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Opioids Under-Prescribed Due to Addiction Fears?

Fear of Addiction Means Chronic Pain Goes Untreated, according to an NPR story that aired last weekend. While there’s definitely some truth to the headline, it obscures the nuances of physicians’ reluctance to prescribe opioids (a.k.a narcotics) for chronic pain in general and headache disorders specifically (particularly migraine).

Opioids were originally prescribed for short-term pain, like from surgery or an injury, or for use in end-of-life care. Chronic pain is a serious medical issue that is both under-treated and has limited treatment options, so it’s understandable that opioid painkillers filled that void, especially because opioids are the only source of relief for many people with chronic pain. Unfortunately, they began to be prescribed for long-term use before there were a lot of studies on their long-term effects. Now that research is catching up, this use is being questioned.

Beyond addiction, other potential problems for using opioids for chronic pain include opioid-induced hyperalgesia, tolerance and the systemic effects of long-term use. Opioid-induced hyperalgesia, when opioid use increases a person’s sensitivity to pain, is one concern. Tolerance — which requires taking increasingly higher doses of the medication for it to still be effective — is another. The repercussions of regular (and often increasingly higher) doses of opioids could have on the body’s systems should also be considered.

Headache disorders have additional issues. Rebound headache (medication overuse headache) is the most widely addressed concern. In addition, the American Migraine Prevalence and Prevention study found that using opioids more than eight times a month can cause episodic migraine to transform into chronic. (Diana Lee recently reported that there may be a difference between short-acting opioids and long-acting ones and that long-acting opioids may be OK for long-term pain management for people with chronic migraine.) Headache specialists also believe opioids impair the efficacy of preventive medications.

On top of all that, opioids aren’t even particularly effective for any type of head pain. In the video I shared last week, headache specialist Mark Green explained why:

“Part of the reason for that is there are fundamental differences in the chemistry of head pain compared to visceral pain. In the receptors subserving head pain, we really don’t have a lot of opioid receptors, so the upside for the use of opioids is rather low. That’s why we use, for example triptans and ergots. Those serotonin receptors are very well represented on those receptors that subserve headache.”

What do I get from all this?

  • Boiling down concerns about opioid use to a fear of patients becoming addicted is an oversimplification.
  • There are a lot of unknowns about opioid use for chronic pain. As more research is published, the less they seem like a good long-term solution.
  • Head pain is different than bodily pain and migraine may different still.
  • Chronic migraine isn’t a chronic pain disorder, nor are chronic cluster headaches. I don’t know where tension-type headache falls on the continuum, but I’m inclined to believe it’s more on the side of other types of headache disorders.
  • Using opioids can significantly alter treatment for an underlying headache disorder.
  • Mostly, I’m left with a lot of questions (and so are researchers and physicians).

I’m not anti-opioid, but want anyone who takes them for headache disorders to know the facts and to be very, very careful. Ideally, your headache specialist would be the prescriber, but fewer and fewer are willing to prescribe opioids (not out of fear of addiction or the DEA, but because of the ramifications for treating the condition you’re using opioids for in the first place). If your headache specialist won’t prescribe them, still be honest with them about how often you use them and at what dose — without that information, your specialist can’t treat your headache disorder properly.

Note: I’ve used words like “potentially” and “can” a lot in this post because not everyone’s the same. It’s important to be aware of the risks, but also to remember that not everyone will have all the same issues.

7 Responses to Opioids Under-Prescribed Due to Addiction Fears?

  1. Dr P says:

    Thanks for tackling this important but controversial subject, Kerrie. Indeed, citing fear of addiction is a vast oversimplification, particularly when discussing migraine and other headache syndromes.

    What’s needed is more research dollars for work looking into headache pain mechanisms and potential drug targets.

  2. Diana Lee says:

    It’s such an important and individual decision involved in utilizing opioids long term for chronic pain, especially a headache disorder. I wish we could move past the obsession on addiction, which I agree oversimplifies things, and address the real needs of pain patients.

  3. Thanks for your comments. It’s nice to know that two people whose professional opinions I respect have similar thoughts. And, yes, Dr. P — we absolutely need more research dollars for headache!

  4. Kim Barker says:

    Hi Kerrie,
    I totally agree with what you’ve said in your article except for one thing. Triptans don’t work for everyone. For me they actually added this kind of burning pain on top of my original migraine. I am also one of those people who get just about every side effect you can get from the preventatives. The few that I could tolerate and actually worked like Elavil stopped working after about a year. Unfortunately opiates are the only thing that helps my migraines now days, and they do help. I hate using them, and do my best to hold off as long as I can because I am cognizant of the dangers.

    • Thanks for your input, Kim. The article talks about generalities — there’s a lot of individual variation in what we respond to. Some people see triptans as miracle drugs, others get no help from them. I’m glad you have something that helps you, though I’m sorry it is one you have to ration.

      Take care,
      Kerrie

  5. Kim Barker says:

    Thanks Kerrie,
    I know triptans don’t work for a lot of people, but have you ever heard of them adding that burning pain to the migraine? I’ve asked quite a few neurologists to no avail.
    Kim

  6. em says:

    An interesting discussion is worth comment. I think that you
    should publish more about this subject, it may not be a taboo
    matter but usually people don’t speak about these subjects.
    To the next! All the best!!

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