In spite of widespread use, surprisingly little good research exists to help patients and doctors decide about long-term use of these medications in treating non-cancer pain. Ample evidence supports opioid use in end-of-life care. Using opioids is also reasonable in acute settings. For instance, no one would suggest that opioids should not be used for a broken leg in the emergency room. But what about someone whose broken leg does not heal properly, who is left with chronic pain? How about more difficult to understand causes of chronic pain, such as those arising in the nervous system (neuropathic pain)?
For many years, doctors were reluctant to prescribe opioids to people with chronic pain. They feared causing addiction. Regulatory policies and language reflected these concerns. However, thinking has shifting in recent years. We now accept that long-term use of opioids is fitting for some cases of chronic, non-cancer pain.
Challenges exist with the new approach. Identifying which patients should use opioids is one. Developing screening tools and guidelines to help doctors manage these medications and better explain their use to patients is another.
As few good, published research-based guidelines had been developed, provincial colleges of physicians and surgeons created a national panel of experts to do this work. The resulting guidelines help doctors understand appropriate prescribing of opioid medications. They also ensure that patients receive consistent information, no matter whom they consult. Go to nationalpaincentre.mcmaster.ca/opioid/ to see these guidelines online.
As the guidelines are used, doctors are changing the way they manage opioids. For instance, someone receiving a prescription may be asked to review and sign an ‚Äòopioid agreement.‚Äô This outlines a responsibility for preventing these medications from being sold illegally on the street. Under the new guidelines, these agreements are recommended for everyone using prescription opioids.
Over the years, many myths have developed about opioid medications. Exploring these can allow better understanding of these medications.
Myth: "If I use an opioid medication, I will become an addict"We know that many people can develop a degree of tolerance to opiates. This means that a certain, constant dose becomes less effective over time. Sometimes a higher dose may be needed to achieve the same effect. As well, stopping a high dose of medication suddenly can lead to very uncomfortable withdrawal effects. This is a normal body response and should not be confused with addiction.
Addiction implies loss of control, compulsive use, and craving the medication. Someone who is addicted will keep using the medication despite negative consequences. However, the rate of addiction in those who are prescribed opioids for legitimate medical purposes is quite low. This is particularly true for patients with no history of addiction problems.
However, there is still some risk. Most doctors ask questions to evaluate the potential for addiction. If there is a concern, a different medication or form of monitoring may be used. Opioid use agreements or contracts provide some assurance that the medications will not be sold on the street. The contract also outlines who can provide refills.
Urine drug screening may be used for safety reasons, ensuring other potentially harmful drugs are not being taken at the same time. Screening may also help to show that the patient has not used any other drug that could lead to dangerous combinations, such as taking tranquilizers and then driving.
This idea comes from a time when it was unusual to have morphine or similar drugs prescribed outside of a hospital, nursing home or hospice. These medications have been associated with end of life care. However, certain patients may now be maintained on such drugs for years.
The benefits of medicinal treatment should always outweigh any potential risks. We are getting better at weighing the risks and benefits of long-term opioid use for non-cancer pain. Opiates clearly play a role in treating elderly people with stubborn pain (such as arthritis). In this case, the common approach is to start with a low dose. The amount can be slowly increased if needed. Continuous release preparations are preferred.
Again, this idea comes from an era when patients on opiates were at the end of life. However, non-cancer pain varies greatly in severity over time. People may have severe episodes of break-through pain, and require strong pain medication to maintain any degree of comfort or function. Some conditions have periods when pain is not as severe and medication can be reduced. For instance, some middle-aged adults develop lower back pain from arthritis. As the arthritis progresses, the affected joints may ‚Äòfuse‚Äô together. At this point, the person may have less movement at that level of the spine, but also less pain.
Both people with pain and their doctors may believe that some illnesses are conditions that can be overcome by applying a large enough dose of medication. Simply put, diabetes serves as a model of this thinking. No matter how high blood glucose rises, a sufficient amount of insulin can set it right. However, the same rule does not apply for chronic non-cancer pain. For most people, medications alone can only reduce pain by 30 to 40 percent. A variety of medications or non-drug treatments may often be needed to move beyond that. Measuring improvements in ability to function, rather than the level of pain, may be a better way to assess treatment. Sometimes, a choice must be made between being active with pain, or inactive with pain. If the medications allow activity, then they are being used properly.
If you have had good results with a low dose of an opiate, it can be tempting to think that double the dose will double the improvement. If only it were that simple! We are still exploring how pain works in the body, but do know that the system regulating pain is incredibly complex. A number of different types of receptors are involved, and only some are sensitive to opiates. To some degree, doctors can anticipate which receptors are involved by listening to a description of the type of pain, location, and history. In the end, it comes down to trial and error for each person.
When a patient has good results, the opiates are usually at a low to moderate dose. The new guidelines caution that for non-cancer pain, doses do not often need to exceed the equivalent of 200 milligrams (mg) daily of oral morphine. (This equates to 2000 mg of oral codeine, 100 mg of oral oxycodone, or 40 mg of oral hydromorphone.) Pain management doctors are happy to see pain scores improve by 30 to 40 per cent using these drugs alone. Often, a larger dose only leads to increased side effects, without a noticeable lasting improvement in pain or function.
Sometimes it makes more sense to add a different type of medication, as the two may work better in combination than either by itself. However, certain drugs are sometimes prescribed in combination pills containing acetaminophen, which may cause liver damage if taken above the total daily recommended amounts. It can be easy to overlook other sources of acetaminophen, such as in cough and cold preparations and end up taking a total amount over the safe limit. If taking a combination pain pill, double check with your doctor or pharmacist before adding any other prescription or non-prescription drugs that also contain acetaminophen.
While effects vary from person to person, on a stable dose side effects may be quite small or not noticeable over time. When first starting these drugs or increasing a dose, it is common to feel tired or have difficulty concentrating. This tends to improve over time. More persistent side effects include constipation, and sometimes nausea and itching. As with other medications, one opioid may be better tolerated than another depending on the presence or severity of side effects.
If true, these would be the perfect drug! There is concern that these medications interfere with hormonal systems that help tissue growth and healing, particularly in higher doses. As well, many people on opiates are more sensitive to other pain, such as a new injury or burn. Opioid medication can disrupt sleep or make sleep apnea worse. Your doctor will watch for tolerance and dependence, which are not necessarily reasons not to increase the dose.
On a low to moderate dose with good results, most people find side effects much less troublesome than the pain the opioids are treating.
In many cases opiates are added later, when other drugs are already being used to manage pain. Taking opiates does not mean that the search for other causes of pain, which could be treated or other methods of treatment cannot continue. Opioids may be used temporarily while other treatment options are being explored or arranged.
There may be some truth to this when you start the medication or change the dose. However, many people on a stable dose can resume driving after a week or two. The test is not whether you are using an opiate, or even any other medication. Rather, it is whether or not you are impaired. Most jobs allow the use of opiates if job performance is not affected. Only occasionally is it necessary to do special testing to check driving ability. Clearly, the risk of being impaired is higher if other drugs are being used, such as tranquilizers or alcohol.
One has to be very careful about crossing international borders while carrying medications, especially opiates. However, if medication is in the original bottle with a label including the prescribing doctor‚Äôs name and dosage instructions, there is rarely a problem. It is wise to have a letter from the doctor (or note on a prescription pad) explaining the ongoing need for the medication. The same is true of a number of other drugs, but applies particularly to those that can be addictive or mood-altering.
One goal of a healthy pregnancy is to minimize the use of medication as much as reasonable. On the other hand, severe untreated pain can cause real risks to the health of the mother. These risks must be balanced and considered against that of taking opioids during pregnancy. As with many other drugs, the risks cannot be stated with certainty. Using these medications during pregnancy is still relatively uncommon, and few formal studies have been done. However, many other medications are considered potentially more harmful to the baby than opioids. Opioids have been used for many years without it being obvious that there are huge problems when used as prescribed.
Opiates are nothing more than molecules that interact with receptors in the body‚Äôs nervous system to reduce pain. By themselves, they have no personality or desire to cause either good effects or harm. We tend to believe they are good or bad based on experience or things that we have heard or read.
While there is much to learn, most doctors are open to the potential role of these drugs in treating chronic non-cancer pain. Like any treatment or drug, using them properly involves careful assessment of the risks and benefits, along with ongoing monitoring to prevent problems.