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 the 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.
What changed then? 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 ’40s. As we
live longer, the degenerative disease 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. Often acute back pain goes away with
surgery or minimally invasive surgery.
So now, we almost all live to an age where degenerative or
even more painful disease starts to affect us like back pain from lumbar spinal stenosis, spondylolisthesis,
cervical spinal stenosis, etc, 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 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 manufacturers 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 or
back 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.
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 overtime to get the same pain
relief that they initially experienced. Depending on the diseases such as
lumbar spinal stenosis, cervical spinal stenosis, spondylolisthesis,
minimally invasive surgery, and spine surgery may be the correct treatment of
pain meds.
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 the 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.
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 stimulus. 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, the 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 the study of the available research. I truly believe that in many patients opioids
eventually make the pain worse instead of improving it.
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 hypersensitivity 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 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, 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 hypersensitivity to pain. There are also non-medical treatments such as electrical
stimulation, bracing, workplace 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.
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