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Long term opioid use for chronic pain is a controversial topic. Thousands of people have died from opioid overdoses and complications. However, some people in chronic pain feel that opioid pain relievers are the only thing that helps them get through each day.
In this article, we’re going to look at the pros and cons of opioids, and some alternatives for pain relief.
Opioids are a group of painkillers derived from opium. They were developed many years ago and are all derivatives of morphine. The main opioid medications are: morphine, oxycodone, fentanyl, Tramadol, and codeine.
They are the most powerful pain relievers we have for acute or short term pain. Opioids can almost abolish most people’s acute pain, even someone with a broken leg will feel pain relief.
Because of this, it was assumed they would also work wonderfully well for chronic pain. (Chronic pain is pain that lasts for longer than three months.)
Over the past few years, opioids been used a lot for people with chronic pain. However, the reality is that the downside of opioid use is much greater than the benefits.
In fact, it is now recommended that you do not use opioids for chronic pain. We’ll explore why this is next.
For chronic pain, researchers have compared opioids to other pain killers like anti-inflammatories, antidepressants like amitriptyline and nortriptyline. They’ve also compared it to the placebo effect.
In a huge meta-analysis, they found that for chronic pain, there was absolutely no difference between using weaker painkillers and using opioids.
In other words, in the long term, opioids are not more effective in treating chronic pain than other commonly used medications. Even though they work wonderfully in acute pain, they’re not very effective for chronic pain.
We’ll go into why this is below, but that’s the first big problem: for something with a lot of side effects and dangers, they don’t give good long term pain relief.
The second big problem is described by a medical word called tolerance. Tolerance means that the longer you take opioid medication, the less effective it becomes.
The first time you take opioids, the relief is immediate and profound. But within a week to ten days, you’ll notice that the relief you feel starts to become less.
What’s happening is that your brain is adapting. The medical term is neuroadaptation. Your nerves are adapting to the opioid, and you’re making less endorphins, your body’s natural pain killers.
Within a few weeks the effectiveness of the opioid as a pain killer will have declined significantly.
In the past, medical people simply pushed the dose up. When you do this, you’ll feel much better for a time. But then over a few weeks, the pain relief declines again.
You can push the dose up and up to scary levels and always your brain will adapt. This is the effect called tolerance, and it’s a major problem in long term opioid use for pain relief.
The next problem is that opioids cause addiction or dependence.
There are two kinds of dependence: psychological dependency, and physical dependence. Opioids cause both kinds.
The psychological dependence comes in the form of a belief you can’t go without the medicine. People feel very worried if they haven’t got it with them, and this anxiety can trigger pain.
The physical dependence can be quite extreme. If you miss a couple of doses, you go into withdrawal, and can become anxious, shaky, your blood pressure drops, you can get nausea and diarrhea.
Withdrawal symptoms can also include agitation, hot sweats, and vomiting. Most people find their pain suddenly flares up and they feel depressed.
These are the two main factors that stop people from reducing their dose and push people to take up opioids again: their pain suddenly explodes, and they feel intensely depressed.
This is a very strange phenomenon, which was only recognized 10-15 years ago. It goes by the name of opioid-induced hyperalgesia.
In a proportion of people, as you put the opioid dose up, it will wind up the amount of pain you feel. It’s not really understood why this happens, and we can’t predict who it’s going to happen to.
But it happens in about 8-10% of people taking long term opioids: the opioid makes your pain worse. In the past, this turned into a vicious cycle where people’s pain was worse, so they took more medicine, which made their pain worse.
The biggest problem is that opioids cause significant side effects. Firstly, they cause cognitive impairment, meaning large doses makes you unable to think clearly. You forget things and can’t problem solve. This generally makes it harder to cope with life.
On the physical side, opioids can cause nausea and respiratory depression. This means they reduce your perceived need to breathe, so you’ll start breathing slower and not enough.
For people with a lung disease, it may actually cause them to slow their breathing down until they die. They can also cause sleep apnea.
Opioid use can make you feel dizzy which increases your risk of falls. It can also cause severe constipation, sexual dysfunction, and depression. The medical word for this kind of depression is anhedonia, which means you no longer enjoy anything in life.
The many negative side effects of opioids interfere hugely with the quality of your life. Added together, it makes no sense to continue taking these medications for chronic pain when the benefits are so small and the costs so great.
Finally, the scariest situation is what happens when people take opioids in high doses and the dose gets slowly pushed up because of tolerance.
This peaked in 2017-18, and is much reduced now. Still, it caused thousands of deaths which could have been prevented.
Here’s what happened. Because opioids don’t do that much for anxiety, medical professionals added antianxiety medications like benzodiazepines, Valium and so on to the prescriptions of people with chronic pain and anxiety. And because opioids cause sleep problems, they often also added sleep medication.
What this did was create respiratory depression so that people would take their pill cocktail, go to bed and then be found dead in the morning.
In the middle of the crisis, the number of people who died from taking longterm opioids in the States was in the tens of thousands every year.
When you look at all of this together, it’s incredibly clear: long-term opioid use in chronic pain is not a good idea.
There are many people who were started on opioid medication by doctors years ago, because at the time the doctors believed that this medication would help them.
These people need to find the very smallest dose that gives some benefit, and they need to stay on that dose. That’s the current expert recommendation.
Anybody who has chronic pain should not be started on opioids because of all the negative effects. In the risk-benefit ratio, the harm caused by opioids is much greater than the benefits.
I work in a multidisciplinary chronic pain clinic. One of our primary jobs is to wean people off opioids. We see quite a lot of people who were started on opioids by specialists, or their family doctors.
One common thing is that they would have an operation and were discharged with opioids for the post-op pain. But the pain didn’t get better, and they kept taking opioids, often at higher and higher levels.
Our job in these cases is to slowly wean them off opioids while we start treating their chronic pain with things that really do help. This includes education, NeuroMind techniques, an increase of exercise, use of the affected part of their body in a very structured way, and cognitive behavioral therapy from a psychologist.
This a multilevel approach to chronic pain make a difference not only to their pain but to their quality of life. They can gradually reduce their opioid medication until they got to either the lowest possible dose or come off completely.
By doing this, they improve the quality of their life hugely because they no longer have the nasty opioid side effects.
The key is not to suddenly stop taking opioids. When you reduce them gradually, your brain has time to adapt. What the opioid has been doing is replacing and suppressing your natural endorphin production.
Endorphins are your natural pain killers. When you reduce the opioid dose you’re used to, the pain level increases. Then after a week or two, your brain starts to make more endorphins and you feel better. Then you can reduce the dose again, you feel awful, and once you make more endorphins you feel okay again. This is the pattern most people go through when they come off opioids.
How quickly you can reduce the dose and how long you take to produce more endorphins is individual. Some people are intensely sensitive and have withdrawal symptoms with the smallest reduction, while others can tolerate more. It’s always worth doing this process with medical supervision.
If you’re interested in non-opioid pain relief, here’s where to find out more.