Issue 9 Stories
Physicians Perspective

Treating Pain … With and Without Opiate Medications

The terms “opiate” and “opioid” refer to a class of pain medicines derived from, or related to, the opium poppy plant. These medications come in a multitude of forms, including codeine, oxycodone, hydrocodone, morphine and fentanyl, just to name a few. Sometimes referred to as “narcotics,” all of these medications are relatively powerful pain-reducing substances, and over the past few years they have been causing a significant amount of controversy in our country. 

Prior to the 1990s, it was uncommon for anyone to be prescribed opiates for a prolonged period. At that time, opiates were used mostly for short spans following painful surgeries or injuries, or for patients dealing with significant pain at the end of life. In the 1990s, however, some in the medical field became concerned that patients dealing with chronic pain were not being treated adequately, which resulted in a push to treat chronic pain more aggressively. One of the consequences of that push was that doctors started prescribing opiate medications in a way not seen previously. Instead of taking these medications for a few days or weeks, patients began taking them for months or years. Although this shift was made with the best of intentions, it has led to some fairly negative consequences. 

Consequences of Opiate Overuse 

Since the 1990s, the number of opiate prescriptions in the United States has escalated markedly, far exceeding the number of such prescriptions written in any other country. Unfortunately, this escalation led to a parallel increase in the rates of opiate addiction and deaths from opiate overdoses, which understandably caused a great deal of alarm in the medical profession. Another troubling fact that came into view during these years was that people taking chronic opiates rarely seemed to do well in the long term. Studies looking at patient outcomes routinely failed to show that people on chronic opiates did better than those who did not take opiates. In fact, those on chronic opiates often tended to do worse in terms of long-term pain control and improvement in day-to-day functioning. 

The failure of chronic opiates to provide good long-term pain control is likely due to a number of factors. First is the issue of tolerance, which occurs when the body’s response to a drug diminishes over time, and then higher and higher doses are needed to achieve the same effect. This phenomenon is often seen in patients taking opiates: the initial medication dose seems beneficial, but over time the benefit becomes less and less, the dose is increased, and the cycle repeats itself.

A second issue is related to the side effects of opiates, which often include constipation, drowsiness and nausea—all of which have the potential to impair a patient’s ability to function, often as much as, or even more than, the pain being treated. Other opiate side effects, including decreased testosterone in men, impaired immune system function and worsening depression, while not as widely recognized, also can have harmful effects on a patient’s quality of life. 

Another serious issue surrounding the use of opiates is the phenomenon of opiate-induced hyperalgesia, a condition in which opiates, when taken for prolonged periods of time, can actually increase the body’s sensitivity to pain. 

Nonopiate Pain Treatment 

Following the experiences of the last 20 years, in which we have seen that opiates, in many cases, are more harmful than helpful, the healthcare community is now making a strong push to treat pain without the use of opiate medications, whenever possible. The good news for patients is that there are many such pain-management options from which to choose. 

One option is the use of nonopiate pain medications, which are designed to provide pain relief without the negative consequences that come with opiates. These medications include over-the-counter agents like acetaminophen and ibuprofen, which can often be very effective in treating pain from muscle strains, arthritis and many other common maladies. Another class of nonopiate medications includes “nerve-stabilizing” medications, which are beneficial in treating pain that is related to nerve irritation, damage or dysfunction, such as the pain from diabetic neuropathy, fibromyalgia or the shingles virus. Various muscle relaxants also exist, which can provide some relief from pain associated with muscle spasms, and a number of antidepressant medications have been found to have pain-relieving properties as well. 

Managing Pain Without Using Medication 

While nonopiate medications do offer some advantages over opiates, it’s important to note that nonopiate options can cause their own unique side effects, and some are not recommended for certain patients or for certain types of pain. For that reason, some patients prefer to manage pain without the use of any medication at all. In such cases, one of the best forms of treatment is physical therapy. Multiple studies have shown physical therapy to be an effective treatment for numerous pain types, including back pain and pain associated with arthritis and fibromyalgia. Furthermore, physical therapy can provide patients with instruction on the development of daily exercise and stretching routines, which are often the best defense for warding off injury and preventing pain from worsening in the future. 

Various procedures are also available to address pain without the use of pills. These procedures often involve injecting small amounts of anti-inflammatory steroids and numbing agents around nerves, joints or muscles that are causing pain. Other procedures involve using electrical current either to stop nerves from transmitting pain signals or to change the way those signals are processed in the brain and spinal cord. Acupuncture is another type of procedure that has been shown beneficial in treating certain types of pain, including neck and back pain. These procedures, all of which are minimally invasive and carry minimal risk, can sometimes eliminate a painful condition by themselves, or may be used alongside other treatments to help keep painful conditions in check. 

The Nonphysical Side of Pain 

Finally, an area that has been getting more and more attention recently is psychological counseling for chronic pain. Although we often think of pain as something simply caused by a pinched nerve or a torn muscle, the reality is that pain is a very complex feeling and is profoundly affected by the emotional, psychological and social environment in which it exists. Treatment to reduce stress and anxiety, improve relationships with family and friends, and change the way the brain reacts and responds to pain signals can all have a very strong impact on chronic pain in a way that medications often cannot. 

A Broad Approach to Pain Management 

None of this is to say that opiates should never be used, or that there are not patients who benefit from them. However, it is important to remember that opiates should not necessarily be the first choice when it comes to pain management, and that there are numerous options to choose from for those seeking to avoid the use of opiates to treat pain.

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