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Medicine Management

Chronic Pain Medication

Opioid, or narcotic, pain medications are beneficial in many ways. Patients with pain from terminal cancer benefit from their use. Patients benefit from their short-term use when recovering from an acute injury or following a painful surgical procedure. However, the long-term use of opioid medications for chronic, noncancer pain remains quite controversial.

On the one hand, there are many strong proponents of their use. They tend to argue that opioids are an effective treatment for chronic pain and that fore-going their use is inhumane. Patients too are often strong advocates for their use.

On the other hand, there are valid concerns that make their use controversial. They are the following:

  • Their questionable effectiveness for long-term use
  • Tolerance
  • Opioid-induced hyperalgesia
  • Hormonal changes
  • Mental cloudiness
  • Physiological dependence
  • Psychological dependence
  • Addiction

Questionable effectiveness for long-term use

Research has found that the use of opioid medications on a short-term basis are modestly better at reducing pain than placebo. However, they found that opioid medications were slightly less effective than non-narcotic pain medications on functional outcomes (i.e., helping patients to do more things).

There is little research on the long-term effectiveness of opioids for chronic pain.  Some research has found that opioids are likely ineffective when used on a long-term basis.

Tolerance

Tolerance is when the body becomes adjusted to the use of opioid medications and as a result the medications lose their effectiveness over time. In short, the longer a patient takes opioid medications for pain the less effective the medications become. In actual practice, what this means is that, over time, patients commonly need periodic increases in their dose of opioids in order to get the same level of pain relief.

Tolerance is a significant problem. For most patients, it is not feasible to use opioid medications for pain on an indefinite basis. Assuming a normal lifespan, most patients eventually get so tolerant to opioids that the medications become ineffective. After five, ten, or fifteen years of use, the highest doses of opioids are no longer helpful. As such, when taking opioid medications on a long-term basis, patients buy pain relief today at the cost of their future well-being. Once having become tolerant to the highest doses of opioids, the medications will be ineffective down the road should there be a need for their use, like an altogether different injury or recovering from a surgery.

Opioid-induced hyperalgesia

Another significant problem associated with the long-term use of opioid medications is that opioid medications, when used over time, can actually come to increase pain rather than decrease pain. Patients often find it hard to believe. But, it is true. It’s called opioid-induced hyperalgesia.

 "Algesia" means sensitivity to pain and "hyper" is a prefix meaning above, beyond or excessive. What happens is that, when taking opioids over a long period of time, the nervous systems become more and more sensitive to pain and so patients subsequently experience more pain. Over time, patients complain that their pain is worsening even though tests or other evaluations show no overall change in the underlying medical problem that causes the pain.

The physical basis of opioid-induced hyperalgesia is not well understood. It is thought that changes occur in the brain or the dorsal horn of the spinal cord or both. In actual practice, it is often difficult to differentiate opioid-induced hyperalgesia from increasing levels of tolerance to medications. In most situations, patients and their providers will simply think that they are becoming increasingly tolerant to opioid medications and will increase their dose. It is hard to know whether the pain is worsening because of opioid-induced hyperalgesia or whether the medications are losing their effectiveness because of tolerance. Now, it may in fact be true that both are occurring. But opioid-induced hyperalgesia becomes evident when patients begin to taper off of their opioid medications. Their pain lessens!

Hormonal changes

Another issue is that chronic use of opioids can lead to changes in the levels of important hormones in the body. In both men and women, long-term use of opioids leads to low levels of testosterone as well as other hormones.  These side-effects can then cause a number of other problems such as loss of sexual desire, reduced fertility, fatigue, depression, and osteoporosis.

Mental cloudiness

A common complaint of patients on long-term opioid management is that mentally they are not as sharp as they used to be. Cognitively, they are dulled. They say that their focus and concentration is limited. Healthcare providers use the term ‘mental cloudiness’ to refer to this sense of mental dulling.

Research shows that when using opioids on a long-term basis patients tend to have significantly lower scores on measures of concentration, short-term memory, timed performance and multi-tasking.

Physiological dependence

When taking opioid medications over a long period of time, patients become physiologically dependent. The body becomes adjusted to having the medication in its system. As a result, patients become tolerant to the medication and will experience withdrawal symptoms if the medication is abruptly stopped. All patients develop physiological dependence when taking opioid medications over time.

Physiological dependence is different than addiction. The American Academy of Pain Medicine and the American Pain Society define addiction to opioid medications as a loss of control over the use of the medication or continued use of the medication despite real or potential harm to oneself. Even if patients never engage in any behaviors that are indicative of addiction, and take their medications only as prescribed, their bodies will develop physiological dependence.

Physiological dependence is also a concern. Many patients simply don’t like their dependency on the medication. There might be many situations in which patients inadvertently do not have access to their medication or to their provider. As a consequence, they go into withdrawal. This dependency produces a sense of vulnerability and fear. One might argue that the minimal effectiveness of opioid medications is not worth the dependent state of vulnerability and fear with which patients must live when taking such medications.

Psychological dependence

When patients use opioid pain medications on a long-term basis, they tend to develop subtle yet strongly held beliefs that lead to a loss of confidence in their own abilities to cope with pain. As such, they come to believe that it is impossible to successfully manage pain without the use of opioid medications. Moreover, they become unwilling to entertain alternatives to their use. As a consequence, patients come to overly rely on the medications long after they are no longer helpful. In other words, opioid medications foster psychological dependence.

This issue is difficult to talk about. It’s difficult because these beliefs are subtle and don’t really come to the foreground unless actually named. It’s also difficult to talk about because it’s a sensitive issue. It can evoke strong emotional reactions. Patients who are psychologically dependent on opioids view the notion that it is possible to manage pain well without opioids as ridiculous. When a healthcare provider raises the notion, they take it that the healthcare provider is incompetent. At other times, patients see it as evidence that the healthcare provider doesn’t understand what it’s like to have chronic pain. They can also see the notion that it is possible to manage pain well without opioids as invalidating the legitimacy of their pain. In any of these ways, patients can get angry. As described, it is a sensitive issue. However, the sensitivity is also indicative of psychological dependence.

Patients who are psychologically dependent on opioids rely on the medications long after they cease to be helpful. They tend to demonstrate tolerance to the medication, describing their pain as severe despite taking high doses of opioids. They may also remain disabled by pain, despite the use of opioid medications. Nonetheless, they swear that the medications are helpful. This disconnect between their subjective belief that the medications are helpful and the objective evidence of their reports of continued high levels of pain and disability is an indication of psychological dependence.  Patients who are psychologically dependent on opioid medications tend to believe that it is impossible to manage their pain without opioid medications. They are sensitive to the notion that it is possible and can get emotional when it is brought up. They lack an openness to any alternative to opioid medications. Lastly, they maintain the belief that the medications are helpful and necessary despite their continued reports of high levels of pain and despite the fact that they remain disabled.

Addiction

Addiction, of course, is also a significant problem. As earlier described, the pain management field defines addiction as a loss of control over the use of opioid medications or continued use of the medications despite harm. Studies have  found that upwards of 20% of patients on opioid pain medications demonstrate problematic behaviors that are suggestive of addiction.

Can Pain Medication be used Long Term?

  • Chronic pain should primarily be treated with nonpharmacologic and nonopioid therapies. Consider opioids only if there are benefits for pain and function. If opioids are used, it should be in conjunction with aforementioned therapies, not in lieu of them.
  • Informed (verbal or written) consent and opioid management plans (written) are part of good practice. Opioid agreement templates can be found through various organizations.
  • Realistic treatment goals should be discussed with patients, including opioid use and reasons for discontinuation and expectations of medical management. Reassessment of opioid therapy benefit and risk should be performed within one to four weeks of initiation and at least every three months for continued use.
  • Strict and organized monitoring of pain intensity, function, aberrant behaviors using drug testing and PDMP, and adverse effects.
  • Continuously reassess the need/indication, dosage, route, and mode of pain management.
  • Monitor all patients regularly and pay particular attention to those who score high on opioid risk assessments. If aberrant behaviors are observed, discuss organized tapering and/or rapid detoxification; be mindful of withdrawal and manage this appropriately. Offer or arrange medication assisted treatment and behavioral therapy for opioid use disorder.
  • Optimize treatment of depression, anxiety and other mental health conditions with collaborated treatment with behavioral health specialists.
Chronic Pain Cycle