Opioids and Chronic Pain

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What is Pain?  

Everyone has felt pain at one point  or another in their lives. It is our body’s way to tell us something is wrong.  Whether from a paper cut or a broken leg, pain alerts us to the problem. This is called acute pain. It happens from an injury and inflammation in an area. This happens after surgery or after a fall.  Pain is part of the healing process because of inflammation.

 

Chronic pain is different. 

Acute pain can become chronic.  Your body can hurt when there is no obvious injury.  It may have started with an injury.  The injured area is often already healed or scarred in, but the pain persists.  In some people, pain can sensitize the central nervous system to respond more fiercely to pain.  These  changes in the spinal cord and brain can result in developing a lifetime of chronic pain and don’t go away on their own.  Many times, we treat the cause of the problem, but the pain continues. 

The kind of chronic back, neck pain, or joint pain that we are talking about are the run of the mill whiplash type injuries of the neck including sprains and joint problems, back injuries, and wear and tear joint problems.  We are NOT talking about ongoing injury to the body such as metastatic cancer, damaged nerves, or uncontrolled rheumatoid arthritis, neuropathies and neuropathic pain or spinal cord injuries. We do not want to see people suffering, but opioids in the long term  generally do not work well and can make the pain worse.  This doesn’t apply to everyone.

 

Why do Opioids/Pain Pills Stop Working?  

Opioids attach to the same pain receptors that endorphins, our natural opioids do.  Endorphins are produced by our bodies to help get thru a short term stressful or painful situation such as childbirth or trying to finish a marathon.  When endorphins attach to these pain receptors, we don’t notice the pain as much.  This happens in the spinal cord and brain.  Endorphins don’t circulate in our blood stream 24/7.  Endorphins can also cause the release of dopamine, our reward hormone.  This creates a sense of wellbeing and happiness.  This is a natural “high” that people can experience.

When opioids are in our system all the time, our endorphin production goes down. This makes it more difficult for us to deal with pain on our own in the future.  To make matters worse, the number of pain receptors also decreases over time while on opioids. 

 

To summarize, with constant opioid use:

  • Our own endorphin production decreases
  • The number of pain receptors that endorphins and opioids attach to also decrease
  • Feelings of joy decrease due to decrease in dopamine release in our brains

 

These effects cause opioid tolerance and increased perception of pain.   What this means is that in the beginning for the first few days to  weeks, the pain goes away AND you feel as sense of wellbeing and feel great.  After a while, these effects decline.  The pain relief is not quite as good, and you no longer feel that sense of wellbeing.  Patients come in and say “the medicine is no longer working.  Can I have something stronger?”  Therein lies the trap.  This is not addiction, this is tolerance.  This cycle can continue with more pills, stronger, pills, eventually with nothing working.  Opioids can increase the perception of pain over time and not just in the original area.

 

Another thing that can happen is opioid dependence.  Dependence shows up as symptoms of withdrawal.  This can happen every day even as an additional hour passes after you normally take a pain pill. The first symptom is increased pain!  The pain receptors demand to be occupied every time at the same time of the day.  Remember what happens with tolerance?  The number of these receptors decreases over time.  Overall this increases the severity of the pain over time.  Severity of the pain doesn’t reflect the severity of injury if any.

 

Addiction is very different from dependence and tolerance.   Addiction occurs in susceptible individuals who are more likely to become addicted to anything whether it be to drugs, stealing, gambling, sex, or alcohol.  Seeking out the item or activity even though they know it’s bad for them. There is a need or compulsion. Addiction is a psychiatric illness whereas tolerance and dependence are not. Treating tolerance and dependence is much simpler than treating addiction.  Its  important to note that we don’t view people with chronic pain on opioids as addicts!

 

Are there exceptions with opioids for pain? 

The short answer is yes.  Managing pain with pain pills alone like opioids generally doesn’t work well in the long term.  Patients who have been on opioids for years, usually do not get the same level of pain relief or no pain relief from the dose  that they are on. We don’t know if everyone is affected the same way by opioids despite studies showing little difference in pain while on opioids and completely weaned from them. There are people out there with persistent chronic pain who are pain free or nearly pain free on the same dose of opioid medications for the last 20 or 30 years, but this is not common.

 

The goal is maintaining or improving function while reducing health risks and if opioid help, then patients should not be weaned, if they are indeed helping improve function. Opioids can be a part of the treatment if the risks are minimized. However, if a patient reports that opioids are not working or requiring a dose escalation or increasingly more potent opioids, perhaps opioids are not the best option for that patient. 

 

Opioids are often not taken by patients just for pain.  Opioids can often mask other psychological and mental issues.  Problems such as anxiety, depression, and insomnia can coexist with people on opioids which can manifest in those trying to get off the opioids, making it difficult to wean.

 

If you are ready for real long-term pain relief without relying solely on opioids or want to get off them, please consult  with us at Southwest Pain Management.  We can help.  We recommend exercise, physical therapy, and injection therapy to help treat the problem and realize your long term goals.  Ketamine infusions may be needed to reset the central nervous system sensitization that occurs often in chronic pain syndromes in those where the pain is particularly resistant to treatments.

 

 

 

AUTHOR:   Dr. Robert Groysman, MD
Dr. Robert Groysman is a Diplomate of the American Board of Anesthesiology and American Board of Pain Medicine, and a proud member of the Texas Pain Society, American Society  of Interventional Pain Physicians, and Spine Intervention Society. He participates in research, frequently attends professional conferences,  and continually adopts new procedures and techniques for relieving pain into his practice at Southwest Pain Management

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