Opioids and Chronic Pain
There have been growing concerns in the media about deaths from opioid use. Should I be worried?
Death from overdose is still rare relative to the number of people receiving opioids for pain. But it is important to understand that opioids can be dangerous if you take a dose that your nervous system hasn’t yet had time to adjust to. You will become drowsy, inattentive and uncoordinated, putting you at risk for falls and accidents. If you take a large enough dose, your breathing may slow down, which could cause your heart to stop.
You and your family can avoid overdose by observing these precautions:
Take your tablets as directed by your doctor
Your doctor will slowly increase the opioid slowly, over weeks or months, giving your nervous system time to adjust to its sedating effects. Your doctor will be especially careful if you are elderly, are on sedating medications or have kidney, liver or lung problems.
Be very careful when drinking alcohol or using sedating drugs
Alcohol and benzodiazepines (“sleeping pills or “tranquilizers” such as valium or ativan or restoril) greatly increase the risk of overdose. Other drugs that sometimes cause sedation (eg antidepressants) also increase the risk. Make sure that your doctor tells you what medications are safe to take along with opioids.
Keep your medications in a locked, secure location
This is especially important if you have adolescent children living at home. Your teenage son or daughter hasn’t had a chance to adjust to the opioid medication, so they could overdose on even one or two tablets, especially if they also use alcohol or other drugs.
Know the warning signs of an overdose
Early signs are drowsiness, lack of coordination, and slurred speech. If you talk to a person who has overdosed for a few minutes, they appear to ‘nod off’ – they’ll fall asleep for a second, then wake up. You may notice that their pupils are small and they are sweating. Anyone showing these signs should be taken to the emergency department immediately, even if they are able to carry on a conversation. Patients who have taken an overdose are able to keep themselves awake when other people are around, only to succumb to the overdose when they lie down for a ‘nap’.
Who is most likely to die from opioid-related causes?
No-one has yet come up with a complete profile of patients who died from an overdose, but we do know that the following groups are at higher risk:
Adolescents and young adults
Illicit opioid use is becoming increasingly common among youth; one study found that 20% of high school students in Ontario had used opioids without a doctor’s prescription in the past year. Young people are usually not tolerant to the sedating effects of the opioid; and when they take opioids at a party they often take doses that are much larger than a starting dose. Often they will combine the opioid with alcohol or other drugs.
Addicted patients often binge on high doses of the drug, inject or snort it, or take the opioid along with alcohol or other drugs.
Are the right people being prescribed opioids?
Opioids are appropriate for patients who have a definite medical pain condition diagnosed by a physician, such as
osteoarthritis or diabetic neuropathy. Non-opioid treatments should be tried before opioids are prescribed. “Weak" opioids (codeine and tramadol) should be tried before “potent” opioids (oxycodone, morphine, hydromorphone). Weak opioids are often effective and are safer than the potent opioids. Patients who are prescribed opioids must agree to use them responsibly, that is, they will keep the opioid safely stored, will not give it to others, will not get opioids from other physicians or friends.
At what dose level do more problems arise - emergency visits /deaths? What is a safer dose range?
Larger opioid doses have a greater sedating and euphoric effect. Patients on doses above 100-200 mg morphine equivalent per day are at greater risk for both acute and chronic problems, including overdose, falls, addiction, sleep apnea and sexual dysfunction. Morphine 200 mg per day is equivalent to 120-130 mg per day of oxycodone or 30-40 mg per day of hydromorphone.
What are some alternative effective treatments?
Acetaminophen and non-steroidal anti-inflammatory drugs (such as ibuprofen or naproxyn) have been shown to help for pain due to muscle, skin or bone injury. Anticonvulsants (such as pregabalin or gabapentin) or certain (tricyclic) antidepressants (like amitryptiline, nortriptyline etc) have been shown to help pain due to nerve damage. Combinations of medications – such as anticonvulsants and opioids – can result in better pain relief at lower doses than by using opioids by themselves.
Exercise therapy, chiropractic, massage, local treatments such as TENS, ultrasound etc are often helpful for chronic pain. Trigger point injections and nerve blocks can also help in some cases. When the pain problem is complex, most of these treatments are much more effective when used in the context of psychological, cognitive and behavioural therapies in combination.
Counselling and lifestyle change
Exercise, meditation or mindfulness training and cognitive/ behavioural therapy are all effective in treating chronic pain.
Comprehensive pain clinics
Comprehensive pain clinics generally employ all of the above strategies. There is strong evidence that comprehensive pain clinics provide the most effective treatment for chronic pain.
Do opioids reduce pain levels?
Opioids work quite well for acute pain, but their effects on
chronic pain are more modest. On average, pain scores improve by about 30%, or 2 points on a 10 point scale, with wide variations: some people get 50% or higher pain relief, while others get no pain relief at all. Some (but not all) studies have found that opioids help patients become more active.
What are side effects?
The most common side effects are constipation, nausea, dizziness and sedation. These effects occur in about 20% of patients. Dizziness and sedation often resolve on their own. Constipation and nausea often respond to lowering the dose, switching to a different opioid, or supplemental treatments bowel stimulants and anti-nauseant medication.
Will I end up being addicted to narcotics?
It is estimated that about 3% of pain patients become addicted to prescription opioids, while another 11% show behaviours that could indicate addiction, such as frequently using more of their medication than was prescribed. Patients are at higher risk for addiction if they:
- Have a current or past history of addiction to alcohol, cannabis or other drugs.
- Have an untreated psychiatric condition, such as severe anxiety and depression. Anxious and depressed people sometimes find that that opioids help control their symptoms.
How do I know if I am addicted?
Individuals are said to be addicted to a drug when they experiences a pleasant effect from a drug, and they feel compelled to seek this effect repeatedly. In some individuals, opioids cause a feeling of peace and relaxation. However, they quickly become tolerant to this feeling, so they must use higher and higher doses to recreate the same effect. Soon they experience unpleasant and frightening withdrawal symptoms when the opioid dose wears off. Eventually they end up spending much time, effort and money acquiring the drug.
Addiction should only be diagnosed by a qualified health professional. It is not always easy to distinguish addiction from undertreated pain. Some signs of addiction that should prompt you to seek medical attention are:
- You experience a mood-altering effect from the opioid and you find yourself often thinking about the drug, wishing you had more or worried about running out.
- You find that you often need to get the opioid from other sources (other doctors, friends or family, or buying it from acquaintances). You often take more than your doctor recommended, causing you to run out early. You sometimes alter the tablet – for example, crush it or peel off the capsule – in order to get a more immediate effect.
- You are on a high opioid dose. You frequently ask for dose increases but the increases don’t help for long.
- You often experience frightening withdrawal symptoms when the opioid wears off, with severe pain, muscle aches, nausea, anxiety, insomnia and a strong need to take another opioid tablet.
- Family members, physicians or others have expressed concern because you are more moody and irritable, less social and functioning less well at home or work.
How long should someone be on opioids?
Most of the controlled trials on opioids lasted only 3-6 months. The long term effects of opioids on pain are uncertain. So this question is easier to answer in the reverse: when should someone stop opioids?
If the opioid stops working
The nervous system responds to long-term opioid therapy by lowering the pain threshold and resisting the pain-relieving effects of opioids. If this happens, it is sometimes best to taper the opioid or switch to a different opioid.
The opioid isn’t needed any more
Sometimes benign pain conditions get better over time.
The opioid causes side effects or complications
Patients should have their opioid tapered if their pain relief is outweighed by troublesome side effects such as constipation or fatigue, and the side effect can’t be controlled with dose adjustment or supplemental medications. Opioids should also be tapered if the patient experiences serious medical complications such as sleep apnea or falls.
The patient is addicted to the opioid
Sometimes addicted patients who also have chronic pain can continue to take opioids, under strict conditions ( for example, daily or alternate day dispensing of small amounts of the opioid.) Often however, the patient is better off if they switch to methadone or buprenorphine treatment. Methadone or buprenorphine treatment has been shown to improve mood, activity level and pain in addicted patients.
Drs. Meldon Kahan, Dr. Angela Mailis, Health Editor:
Dr. Marc White
Meldon Kahan, MD, CCFP, FRCPC, is an associate professor and researcher in the Department of Family Medicine at the University of Toronto. He is also medical director of the Addiction Medicine Service at St. Joseph’s Health Centre in Toronto, and an author and editor of two textbooks on addiction.
Dr. Angela Mailis-Gagnon is Director of the Comprehensive Pain Program at Toronto Western Hospital and Professor of Medicine at the University of Toronto. Her work is divided between her clinical practice, research into the causes and treatment of chronic pain, guideline development and other activities to help change patterns of pain practice, as well as advocacy for patients with pain.
Marc White is the President and CEO for the Canadian Institute for the Relief of Pain and Disability and a Clinical Assistant Professor, Department of Family Practice, University of British Columbia.
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