OK – now let’s talk about the Big Guns – that is, the opioid medications. They’re called opioids because they either come from the opium plant, that people recognized thousands of years ago could ease pain. Or they work like the opium products.
Just a few of the medications in the opioid class are Morphine (like MS Contin®), Fentanyl®, Oxycontin ®(oxycodone) and Vicodin ®(hydrocodone).
In particular, I want to talk about why there’s such a fuss about keeping people on opioids, and especially at high doses.
I’ve been on this medication for years, why stop it now?
I see a lot of people who have been on medications like Vicodin® or Oxycontin® for years. And it’s been helpful to them. Many of them haven’t gotten back to doing the things work-wise and play-wise that they used to. But they don’t feel as uncomfortable.
But all of the sudden, they feel like they’re being treated like criminals. They don’t abuse their medication. They never took it any way than what was prescribed, so what’s the big deal?
Well, the big deal, is that doctors prescribed these drugs without realizing the problems they could cause. And they were prescribing them for types of pain (I talked about differences in pain in an earlier post https://www.sjdpsych.com/post/are-your-meds-making-you-sick-pain-meds) that could have been treated better with other kinds of medications that weren’t as likely to cause as much trouble.
Also, the pain specialists tell us that one of the big goals of pain management is helping the person to be able to do more things, get back to more normal activities. And the opioids often can’t do this.
As I’ve said before everything, even water, that we take into our can cause side effects. It’s just that some are more likely than others to cause life-threatening or even fatal side effects.
And some of the really strong opioid medications are included here.
Now we’re trying to undo the damage of the last twenty years and our patients are suffering for it.
Opioids aren’t the best medications for treating chronic pain
The medications in the opioid family relieve sudden pain fast. And we know that people who have been suddenly injured, like a broken bone, or have had surgery, will be in a lot of pain.
So we jump in with morphine or fentanyl or one of these drugs to try to reduce the pain as
fast as possible. We don’t like to see people suffering.
But pain is your body’s way of telling you something is wrong. And if it can, your body will find ways for you to have pain to alert you that things aren’t going the way they should. If you get to a point that you can’t feel things at all, you’re more likely to hurt yourself.
One example of this is people who have diabetic foot and leg pain, called “neuropathy.” When someone with diabetes has sugars that aren’t controlled for long enough, the nerves begin to die off. What this also means is that they’re more likely to hurt themselves without knowing it.
And the injuries, if not treated, can lead to death of the limb, which results in having to have that toe or leg cut off.
Long term use of opioid medications makes you more sensitive to pain.
Your body wants to take care of you. Without pain, you wouldn't know to pull your hand from a fire. You wouldn't know that you sprained or broke your ankle. Your body wants you to know if you’re injuring yourself so you can do something about it.
What we’ve found out is that if some nerves are permanently more numb, like from opioids constantly deadening them, your body will make more nerve endings that haven’t been shut down.
And because you have more pain fibers, you’re a little more sensitive than you were.
And things that wouldn’t have hurt so much before, are causing you more pain than they did.
And when these nerves get numbed by opioids, your body makes more. And in turn, you find that even small things cause more pain, and so on.
We used to think that people coming in on opioid medications and saying they were in a lot of pain were just trying to get more pain meds. It was hard to believe that something as simple as a stubbed toe could cause so much discomfort.
Now we know, though, that people who have been on these medications long term actually do experience a lot of pain after a very little injury. The term for this is “hyperalgesia.” But the important thing is that if you use opioid medications long enough you hurt more over all.
So what else is the problem?
It might seem like scare tactics, but it’s a fact that there have been a lot of accidental overdoses because of opioid medications.
Over the years, some people gradually got to a point where they were on very high doses of opioids. Part of the reason for this is hyperalgesia, as mentioned above. But also their bodies “got used to” one dose and it didn’t work as well. This is called “tolerance.” I’ll talk about this next time.
So thinking a little more might help, the people and their providers slowly upped the doses. Eventually they were on dangerously high doses of their medications, but getting along okay.
Now, as long as everything stayed the same; their breathing was fine, they were otherwise generally healthy, they weren’t taking any medications that might interact with the pain meds, things were okay.
However, even a slight change put their lives at risk.
We’ve seen people die because they were on high doses of these medications and had a couple of beers at a football game. The combination was too much for their bodies.
We’ve had fatalities because someone took an extra couple of sleep medications on a bad night (opioids often interfere with sleep). Once again, alone this might have been okay, but with high doses of opioids already in their bodies, their bodies couldn’t handle it, so they stopped breathing.
We found out that no matter how “used to” a dose someone’s body was, even a slight change in other things could kill them.
So what's next?
A few years back, because of the huge numbers of deaths caused by prescription opioids, the Centers for Disease Control (CDC) issued guidelines that pretty much told docs not to prescribe these drugs. And the doctors got scared.
They were worried about what the doses they were prescribing could do to their patients.
But they were also worried about what would happen to their medical licenses.
Some providers acted unethically, basically cutting patients off from their medications without warning. This meant that the patients’ pain was untreated.
But it also meant they went into withdrawal from their opioids. And although withdrawal isn’t usually going to kill anybody, it’s miserable with nausea, diarrhea, and vomiting. And it can last for days.
Now the CDC is revising its recommendations for prescribing opioids. It recognizes that some people, if they only take these medications occasionally and at safe doses, can probably stay on them.
It’s also clear that the clinician, the person prescribing the medication, has a responsibility to the patient. They need to help people withdraw from these medications gently and over time.
And they need to try to help these people find ways to relieve their pain safely.
What can you do?
I strongly recommend that if someone is on a Big Gun for more than six months:
1. Consider requesting referral to a pain specialist for re-evaluation and recommendations
2. Check on the dose. If it is a high or moderately high dose, ask your provider to work with you to gradually reduce the medication to a safer level while finding other medications that might work better for your pain.
3. Be SUPER careful about using ANY medications or alcohol in combination with one of these drugs.
4. If your provider suddenly stops your medication or reduces the dose rapidly, ask them to reconsider. Just stopping a medication and causing the person to go into withdrawal is unethical and against rules regarding patient care.
5. Remember that one of the goals of pain management is to get you to a point where you can do things again, not just sit in a chair. If all you want to do is sit and watch the world go by, you can probably do that with little or no medications at all.
6. Being on a BIG GUN can be done safely, but it takes work on your part to see to it that it doesn’t cause problems for you.
Image of angry man @Can Photo Inc./oocoskun
Image of doctor refusing @Can Stock Photo Inc./elnur
Image of back pain @Can Stock Photo Inc./ribah2012
Image of stubbed toe @Can Stock Photo Inc. blamb
Image of guys at bar © Can Stock Photo Inc. Nejron