Opioids continue to be the most powerful class of painkilling drugs globally. Still, there are clear downsides to their use, particularly in the long term, and many pain specialists have reservations about recommending them for chronic pain. Opioids owe their usefulness to how effectively they shut down pain signals in the brain – but patients with chronic pain need more than a single burst of painlessness. The fact that opioids can lose their edge over time (due to tolerance) and can lead to addiction makes them difficult to recommend for patients living with ongoing, continuous pain.
That doesn’t mean opioids have no place at all in the treatment of chronic pain. But it does mean that the use of opioid drugs must be even more carefully considered in patients with chronic pain versus acute pain. There also needs to be an even heavier emphasis on alternative pain management options, particularly a multimodal approach combining lifestyle changes with conservative physical treatments, over-the-counter medication, and mental healthcare.
How Do Opioids Work?
Opioids are a class of drugs that affect the opioid receptors in our nerve cells. Originally, opioids were based on the narcotic opium. Opium has been harvested from the latex of the poppy plant for thousands of years and has been used as an analgesic and anesthetic in countless cultures. Some opioids are still won from opium (like morphine and other opiates), but many others are synthesized in laboratories to target the same receptors in the body. The most common opioids include:
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- Fentanyl
- Hydrocodone
- Oxycodone
- Morphine
- Oxymorphone
- Codeine
- Diamorphine (medical-grade heroin, not available in the US)
Opioid receptors can be found on nerve cells throughout the gut and central nervous system. Opioids bind to these receptors, sending signals that block pain messages (nociception) from registering in the brain. The potency of the effect and its duration are based on the compound itself, its dosage, and the person’s individual sensitivity. Although rare, some people are allergic to opioids. But most people react well to opioids, which is why they are still a common first-line treatment for acute pain.
However, opioids do have their fair share of side effects. The most worrying one is addiction. High opioid usage – even when used purely for medical reasons – can lead to painful withdrawal symptoms and even substance use disorder. While the risk is much higher in cases of recreational use (mostly because there are no limits on how or when someone would self-administer an opioid recreationally), one of the biggest worries when treating long-term recurring pain with an opioid is that the pain will eventually be replaced by a dependence on the painkiller.
This is part of why opioids play a less prominent role in treating chronic pain versus acute pain. The goal of treating acute pain is to dull an intense and short-lived algetic response to trauma or injury. Chronic pain can be ongoing for years, even decades. Treatment must be sustainable, reassessed frequently, and tackle the pain from all angles (i.e., through a biopsychosocial model).
How Opioids Affect Chronic Pain
Opioids often work to reduce and even eliminate the feeling of pain in a patient with a chronic pain condition. The biggest difference between chronic and acute pain is the duration of the pain – patients with chronic pain conditions experience recurring, and even daily pain, for more than three months. Opioids can still be prescribed and used in the short term to deal with the worst days in a chronic pain patient’s life, but they are not usually prescribed as a wholesale solution. Instead, they are but one part of a larger pharmacological treatment plan within a multimodal treatment plan that may include physical therapy, nerve stimulation, non-invasive interventions, and talk therapy.
Opioid Prescription During a Drug Crisis
It needs to be mentioned that opioids are not the only kind of prescription medication with addictive potential. However, opioids are in a controversial position because of the ongoing opioid epidemic the United States has been struggling with since the late 1990s. 50,000 people died in the United States in 2019 from opioid-related overdoses, including prescription painkillers, heroin, and illegally manufactured fentanyl.
The government estimates that almost a third of patients prescribed opioids for chronic pain misuse them. Up to 12 percent of prescribed opioids for chronic pain develop an opioid use disorder (addiction). However, the situation is not all black-and-white. Opioids are also the key to a better quality of life for millions of people struggling with chronic pain conditions and are invaluable in treating intractable pain. Their use in chronic pain treatments requires frequent reassessments and a very measured implementation.
How Chronic Pain Is Treated Today
Aside from opioids, chronic pain is treated through a wide variety of effective modalities. Some of them include:
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- Transcutaneous electrical nerve stimulation
- Nerve blocks
- Physical therapy
- Hot and cold therapy
- Non-opioid analgesics (including OTC medication and other prescription drugs)
- Antidepressants
- Anti-anxiety medication
- Muscle relaxants and anticonvulsants
- Botox treatment
- Prescription NSAIDs (such as high-dose ibuprofen and celecoxib)
- Migraine medications (such as triptans)
- Talk therapy
- Nutritional planning
- Improving sleep
- Trigger point therapy
- And more
A chronic pain patient’s treatment will depend highly on the cause of their pain, comorbidities, patient and family history, and how they respond to certain first-line treatments. Every pain patient’s treatment must be tailored to their needs and circumstances, and any multimodal approach will attempt to address the pain itself, its cause, as well as the impact it has had on their quality of life.
Pain is a highly complex sense, affected by our mental state, physical fitness, genetic factors, and much more. Affecting pain in the long term requires consistent medical and social support, and it’s important not to downplay the impact that friends and family can have on helping a chronic pain patient lead a better life. If you want to learn more about modulating chronic pain, get in touch with a pain specialist today.
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