What You Should Know about Opioids for Chronic Pain?

Controversial Narcotic Pain Medications for Chronic Pain

Oxycodone is a commonly used opioid.
What are opioids and why are they sometimes used to manage chronic pain?. GIPhotoStock/Getty Images

If you're suffering from chronic pain and you've tried everything you could to relieve your pain, opioids (narcotics) may be a route you choose to take. While the use of these powerful painkillers (analgesics) for the long-term treatment of chronic pain is somewhat controversial, these drugs can be effective and safe when taken under close medical supervision. Here's what you should know before deciding if opioids are right for you.

What Are Opioids?

Opioids come from one of three places: Some are derived from plants, some are manufactured in a lab, and others, such as endorphins, occur naturally in the body. Opioids are very effective in the treatment of severe pain. In fact, they are frequently used to treat acute pain, such as post-surgical pain, as well as severe pain caused by diseases such as cancer.

Types of Opioids

Depending on your needs, you may take one of a few types of opioids used to treat chronic pain. Among the class of medication known as opioids, there are many difference.

First, opioids can be formulated as long-acting or short-acting pain medicine.

Opioids also different from each other in the way they are given. Some are given intravenously through an IV in the hand, arm, or in a port or picc line. Some are given orally, some may be give as a rectal suppository, and some come in the form of patch which you apply to your skin.

Some opioids can be given in more than one way, but others are limited to only one method of delivery.

Another important difference is that some opioids, such as oxycodone ad hydromorphone are "straight narcotics. Others, such as Tylenol #3 and Vicodin, may be mixed with other pain killers such as Tylenol (acetominophen.)

Another class of opioids, defined as agonist/antagonist, combine medications to decrease pain and to decrease the potential for dependence. These include buprenorphine and butorphanol.

Opioid Side Effects and Other Complications

Many people with chronic pain tolerate the same opioid dosage for years without building up drug tolerance, or without developing physical dependence on the drug. However, dependence and addiction are legitimate concerns.

Unfortunately, many chronic pain sufferers who take opioids may wrongly be labeled as "addicts," even if they do not meet the actual criteria for addiction. There is sometimes a certain stigma associated with taking narcotic pain medication, which can be frustrating for the person with severe chronic pain.

In addition to tolerance and physical dependence, opioids do have a number of other potential side effects. These may include:

  • Drowsiness
  • Confusion
  • Nausea
  • Constipation
  • Urinary retention
  • Difficulty breathing
  • Sexual dysfunction
  • Low blood pressure
  • Itching sensations

Opioids tend to affect seniors and children more than adults, so these populations must be monitored even more carefully. Often, physicians will start opioid doses very low and slowly increase them until a therapeutic level is reached.

Certain medications may interact negatively with opioids, so careful monitoring is required if you also take other prescriptions regularly. Be sure to inform your doctor of any other medications you take, including those purchased over the counter, to avoid potential complications, such as a drug overdose.

Certainly, given the drowsiness and confusion that may occur as a side effect of these medications, but as with the addiction issue, a recent study found that driving while using opioids for chronic pain did not worsen performance.

CDC Guidelines for Prescribing Opioids for Chronic Pain

Given the major increase in overdoses related to the use of opioids for non-cancer related pain, the Centers for Disease Control and Prevention (CDC) have issued guidelines for the safe use of opioids in people with chronic pain.

Some of these 12 recommendations include:

  • 1. Opioids should not be used as "first line" therapy for chronic pain. Other non-opioid pain medications should be used first before resorting to opioids. When opioids are needed, they should be used along with these other treatment approaches (to minimize the does of opioids needed among other reasons. Non-opioid pain medications include non-steroidal anti-inflammatory drugs such as Advil (ibuprofen), tricyclic antidepressants, and anti-seizure medications (anticonvulsants) such as Neurontin (gabapentin.)
  • 2. Goals of therapy must be established. It must be determined that adding in opioid therapy will improve function or quality of life enough to make facing the possible side effects reasonable.
  • 3. A patient-physician conversation must occur in which the patient understands clearly the risks and benefits of using opioids to treat their pain.
  • 4. Immediate release opioids (in contrast to long-acting opioids) should be used first.
  • 5. The lowest effective dose of the medication should be prescribed. (There are tables which compare doses of the different narcotics if you will be switching from one medication to another.)
  • 6. Short courses of narcotics should be prescribed for acute pain which occurs on top of chronic pain.
  • 7. Close follow up is needed. Early on in treatment, clinic visits should take place once a week or at least several times per month. When these medications are being used long term, their use should be evaluated at least every three months and if pain is not improving on the medication it should be stopped.
  • 8. Physicians must use strategies to decrease misuse of the medications. This may include using a combination agonist/antagonist if the potential for abuse exists.
  • 9. Physicians should use POMP data to make sure another physician is not prescribing opioids in order to lower the risk of overdoses.
  • 10. Urine drug testing should be used to make sure that a person is both using her prescribed medication and is not using drugs which could interfere with treatment.
  • 11. If at all possible, opioids should not be combined with benzodiazepines.
  • 12. If dependence on opioids occurs, physicians must be ready to offer substance abuse treatment.

Why Use Opioids at All?

With so much controversy surrounding their use in chronic pain conditions, you may wonder why doctors prescribe opioids at all. Simply put, opioids are very effective at reducing severe pain, and many people who have not gotten relief from other treatments find relief only through opioid use. For these people, the benefits of opioids outweigh the risks. Negative side effects and potential for dependence do not happen in every case. For many people with chronic pain, opioids can help give them back their quality of life.

Before starting you on opioids, your doctor should perform a full assessment as well as schedule regular consultations to monitor your condition. Some doctors may begin with an opioid trial, gradually increasing your dose while you are watched for potential complications.

Sources:

Campos-Outcalt, D. Opioids for Chronic Pain: The CDC’s 12 Recommendations. Journal of Family Practice. 2016. 65(12):906-909.

Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report (MMWR) . CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. Updated 03/18/16. https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

Chou, R., Devo, R., and J. Friedly. Systemic Pharmacologic Therapies for Chronic Low Back Pain: A Systematic Review for the American College of Physicians. Annals of Internal Medicine. 2017 Feb 14. (Epub ahead of print).

Schumacher, M., Jongen, S., Knoche, A. et al. Effect of Opioid Therapy on Actual Driving Performance in Non-Cancer Pain Patients. Psychopharmacology. 2017 Feb 12. (Epub ahead of print).

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