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Treating Pain With Opioids

multicolor pillsKUOW, one of Seattle’s public radio stations, had a program yesterday on treating chronic pain with opioids with an expert panel weighing in. I only listened to the first half, but what I heard was informative and interesting.

They discussed a recent rise in overdoses among chronic pain sufferers. These are thought to be accidental, resulting from the need to increase dosages when the the patient develops tolerance.

Something I didn’t realize is that, according to the panel, most of the studies on opioids and pain focused on cancer pain, not chronic pain. There’s a significant distinction between medicating people with progressive, potentially fatal diseases and treating people with lifelong pain. Addiction and dependence are concerns, but tolerance — and the higher doses it requires — is a big risk too (not to mention potentially fatal).

Not covered in the program was that opioids appear to change the brain so that the patient actually becomes more sensitive to pain. Building tolerance is not only your body getting use to the drug (called desensitization), but you actually become more sensitive to pain overall (referred to as sensitization), not just the pain that you are specifically treating. It also increases allodynia, which is already a migraine symptom.

This is a summary of the clinical implications of these findings:

“The diminishing opioid analgesic efficacy during a course of opioid therapy is often considered as a sign of pharmacological opioid tolerance. As such, an opioid dose escalation has been a common approach to restoring opioid analgesic effects, assuming that there are no contraindications and no apparent disease progression. . . . [A]pparent opioid tolerance is not synonymous with pharmacological tolerance, which calls for opioid dose escalation, but may be the first sign of opioid-induced pain sensitivity suggesting a need for opioid dose reduction.”

While I firmly believe that pain sufferers should have access to opioids, the issue is much more complicated than DEA intervention. They’re an easy scapegoat and a problem for sure, but the body’s roadblocks may be a greater obstacle. Perhaps we should listen to our bodies and not rely so heavily on opioid pain relief.

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4 Responses to Treating Pain With Opioids

  1. katy says:

    I’m not going to get into a debate about whether or not opioid therapy is “good” or “bad” or even what I think about “opioid induced pain” etc., but you have to take into consideration that just because someone takes long-acting opioids on a long term basis, that doesn’t mean that they don’t still have pain from day one. That is to say that it’s the norm that your migraine pain would be at an 8 when you start opioid treatment, and within a month you get it down to a 5 and it stays there. Opioid treatment has never been about getting rid of all pain–only getting it under better control and learning to live with the lower pain level. If you have a baseline pain level already, and add in a fluctuating pain level because of ongoing acute migraines that are often severe enough to breakthrough your pain control, it’s extremely difficult to determine if that’s just the migraine or if it’s this opioid induced pain they suggest. It’s very complex. All I know is that I can manage much better now, and I’d have that pain level regardless.

    Recently I’ve been able to reduce my breakthrough opioid level because of a dose increase in a preventative med (Lamotrogine). Is that working on migraine pain or something else? dunno.

    Also, there is a lot of evidence that adding a small amt of methadone to your daily opioid can greatly reduce any chance of tolerance to that opioid. Since tolerance was discussed, thought I’d mention it.

    *********
    Thanks for the input. I don’t use opioids, so I really appreciate getting your point-of-view.

    I didn’t mean to imply that the person didn’t have pain from day one, but that, according to the article, being on opioids could cause more pain in the long run. I agree that it’s hard to sort out migraine pain from medication-induced pain.

    Interesting about methadone. I hadn’t heard that before.

    I hope you don’t feel like I’m judging you for being on opioid therapy. I vehemently support pain patients having access to prescription painkillers. I always look at the other side too (of anything; it can be a _huge_ problem!).

    Kerrie

  2. katy says:

    I didn’t mean to imply that the person didn’t have pain from day one, but that, according to the article, being on opioids could cause more pain in the long run.

    No, I realize, but I think this is one of the factors that makes it so incredibly difficult to sort out and I do really wonder if it plays a critical role in whether or not the person will experience this negative effect of ‘more pain’. I guess I’m wondering if still experiencing a moderate level of pain on a daily basis gives the person any kind of “buffer” against this desensitization effect and maybe it’s more likely to affect the people who try to completely eradicate their pain? If the cause is more perception based, this would make sense to me at least. It’s just something I wondered when reading it yesterday.

    I did notice that one of the articles you linked did talk about the *correct* approach for chronic non-cancer pain management with opioids and that is to reduce pain to a manageable level, NOT to zero.

    ********
    Although patients go for treatment to be pain-free, I don’t know if any doctor has that same goal. And that’s for any kind of treatment, not just opioids. To a headache specialist, a treatment is successful if the severity and frequency are reduce by 50%. Obviously there’s a big disconnect there!

    Thanks for making the distinction.

    Kerrie
    Kerrie

  3. katy says:

    I hope you don’t feel like I’m judging you for being on opioid therapy. I vehemently support pain patients having access to prescription painkillers.

    Absolutely not Kerri 🙂

  4. Christina P says:

    Sorry for being awol, but sometimes, life intervenes!

    No–having a level of pain does not protect from tolerance, nor from allodynia, (meaning that a stimulus normally perceived as nonpainful now causes pain.) Tolerance is dose-related, and will eventually occur. Your brain adjusts to the dose you are taking, and makes more receptors.

    Lamotrigine can be an effective migraine preventative, and is most effective in migraine with aura. I am glad it is working for you.

    *********
    Thanks for the input!

    Kerrie

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