By: Dr Alex Robber
Opioid analgesics are commonly diverted and misused, leading to a nationwide epidemic of opioid overdose deaths and addictions due to widespread use of the medications. More than one-third (37%) of the 44,000 drug overdose deaths recorded in 2013 (the most recent year available for estimates) were due to prescription opioids; heroin accounted for an additional 19%. At the same time, the prevalence of opioid addiction has been increasing in parallel, affecting nearly 2.5 million adults in 2014.
Opioid therapy in fibromyalgia is considered to have much more severe side effects than pain relief benefits.
Chronic pain is a major public health issue that frustrates everyone affected by it, particularly the elderly who feel like they have failed healthcare but want to remain in their own homes, live comfortably and avoid being a burden on others.
Psychiatrists provide expertise that are now accepted as useful in the control of chronic pain through pharmacological and psychological therapies. Recent developments in chronic pain treatment include the diagnosis and treatment of psychiatric co-morbidity, the application of psychiatric therapies to chronic pain, and the advancement of interdisciplinary strategies to provide comprehensive clinical services to chronic pain sufferers.
More isn’t better
How much opioid it takes to suppress the perception of pain in the brain is a moving target and the direction is always upwards. After a brief honeymoon of intense pain relief when you start taking opioids for the first time, their pain-numbing effect disappears, and the dosage escalates quickly. You can end up taking dangerously high doses in months, just to maintain the same amount of relief.
“This isn’t a good long-term solution but not because it doesn’t work today or tomorrow,” Dr. Rathmell says. “What do we do when it’s not working as well next month? The knee jerk response is to raise the dose, but where do we stop? Do we stop when you are falling asleep in your soup every night at dinner? Do we stop when you fall down and break your hip?”
Why opioids are abused?
Opioid medications exert their analgesic effects predominantly by binding to mu-opioid receptors. Mu-opioid receptors are densely concentrated in brain regions that regulate pain perception (periaqueductal gray, thalamus, cingulate cortex, and insula), including pain-induced emotional responses (amygdala), and in brain reward regions (ventral tegmental area and nucleus accumbens) that underlie the perception of pleasure and well-being.
This explains why opioid medications can produce both analgesia and euphoria. Mu-opioid receptors in other brain regions and in peripheral organs account for other common opioid effects. In particular, mu-opioid receptors in the brain stem are mainly responsible for the respiratory depression associated with opioid-overdose incidents and deaths.
The use of opioids as a treatment for non-malignant chronic pain
The use of opioids as a treatment for non-malignant chronic pain remains a subject of considerable debate. Until recently, opioids were reserved for use only in the treatment of acute pain and cancer pain syndromes. Non-malignant chronic pain was considered to be unresponsive to opioids, or the use of opioids was associated with too many risks. Fears of regulatory pressure, medication abuse and the development of tolerance create a reluctance to prescribe opioids and many studies have documented this “underutilization”.
Fortunately, recent studies of physicians specializing in pain, as well as those who do not, have shown that prescription of long-term opioids is increasingly common. Surveys and open label clinical trials support the safety and effectiveness of opioids in patients with chronic non-malignant pain.
Lethal effects of mixing alcohol and opioids
Alcohol and prescription painkillers like hydrocodone, oxycodone, and morphine are particularly deadly when individuals mix them. This type of overdose has been on the rise due to an increase in opioid drug addictions in the US in the past few decades.
Many people have become addicted to prescription painkillers that are based on hydrocodone, oxycodone, and morphine, and sometimes, people who become addicted to these drugs also abuse alcohol. That being said, even if a person takes a painkiller as prescribed and drinks a small amount of alcohol, the drugs can enhance each other’s effects, leading to dangerous intoxication and possible overdose.
Difference between addiction and dependence
According to the Substance Abuse and Mental Health Services Administration (SAMHSA), about 1.9 million people depended on or abused prescription pain medications in 2013 alone. But there’s a difference between addiction and dependence, as pain advocates are quick to point out.
“Addiction is a behavior. Dependence is where their body has become totally and completely dependent on that medication, and that’s the key to tapering them off of that medication,” said Penney Cowan, the CEO of the American Chronic Pain Association (ACPA). People who are dependent on medication “believe wholeheartedly that that medication is the only thing that’s going to help them manage their pain, because that’s the way it’s been treated for so many years,” Cowan said.
When opioids help
No one is proposing to withhold opioids during the “acute” phase of a pain condition that would be relieved by these drugs. This means the hours, days, and weeks it takes your body to heal from an injury or surgery. The general rule of thumb is to use them for four to six weeks, then taper off and switch to other options.
People recovering from a flare-up of back pain, a severely injured joint, or surgery can often transition to acetaminophen (Tylenol) or a nonsteroidal anti-inflammatory drug (NSAIDs) like ibuprofen (Advil, Motrin) or naproxen (Aleve).
Discontinuation of opioids
In the context of chronic pain management, the discontinuation of opioids requires dose tapering in order to prevent the emergence of such withdrawal symptoms. In some patients, the repeated use of opioids can also lead to hyperalgesia, which is a state of heightened pain sensitivity.
In the clinical context, hyperalgesia can lead to inappropriate increases in opioid doses, which further exacerbate rather than ameliorate pain. In the case of hyperalgesia, dose tapering or tapering to discontinuation is a better pain-relief strategy.