Is an opioid really the best medication for my pain?

As physicians, many of our daily practices involve administration of substances that are shrouded in mystery. Certain medications, specifically opioids, have been part of tragic news stories, and have turned young children into orphans, happy spouses into widows and widowers, and once-aspirational youth into memories. The CDC reports that on average, 130 people die each day from an opioid overdose.

With such harrowing statistics, why take opioids in the first place? Well, if used appropriately, opioids can significantly improve pain with relatively tolerable side effects. A short-term course of opioids (typically three to seven days) prescribed following an injury, like a broken bone, or after a surgical procedure, is usually quite safe. It’s long-term use that can lead to problems, including the risk of addiction and overdose.

National guidelines for physicians recommend the shortest duration of opioids possible for acute pain, as a person’s chances of unintentional long-term use increase with the degree of exposure. One large study found that in first-time opioid users, one in seven people who received a refill or had a second opioid prescribed were on opioids one year later.

While widespread overuse of opioids has contributed to increased scrutiny regarding their administration, careful consideration of a variety of factors can help physicians and patients determine whether opioids are the right medication.

Here are several important things you may want to discuss with your doctor when considering taking opioids for the first time.

What kind of pain am I having?

Classification: This can be tricky, since many conditions include a wide variety of pain signals that can overlap. Two of the main types are:

• Nociceptive: This is the most common form of pain. It occurs when some sort of stimulus (i.e., inflammatory, chemical, or physical) causes your skin, muscles, bones, joints, or organs to send a message by way of your nerves to your brain.
• Neuropathic: This is a type of pain that is caused by a direct injury to the nerve itself. This type of pain is commonly seen in people with diabetes, neurologic issues, or prior amputations. Opioids are not effective in treating this type of pain.

Time course:

• Acute: Pain lasting less than three to six months (often much less). It typically goes away when the underlying cause of pain is resolved. Classic examples include surgery, broken bones, and labor during childbirth.
• Chronic: Pain lasting for more than three to six months. This tends to be more difficult to treat than acute pain, since the pain signals adapt over time, which can change the way the brain perceives painful sensations. Common conditions that may cause chronic pain include arthritis, some types of back injury (such as a bulging disc), and fibromyalgia.

What are some of the most common side effects?

Many of the side effects of opioids are due to their effects on your brain and gastrointestinal tract, so you are most likely to experience constipation, nausea, sleepiness, and confusion. Some ways for you to minimize your chances of experiencing these include using the smallest dose possible and treating the side effects directly. For instance, constipation can be initially treated with a high-fiber diet and increasing fluids, though you may be directed to prophylactically start taking treatment medication like stool softeners and/or stimulant laxatives. At times, adequate treatment of any underlying constipation may resolve any nausea you might be experiencing, though this will not help if your nausea is caused by direct activity of opioids on the part of your brain that induces nausea. When this is the case, your doctor may prescribe anti-nausea medications.

What’s my risk for tolerance, dependence, and addiction?

• Tolerance occurs when a person’s response to a medication changes over time, in that they require a higher amount of a medication to achieve the same effect, such as pain control or euphoria. In the context of opioids and addiction (more below), with time the brain adjusts to the excess of the reward hormone, dopamine. As the brain adapts, it requires more opioid in order to feel the same effects or benefits. Tolerance is a gradual process that is highly dependent on the specific opioid being used, the dose of the medication, and a person’s biology. To some degree, everyone would eventually develop tolerance to opioids if taken long enough.
• Dependence happens when a person requires a substance in order to feel normal and to prevent withdrawal. Many of us have experienced this on a much smaller scale on days we are deprived of coffee. With opioids, once a person is physically dependent, abrupt cessation of the medication can lead to gastrointestinal symptoms, anxiety, and agitation. Everyone exposed to a drug long enough will become dependent, though only a small percentage of people truly become addicted.
• Addiction is a disease state that is seen when a person continues to use a drug despite harmful health, social, and/or economic consequences. Assessing individualized risk of becoming addicted is complex and involves many factors: biological, developmental, and environmental factors combine to influence a patient’s individual predisposition. Ultimately, a fatal overdose can happen when too much of the drug is taken or combined with other dangerous drugs, which may cause a person to stop breathing.

What other medications am I taking that may pose safety concerns?

As mentioned earlier, opioids affect your brain and can make you sleepy and slow your breathing. Certain medications or substances, when combined with opioids, can increase this effect. Medications commonly considered are those used to treat seizures, sleeping problems, psychiatric disorders, and muscle spasms. There are many things you can do to avoid drug interactions.

In our era of controversy related to excessive opioid use, there is a well-deserved focus on judicious prescribing. Procedural techniques, like injections and non-opioid medications, are being used more often as effective treatments for people in pain, as these interventions don’t carry the risk of serious side effects such as overdose. But there are times when an opioid is the right choice; it’s a matter of thoughtful discussion and understanding your risks.

If you find yourself on a course of treatment requiring opioids for chronic pain and are concerned about your likelihood of opioid misuse, discuss this with your doctor, along with a plan for addressing side effects of these medications. Together you can weigh the pros and cons of taking opioids and work to manage your particular type of pain.

Resources

CDC Injury Prevention & Control: Opioid Education Resources for Patients

Harvard Medical School Longwood Seminars: The Science of Pain