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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.

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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 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 — and particularly migraine — 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 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 all these unknowns plus the generally negative outlook of what we do know make me very, very cautious. 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.

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Opioids for Chronic Pain & Questioning Pain Doctor vs. Drug Pusher

Pain specialist Ronald McIver is serving a 30 year sentence for drug trafficking. The drugs? Opioids prescribed for pain relief. NY Times Magazine looks into McIver’s case and the mess surrounding opioids for pain management.

The in-depth piece definitely supports the use of opioids for pain management. I’ve created a PDF of the article so I could highlight what jumped out at me. I didn’t highlight any details of McIver’s case.

I, too, believe that opioids should be available for people with chronic pain. However, the devil’s advocate in me jumped on a bunch of thoughts that I hope to explore this week:

  • Not feeling the body’s pain signals isn’t necessarily good.
  • The effects of long-term opioid use aren’t well known. Most research has been with cancer patients, who do not use the drugs for extended periods.
  • Building tolerance is not only your body getting use to the drug (called desensitization), but becoming more sensitive to pain overall, not just the pain that you are specifically treating.
  • When most patients (and some doctors) feel like they’ve tried
    everything, they haven’t. Often other treatments should be considered
    before turning to opioids.

Just reading this list may raise your ire. Please give me a chance to write about the topics before jumping down my throat. We’ll be able to have a more thorough discussion that way.

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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.

Related stories:

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Opiods: Addiction vs. Dependence (and Getting the Meds You Need)

Pain patients are highly unlikely to be addicted to painkillers (opiods). They are, however, likely to become dependent on a drug, which is very different than addiction.

If you stop taking an opiod, you may have withdrawal symptoms, including nausea, vomiting, diarrhea, sweating, muscle twitching and aches and pains, and increased pulse and blood pressure. Even though this list is reminiscent of the withdrawal scene from Trainspotting, it doesn’t mean you’re an addict. It means that you have a physical dependence on the drug.

You can develop a physical dependence and experience withdrawal symptoms with many different meds, including antidepressants, but you aren’t addicted to them. It works the same way with opiods. Docs make a schedule for to reduce the amount of a drug we take slowly to avoid these unpleasant symptoms, but they may be inevitable. Just as you might be nauseated and dizzy when you stop taking an antidepressant, you may have diarrhea and a racing pulse when you stop taking opiods. (For a personal tale of dependence and withdrawal, read Chapter 19 in All in My Head by Paula Kamen.)

Tolerance is another physical phenomenon that may cause fears that you’re addicted to opiods. Maybe a small amount of a drug relieved your pain initially, but over time you need higher and higher doses to maintain the same level of pain relief. Like dependence, tolerance is not a sign of addiction.

Patients who take opiods may exhibit addict-like behaviors (called pseudoaddiction) — like hoarding pills and being preoccupied with taking the next dose at the precise time it is OK to do so. Understandably, seeing a patient with these behaviors make a doctor very cautious. However, pain patients stop behaving like addicts when they get adequate pain relief.

That deserves repetition and it’s own paragraph: Pain patients stop behaving like addicts when they get adequate pain relief!

Pain specialist Scott Fishman sums up the difference between patients who are dependent and those who are addicted well: “The difference between a patient with opioid addiction and a patient who is dependent on opioids for chronic pain is simple. The opioid-dependent patient with chronic pain has improved function with his use of the drugs and the patient with opioid addiction does not.”

You may be reassured that you’re not an addict, but that doesn’t mean it will be any easier to get docs to prescribe opioids. Here are some thoughts for patients seeking pain relief with opioids:

  • It will probably take multiple visits to a pain specialist to get a response. He or she needs to get to know you and your case before prescribing opioids.
  • A specialist at a pain clinic rather than a pain specialist in a solo practice or one in a team of many different types of doctors may understand your pain better.
  • Pain specialists may not give you the time of day if you haven’t seen a neurologist or headache specialist first.
  • Patients who say they’ve tried everything to treat their headaches often haven’t. There are so many preventives and abortives available that there are probably many that you’ve never considered. This may be a sticking point with a pain specialist. (Although I know that many readers have tried just about everything.)

And some recommendations:

  • If your neurologist agrees that the next step for you is opiods, ask him or her to call or send a letter to a pain specialist to explain this.
  • Have your neurologist’s office send your medical records to the new doc before your appointment.
  • Look for a doctor who specialized in pain medicine during his or her residency (probably through a fellowship).
  • Seek out doctor who finished residency recently. He or she may be more afraid of legal repercussions, but may also have more current attitudes about pain management.

P.S. I’m afraid this reads like a tip sheet on feeding a prescription painkiller addict’s habit. Chronic pain management with opiods is absolutely necessary for so many people that I’m publishing it anyway. So there.