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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