opiods in pain management

As we all know, opioids are commonly prescribed for pain. The news has portrayed some scary stories, highlighting celebrity opioid overdoses and stories of addiction. Although opioids have definite risks, they can be quite effective for certain patients with chronic non-cancer pain In patients with cancer pain or those experiencing pain at the end of life, opioids are critical. About 20% of patients going to physician offices with non-cancer pain symptoms or pain-related diagnoses (including acute and chronic pain) receive an opioid prescription.*

Opioids are powerful painkillers that remain the gold standard for easing postoperative pain. Since the 1990s, more pain specialists and especially primary care doctors have prescribed opioids for patients with persistent pain. Unfortunately, we’ve seen an escalating number of people die from opioid related overdoses. However, opioid related deaths are now beginning to plateau. When examining the literature, there are no studies that compare opioids to other possible treatments with respect to long term outcomes (greater than a year) in pain, function, or quality of life. The Centers for Disease Control (CDC) has responded by recently issuing their opioid prescribing guideline. Their recommendations focus on incorporating non opioid therapies and non-pharmacological therapies (exercise, weight loss, procedures like nerve blocks, and psychological therapies like cognitive behavioral therapy) as therapies for chronic pain instead of opioids.

On the other hand, many of these deaths resulted from combining opioids with alcohol or drugs called benzodiazepines. Some pain experts and patients feel that the “War on Opioids” is hurting patients who need them, saying that the majority of people becoming addicted to opioids are not chronic pain patients. Rather, they are people using opioids non-medically to get “high”, or treat other medical problems like anxiety or depression.  As the debate continues, we are seeing more physicians and healthcare providers prescribe fewer opioids primarily due to the FDA’s recommendation to limit the supply, the CDC’s guideline, and fear of media scrutiny. Opioids can produce significant side effects, including constipation, nausea, mental clouding, and respiratory depression, which can sometimes lead to death*. As a patient, it’s important to make sure the prescriber is well versed in opioids as a therapy before initiating them.

Some of the lesser known side effects of opioids include decrease in testosterone and estrogen levels, worsening pain (opioid induced hyperalgesia), and sleep disordered breathing. In fact, there is mounting evidence that long term opioid use for pain can actually produce a chronic pain state, whereby patients find themselves in a vicious cycle of using opioids to treat pain caused by previous opioid use*. Due to the uncommon, but serious risk of respiratory depression and the number of unintentional opioid overdoses, both the American Medical Association and Substance Abuse and Mental Health Administration recommend co-prescribing naloxone to patients at risk who are taking opioids. Naloxone is an opioid antagonist (reversal agent for opioids) and is FDA approved as a nasal spray (Narcan® made by Adapt Pharma) and a subcutaneous or intramuscular injection (Evzio® made by Kaleo). Naloxone is intended to be used by first responders, relatives, or friends of people taking prescribing opioids or using heroin in order to reverse sedation, respiratory depression, and lowered blood pressure.

Pain continues to be a substantial public health problem worldwide. Despite advances, opioids are still needed for pain after trauma or surgery. They are needed for cancer pain, palliative care, and in select situations can be effective for chronic pain. There are an array of options available instead of opioids. For instance, antiepileptic drugs, antidepressants, and NSAIDS can be effective analgesics along with spinal cord stimulation, peripheral nerve stimulation, nerve blocks, pain pumps, psychology, holistic approaches, and integrative therapies. Don’t be afraid to ask about these therapies and to try them. Pain therapies are customized because each person’s pain is unique. A pain treatment that is successful for one patient may not offer than same relief in another.  I have spoken about many of these therapies on my radio show, Aches and Gains.

Education is important. Be aware of the side effects of opioids. Keep in contact with your doctor or healthcare provider who can monitor the safe use of opioids if that therapy is chosen.

For more in-depth insight on opioids, listen to my radio show War on Opioids.


*NIH.gov “The Role of Opioids in the Treatment of Chronic Pain”
*CDC.gov “CDC Guideline for Prescribing Opioids for Chronic Pain – United States 2016”