Feldman

    Doctors who obviously never heard of CRPS.

    • Glen

      You do have Some information correct, but are lacking with others. Long term opioid treatments Have been Proven to work. As you should notice the “studies” that show different we’re not done correctly or are largely Bias. Opiods are from the Poppy plant so it’s not different than mine in that aspect. The Only time people are in danger of addiction is if they Already have addiction issues period! The FDA and CDC admitted that they Grossly skewed and outright Lied about all the original information they published on this in late 2017. According to the CDC only .02% of Legally prescribed opiod patients ever became addicted. Less than 2% ever abused the opiod meds Period including those that sell them. Opiod meds are actually safe if you do Not have addiction issues! Both short and long-term. All this crap our government and Media has done was Created Only for Profit Period!

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