The Opioid Crisis & Why It Matters
What is all the fuss about narcotics, specifically, about opioids?
It all starts with pain.
Back pain, neck pain, any pain. On the surface pain seems like a simple sensation. It is the brain’s way of interpreting nerve signals from the body that suggest there is something bad happening to it. Usually the body is correct, for example when we touch something hot or sharp. This is an example of what we call “acute pain.” Acute pain serves the basic purpose of preventing injury, or if injury has occurred, then preventing further injury. If you look at it this way, pain is a good thing: it’s protective. It is not surprising then that historically pain was not thought of as necessarily bad; it was thought of as a normal part of recovery from an injury.
Actually, a lot of things. First with improvements in nutrition and medicine and a decrease in trauma, people started living longer. In 1900, the average life expectancy was only in the 40’s. As we live longer, degenerative disease – such as lumbar spinal stenosis, spondylolisthesis, cervical spinal stenosis, etc. – has a greater effect and we start to experience more daily pain that is not directly related to acute injury. Not to mention that as we get older, we are more likely to get cancer or other diseases that may cause extreme pain. Another factor is the decrease in physical activity. Over the past few decades, people have become more sedentary. It is now well established that regular exercise significantly decreases pain and conversely, being inactive is related to increased pain. Another important factor is that over the past 50 years or so, a change in our diet that has led to increased obesity. The shift to eating processed, hyper-flavored food with high calorie density has had a dramatic effect on our bodies and it continues to get worse. In addition there is mounting evidence that many foods in our diet cause systemic inflammation which leads to pain. For more on this, see my post on an anti-inflammatory diet.
So now, we almost all live to an age where degenerative or even more painful disease starts to affect us, and we tend to be overweight and out of shape, both of which make pain like back pain worse. It’s no wonder that we have more pain.
Chronic pain is different than acute pain. Chronic back pain and neck pain doesn’t just stop. It is caused by some ongoing process that continues to stimulate the nerves associated with acute pain. It may be constant or it may wax and wane, but over time, it does not go away. There is a lot of ongoing research into what happens to the brain when it receives constant pain stimulus. Conventional wisdom was that people would get used to the pain, but the opposite is true. According to biochemical and functional neurology studies, when exposed to chronic pain, the brain actually goes through a series of changes which make it more sensitive to pain. So people with chronic pain tend to be even more sensitive to pain than they were before their chronic pains started.
Medical care has also changed. With advancements in technology we are now more able to alter disease processes through interventions, or said more simply, fix things. Fixing things often requires procedures that are painful and could not be tolerated without medications to control the pain. So naturally research has focused on finding ways to control pain including newer and stronger pain medications.
It turns out that we have had a very effective treatment for acute pain for thousands of years. Mediterranean cultures including the ancient Greeks used opium for pain relief and even as anesthesia during surgery. Morphine, which is derived from opium, was first produced in the early 18th century and was used extensively during the American Civil War. This actually led to the first opioid crisis in America. After the Civil War, opium use skyrocketed especially among soldiers that had been wounded and in the South where, in addition to being wounded, many lost their wealth and property. It is estimated that 2 out of every thousand people in the post war South were addicted to opium or morphine.
To make it worse there was no regulation at the time and medicinal treatments marketed for everything from aches and pains to children’s coughs contained morphine, usually without even notifying consumers in their labeling. This crisis eventually led to the first federal regulation of narcotics and helped pave the way for the development of the Food and Drug Administration.
Our modern opioid crisis is similar to the post-Civil War crisis in several ways. First, many people initially become exposed to narcotics for legitimate prescribed treatment. Second, people that are struggling socially or economically are more likely to develop addiction problems. In modern America, addiction is highest in areas of the country that have seen significant economic downturn or that have not recovered from recent recessions. Third, recent advancements in medical technology have led to significantly more potent opioid formulas. Fourth, drug manufactures have heavily marketed these new formulations of opioids directly to physicians and through more subtle routes such as political lobbying and litigation.
The truth is that opioids work really well for acute pain. They do this by binding receptors in the nervous system that decrease sensitivity to pain and thus increase tolerance to pain. Patients are aware that they are experiencing pain but the severity of the pain is lower. There are actually several different types of opioid receptors that have varying effects in addition to decreasing pain, including causing the feeling of euphoria or getting high, reducing or causing anxiety and depression and causing constipation, nausea and other side effects.
Problems with Opioids
Unfortunately, though they work well for acute pain, there are several problems with opioids. The first is that the nervous system quickly responds to opioids by developing tolerance. There are several ways this happens but the main one we think about is receptor upregulation, meaning that the opioid receptors become more sensitive or increase in number making them harder to block. There is evidence that this effect begins within hours of the first narcotic dose. So pretty soon, patients need more opioid to get the same level of pain control. In acute pain, this is not really an issue. As patients heal, they have less pain and so they no longer need pain relieving medications. But for someone that has chronic pain, that means that they will need greater and greater doses of narcotics over time to get the same pain relief that they initially experienced.
The second is that when someone takes opioids, they soon develop physical dependence. While some people seem to develop dependence more quickly this will eventually happen to everyone. Essentially, if you take opioids for very long then stop, you will get a variety of symptoms that are kind of opposite of all the good effects that opioids had. These symptoms include things like aches and pains, diarrhea, difficulty sleeping, nausea and vomiting, tremors and shakes, depression, and anxiety. Most of these symptoms resolve within a week or so, but the depression and difficulty sleeping can last months in some people.
Opioid Induced Hyperalgesia: More Pain
The third problem is less well understood because it is a very difficult thing to actually study. It is called Opioid Induced Hyperalgesia. Hyperalgesia means more pain. It turns out that though opioids initially increase pain tolerance, after prolonged use, they actually decrease it. This has been well demonstrated in animal studies. In one particular study, rats were exposed to a mildly painful stimuli. Untreated rats would tolerate the pain for a few seconds before moving away from the source. Initially, when these rats were given opioid medication they would wait longer before moving away from the pain source, but after a few days on the opioids, they would actually have a lower tolerance for the mild pain than rats that were not on the opioid. So in only a few days, opioid medication actually made them less tolerant to pain. While studies that involve causing pain are not easy to do in humans, similar studies have been done with cold tolerance and have demonstrated the same thing. People who are on chronic opioid therapy demonstrated a lower tolerance for cold. The best evidence for opioid induced hyperalgesia is clinical. Here, I can speak from years of personal experience in saying that I believe this is actually the biggest problem with opioid medications. I have seen hundreds of patients that take opioid medications long term and have a lower tolerance to pain than non-opioid taking patients. Here, my opinion varies from some of my colleagues, especially those who are pain management specialists, and I want to explain that my opinion is developed mostly out of years of clinical observation as well as study of the available research. I truly believe that in many patients opioids eventually make pain worse instead of improving it.
Recreational Usage? Not the Main Issue
I also want to acknowledge that I still have said nothing about taking opioids to “get high.” While I know some people take opioids as a recreational drug, I think it is a very small part of the “opioid epidemic.” The truth is the vast majority of patients taking opioids for chronic pain are doing so just to try to feel normal. Their bodies have adjusted to the presence of opioids and if they miss a dose, sometimes even by an hour, they start to get withdraw symptoms, especially pain and anxiety. Labeling these patients as “abusers” of opioids is completely wrong. They are not doing this for fun, they are stuck in an extremely difficult and life threatening situation.
To summarize, opioid medications provide excellent relief of acute short duration but with continued use, patients develop tolerance making opioids ineffective – and many patients actually develop a hyper sensitivity to pain called Opioid Induced Hyperalgesia. To make things worse, once a patient is used to being on opioids, getting off of them also causes increased pain, depression, anxiety and generally makes them feel pretty awful. This is the reason patients feel like they need to keep taking them. Patients will argue that without opioids they feel awful, and it is true. It may take months of being off of them to feel normal again.
So, What Can We Do?
So what can be done? The first and most important thing is to limit opioid prescriptions to short term use for acute pain or for terminal chronic pain such as cancer patients that are not expected to live long enough to build up significant tolerance. This also goes for intermittent acute pain, such as the back pain that flares up once a year but is otherwise fine. For chronic pain patients, we should do everything we can to cure the cause of the pain. This may be as simple as exercise, dietary change and weight loss. In other cases, surgery like minimally invasive surgery, or other medical treatment may be needed. In cases where chronic pain is expected to persist and no cure is available, then non-opioid treatments should be exhausted. There are numerous non-opioid medications that do not result in patients developing tolerance and do not cause hyper sensitivity to pain. There are also non-medical treatments such as electrical stimulation, bracing, work place modification, inversion tables, traction, osteopathic and chiropractic adjustments, massage, acupuncture, just to name a few. In chronic pain, opioids should only be used when other agents have failed, and only with the patients understanding that they will develop tolerance and may develop hypersensitivity to pain with prolonged use.
What if you are already taking opioids and have been for some time? I believe that the most important thing is education and that is my primary goal in writing this. Once patients understand that chronic opioid therapy is probably not helping them and may in fact be increasing their pain, they will generally want to get off opioids. If a patient does not believe they will be better off without opioids, it is very hard to get them to go through the unpleasantness of weaning down on the medications. Once you have decided to get off of your opioids, the best thing to do is work with a physician that understands opioid weaning strategies. There are a variety of things that can be done to decrease the negative side effects and to help with your chronic pain once you are off the medications. It is also important to find out if there is a treatment for the source of the chronic pain. I have treated numerous patients that have had years of chronic pain from spine conditions that, once treated surgically, were no longer painful. Historically these have been among my happiest patients because surgery not only alleviated their pain, but allowed them to get off of their chronic medications.