[Scroll to the end of the article to learn about the statue of Spinario]
Opioids are a problem and pain is extremely complex involving changes in both the brain and body.
When treating someone with chronic pain, compassion and caring come first. However, it is important we stop the illusion that opioids are a cure for chronic pain and provide patients with risks associated with long-term use of these drugs.
If you have pain there is no doubt you have been prescribed a pill. Doctors have used and prescribed opioid medications for thousands of years to treat all types of chronic pain from a sore back, sciatic pain, low back pain and all types of chronic joint pain. During the past 20 years, the acceleration of narcotic painkillers in America has increased by more than 600 percent. This is a problem.
This becomes especially alarming put into perspective: While the United States consists of 4.6 percent the world’s population; we use 80 percent of the world’s narcotic opioids. This use – and often, misuse and abuse – has increased treatment for opioid addiction, deaths and is not a solution for your chronic pain.
Doctors have turned to opiate prescriptions for multiple reasons with the belief they are safer than alternatives like nonsteroidal anti-inflammatory medications (NSAIDs) and non-addictive. This is patently not true. As you’ll learn, narcotics for pain are very dangerous and have many side effects. Let’s take a look at a few of them.
Side Effects of Opioid Medications
All healing begins in the gut, but not if you are taking an opioid drug. Intestinal distress is one of the top side effects of these medications and include:
Constipation. Opioids slow down digestion, and constipation results in about 40 to 95 percent of people who use them. (1) Doctors actually prescribe medication now that treats opioid-related constipation. Now you are on two drugs.
Nausea and vomiting. This commonly occurs in about 25 percent of people who use opioids. (2) This mechanism is still being explored but the decreased transit time caused by constipation is often to blame which may lead to intestinal dysbiosis and infection.
Gut bleeding. Gastrointestinal (GI) bleeding frequently occurs with NSAID medications and is also an opioid side effect. Researchers find gut bleeding occurs in 14 out of every 1,000 elderly patients who use opioids as well. (3)
Pain is a normal part of the inflammatory process after an injury. Opioids do nothing to accelerate the body’s natural ability to heal. Click To TweetDoctors frequently prescribe opioid-based drugs to reduce pain that occurs when a patient is injured. The rationale is reducing pain can help patients resume activity more quickly and recovery will become more effective.
Unfortunately, that’s not true. Studies show prescribing opioids following an injury actually delays recovery and increase your risk of permanent disability. This has been noted in patients with extreme lower back pain. Those who were prescribed opioids early had a worse outcome. (4) In other words, patients who did not use opioids recovered better than those with higher-dose opioid treatment. And those who received the opiate had an increased risk for future back surgery. About 1 out of every 3 workers receive an opioid medication for a back injury. (5) Another study found opioids prescribed within six weeks of injury doubles your risk for disability one year later. Opioids are a major risk factor for future disability. (6)
Several studies have shown that giving opioid meds prior to surgery will lead to worse outcomes. Increased preoperative opioid consumption causes somatic disturbances and increased depression prior to undergoing spine surgery and predicted worse patient-functional outcomes. (7) Patients who chronically use opioid medications prior to total knee arthroplasty may be at a substantially greater risk for complications and painful prolonged recoveries. (8) Opioids used following surgery can delay recovery. Excessive pain that adversely affects recovery requires an integrated approach to pain relief and minimize the use of oral and long-acting opioids.
Breathing and Respiratory Function
Here is where it gets scary. This is where deaths occur, even when used responsibly.
Opiate painkillers adversely impact your respiratory system. Carbon dioxide (CO2) levels in the blood stimulate your respiratory drive—your ability to breath. When breathing slows down, CO2 levels increase, stimulating your brain to increase breathing. Low oxygen levels don’t stimulate breathing. Therefore, sensitivity to CO2 levels becomes an important function of nerve cells in your brain. (9)
Opioids block this natural breathing process. During sleep, the CO2 feedback loop keeps you breathing. Opioids can impair that feedback loop, causing your breathing to slow or stop. You could literally suffocate.
This especially becomes a problem for people with lung disease or for the 22 million people with sleep apnea. Sleep apnea occurs when someone intermittently stops breathing at night. When opioids interfere with this response, the results could become life-threatening. Opioids worsen apnea episodes in people with sleep apnea. (10)
How’s your libido? Opioids literally rob you of the ability to love and be intimate.
Opioid medications lead to hormonal imbalances in both men and women of all ages. The biggest one is a decrease in gonadotropin releasing hormone (GNRH). GNRH is the master hormone, which stimulates your body to produce the sex hormones estrogen and testosterone. As GNRH drops sex hormone levels plummet in about 50 percent of men and women on chronic opioid therapy. Persistently low sex hormone levels reduce your sex drive. One study found sex hormone levels were 30 to 70 percent lower in women on chronic opioid therapy compared to those not using opioids. (11)
Low levels can also create or exacerbate:
- Loss of muscle strength and mass
- Alteration in gender role
- Compression fractures
- Impotence for men
- Menstrual irregularities in women
- Galactorrhea (excessive milk production) in women
Pain Sensitivity and Opioids
Now, this is interesting…
A pain reliever can make your pain worse. What an oxymoron. Click To Tweet
It’s called opioid-induced hyperalgesia. Hyper means “over or excess,” and algesia means “sensitivity to pain.” This occurs when your body develops an increased sensitivity to pain secondary to opioid use. Unfortunately, many prescribers simply listen to your complaint of increased pain –and prescribe more meds. This is where it gets scary.
Pain is an important part of your body’s defense system. Pain is always about protection. It’s a signal from your brain about a current or impending threat or injury.
As opioids decrease your brain’s sensitivity to pain signals coming from the rest of the body, your brain compensates by increasing its sensitivity to pain. Nerves going up to your brain actually change, making them more responsive to a painful stimulus and increase your perception of pain; hence the hyperalgesia. (12)
Opioid hyperalgesia increases pain for patients using opioids. Unfortunately, increasing pain can also mean increasing tolerance for an opioid, requiring more to get the same effects. For these conditions, doctors often increase opioid doses. That’s the wrong approach. Treating opioid-induced hyperalgesia demands decreasing or discontinuing opioids. Even experts in pain management may not recognize or treat this complication in the right manner.
Brain Changes and Mental Capacity
Pain is a function of the brain, although there is no one “pain center.” Many parts of the brain fire in a beautiful symphony to create the pain response. It’s primitive, yet advanced. Continually dousing our most vital organ with an addictive substance serves little purpose. Significant changes in the brain can occur using opioid medications to treat pain.
Individuals with chronic low back pain who receive oral morphine daily for one month have significant changes in the volume of several critical areas of the brain – some areas got bigger and some got smaller. (15) Even after stopping the morphine and measuring for up to 4.7 months later, these changes persisted. And the changes can begin as early as 24
Opioids also impair mental function, leading to drowsiness, lethargy, and even death. Pain itself may compromise brain function and opioids further impair cognitive abilities. At the same time, people in pain experience cognitive impairment. From that understanding, people struggling with pain and using opioids may experience higher rates of cognitive impairment. People with chronic pain on opioid therapy suffer cognitive deficits including reduced memory capacity and impaired memory assessment. (16)
Tolerance and Withdrawal
Tolerance occurs when your body develops changes that result in decreased effectiveness, requiring higher amounts of a medication to get the same effect. Withdrawal happens when you decrease or stop using that medicine.
Interestingly, brain changes and measurable withdrawal symptoms can occur after just one dose of an opioid medication and withdrawal symptoms can occur after five to seven days of opioid medication. (17, 18)
Withdrawal symptoms can include:
- Muscle pain
- Increased pain
- Rapid heartbeat
- Dilated pupils
Addiction is different than tolerance and withdrawal. Tolerance occurs from the physiologic changes resulting from using opioids. Withdrawal is the unpleasant physical and emotional symptoms that occur when someone withdraws from an opioid after they develop a tolerance.
The American Society of Addiction Medicine says addiction is a disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits manifests in adverse biological, psychological, social and spiritual changes. As a result, you might seek a reward and/or relief by substance use, abuse, and other behaviors.
- An inability to consistently abstain from a drug
- Impairment in behavioral control
- Diminished recognition of significant problems with one’s behaviors and interpersonal relationships
- Dysfunctional emotional response
Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or participating in recovery activities, addiction can progress and can result in disability or premature death.
Rather than a moral weakness, we must see addiction as a complex disease. Sadly, addiction can occur in some individuals after their first dose, even if a doctor prescribed that dose responsibly. We all have genetic differences in how we process opioids. The challenge is one screens for this before prescribing the drug.
Doctors often fail to factor in the overall increase in deaths when they prescribe opioid pain medications. In fact, opioids account for more deaths than any other medication, and over 16,000 people die every year from opioid overdose. The musician Prince’s recent death made that all too clear, putting opioid misuse into mainstream culture.
The ethic “Do not harm” now extends beyond the exam room. How a doctor interacts with a patient can adversely impact the life and health of someone else not a part of the medical decision.
You also increase your risk of death when you combine opioids with benzodiazepine medications. In fact, the combination of opioids and benzodiazepines are the leading cause of overdose deaths when multiple medications are involved. Despite these dangers, doctors prescribe benzodiazepines to about 30 percent of people on chronic opioid therapy.
Unintentional death becomes a huge side effect of using opioid medications. Illicit use of opioid medications and crime associated with that misuse becomes a significant problem for law enforcement and the public in many areas of our country. Opioids are a gateway drug to heroin.
Wilmington North Carolina has the highest rate of opioid abuse in the nation estimating more than 11.6 percent of the City’s population that receives prescription painkillers abuse the drugs. That rate places Wilmington just ahead of Anniston, Ala., and Panama City, Fla., both at 11.6 percent, and Enid, Okla., at 10.2 percent.
Private businesses lose significant money prescribing opioids. Opioid pain medications increase the cost of Workers Compensation and increase disability. Equally troubling, they decrease worker productivity. Opioid use cost society $55.6 billion and the workplace $25 billion. (19)
Whether you have upper back pain, a simple back strain, spinal pain or any type of chronic joint or muscle pain there are natural remedies for inflammation and pain relief. I have written about this extensively on my blog and spoke about it on the Healing Pain Podcast. One of my favorite ways to alleviate pain is yoga—especially for back pain—but works for any ache or tightness you may have. Ask your physician for natural remedies for pain including physical therapy, nutrition, and psychotherapy.
Here is a (short) opioid list for you just in case:
- codeine (only available in generic form)
- fentanyl (Actiq, Duragesic, Fentora)
- hydrocodone (Hysingla ER, Zohydro ER)
- hydrocodone/acetaminophen (Lorcet, Lortab, Norco, Vicodin)
- hydromorphone (Dilaudid, Exalgo)
- meperidine (Demerol)
- methadone (Dolophine, Methadose)
- buprenorphine and naloxone (Suboxone)
Spinario (Boy Pulling a Thorn from His Foot) Metropolitan Museum of Art, New York City
This small Italian sculpture embodies two acts of concentration—that of the youth about to pull a thorn from his foot as quickly and painlessly as he can, and that of the sculptor who has personified the complexity of pain. The Spinario has no known story. Instead, it was celebrated as a supremely beautiful representation of the human body in complex action. Note the attention the boy offers his wound while at the same time ignoring pain caused by the bumpy log upon on which he sits. A closer look reveals both the physical and emotional aspects of the pain experience. One that a drug alone cannot address.
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Toward a pain-free life.
Dr. Joe Tatta, DPT, CNS