News of the growing opioid crisis has become inescapable. Daily reports of lives ruined and lives lost to opioids dominate headlines — with addictions that started with a legitimate prescription for pain killers being an…
News of the growing opioid crisis has become inescapable. Daily reports of lives ruined and lives lost to opioids dominate headlines — with addictions that started with a legitimate prescription for pain killers being an oft-cited reason for the downward spiral into overdose. The Centers for Disease Control and Prevention reports that “from 1999 to 2016, more than 200,000 people died in the United States from overdoses related to prescription opioids. Overdose deaths involving prescription opioids were five times higher in 2016 than in 1999.”
Why exactly is a complicated question, but it often starts with acute pain and the need for relief. Acute pain is a relatively common problem that can result from any number of illnesses, injury, surgical procedures and labor or it can seemingly come completely out of the blue. Acute pain can be debilitating, but by definition, it doesn’t last very long. Chronic pain is the term used to describe pain that lasts longer than three months.
“For the past couple of decades, prescription opioids such as oxycodone, hydrocodone, codeine, and morphine have been popular choices for helping patients to manage acute pain,” says Dr. Steven Severyn, an anesthesiologist, and director of the Comprehensive Pain and Headache Center at The Ohio State University Wexner Medical Center‘s Neurological Institute. While there are many different ways to treat acute pain, “opioids have long been considered the ‘go-to’ drugs to help manage acute pain,” Severyn says, but they may be overkill for some conditions.
When used correctly, these powerful pain relievers can make life bearable for people dealing with intense pain, and as such, drugs like Vicodin, Percocet, morphine and OxyContin are often prescribed to terminal cancer patients or people who’ve undergone surgery. Some opioids are derived from the poppy plant and some are synthesized in the lab. All of them interact with opioid receptors in cells to block your perception of pain. These drugs can also cause feelings of euphoria, which is how some people become addicted. Overdosing — taking too much of an opioid — can cause death by slowing down the heart, decreasing blood pressure and suppressing respiration.
Treating pain is sort of a Goldilocks problem — too little pain killer and the patient has difficulty functioning; too much and they risk overdose and death. It’s a tricky problem made worse by the availability of black market drugs that some patients turn to when their prescriptions run out or don’t go far enough in alleviating pain.
“Treating pain is not like curing pneumonia,” says Dr. Robert L. DuPont, founding president of the Institute for Behavior and Health Inc., a non-profit drug abuse research and policy organization. Also clinical professor of psychiatry at the Georgetown University School of Medicine, DuPont recently published the book “Chemical Slavery: Understanding Addiction and Stopping the Drug Epidemic,” and says there’s a misunderstanding surrounding how and why opioids are addictive. “You have to separate physical dependence from addiction. Most people think a person who’s taking opioids for pain and taking them as the doctor prescribed and does it for a long time is addicted,” but that’s not necessarily the case. Over time, patients build up a physical dependence to these drugs. “Physical dependence means your body has gotten used to the drug. If you stop it abruptly,” you’ll experience the unpleasant effects of withdrawal and the pain may come back.
“Addiction is an entirely different phenomenon that has to do with the use of drugs to produce a feeling of reward in the brain,” he says. This happens when patients decide the high associated with a drug is so compelling they begin “using it outside of medicine.” These individuals often progress to other high-producing drugs such as heroin, and black market drugs are often laced with extremely potent drugs such as fentanyl.
With addiction, DuPont says, come other behaviors. “The hallmark of addiction is dishonesty.” Addiction causes people to lie to get more of the drugs they need to continue the sensations they want to experience. His point is that even though opioids can be highly addictive and he believes they’re overprescribed, “patients who are taking them as prescribed are not addicts.” And while patients should proceed with caution when they are prescribed opioids, their use in a medical context doesn’t always lead to a dangerous outcome. Not everyone who uses opioids will become addicted.
Still, given the current climate of fear around opioids, many patients and doctors are looking for alternatives, and there are some, each with its own list of pros, cons and efficacy.
One major class of pain drugs is oral analgesics, or pain relievers taken by mouth. Within that broad group, a widely available category of drugs is non-steroidal anti-inflammatory drugs or NSAIDs. Sometimes these are prescribed at higher doses, but these drugs are also available over the counter in virtually every grocery store and pharmacy in America. NSAIDs reduce pain and inflammation by curbing the production of certain enzymes that cause inflammation. They function in a similar manner to steroids, but have fewer side effects. Examples of NSAIDs include medications like ibuprofen (Advil), acetylsalicylic acid (aspirin) and naproxen sodium (Aleve).
NSAIDs can be very effective, but are not recommended for patients with kidney diseases. The National Kidney Foundation urges caution when using NSAIDs, noting “heavy or long-term use of some of these medicines, such as ibuprofen, naproxen, and higher dose aspirin, can cause chronic kidney disease known as chronic interstitial nephritis. The warning labels on over-the-counter analgesics tell you not to use these medicines for more than 10 days for pain and more than three days for fever.”
Also in the over-the-counter bucket are other analgesics, such as acetaminophen (Tylenol), that relieve pain and reduce fever. A recent JAMA study showed that for emergency department patients who had acute arm or leg pain, there was no difference in pain reduction after two hours with ibuprofen and acetaminophen or three different opioid and acetaminophen combination pain relievers.
Clearly, acetaminophen can be highly effective when used as directed, but misusing it and taking too much can cause liver damage. The Mayo Clinic reports that acetaminophen overdose is the leading cause of liver failure in the United States. “Acute live failure can occur after one very large dose of acetaminophen, or after higher than recommended doses every day for several days.”
Topical analgesics — typically applied directly to the skin as a gel, spray or cream — may also be useful for some types of acute pain and are slathered on the skin at the site of pain. They can be especially useful for joint pain associated with arthritis, diabetic nerve pain or muscle aches related to sports injuries. Some of these products contain NSAIDs that relieve pain on contact through the action of these drugs. Others contain menthol, camphor, capsaicin or trolamine salicylate. The cooling or heating effect of these compounds can bring relief to the area.
Because they’re not ingested, these topical applications may be less toxic to internal organs, but you need to be careful not to combine them with oral analgesics, as that can lead to overdose. Talk to your doctor about whether a topical analgesic might be a good option for your situation and if so, which is the best one for you.
Muscle Relaxers and Nerve Blocks
For patients who have conditions that generate muscle spasms or cramps, a class of drugs called muscle relaxers could be an effective alternative to opioids. Often prescribed for neck and back pain after OTC drugs like acetaminophen or ibuprofen prove ineffective, drugs like Valium (diazepam) may be an alternative to opioids but also have side effects and carry a risk of addiction.
In addition, “physicians are increasingly utilizing nerve blocks,” says Dr. Asokumar Buvanendran, president of the American Society of Regional Anesthesia and Pain Medicine and an anesthesiologist at the Rush University Medical Center in Chicago. These drugs are usually delivered as an injection to a specific area of the body to numb the pain response. Essentially a local anesthetic, therapeutic nerve blocks can be useful for treating acute pain. Some nerve blocks are also used diagnostically to pinpoint the source of pain. They’re highly effective for pain that’s localized, but aren’t likely to be useful for more dispersed pain conditions. And as with any drug, they have side effects and varying levels of effectiveness depending on the specific drug and your situation.
Nerve ablation is a surgical approach that works on a similar principle to nerve blocks. In this method, the doctor destroys or removes nerve tissue to interrupt the transmission of pain signals in a specific area. However, nerves are resilient and often grow back. Many patients experience about 6 to 9 months of relief from a nerve ablation procedure.
Beyond drugs and surgery, there are a few other ways to tackle pain. Severyn says “the importance of regular exercise and physical therapy is especially well established,” and some alternative therapies have also been shown effective at controlling pain in some patients. “Various studies have shown the benefits of using non-drug treatments such as acupuncture, aromatherapy, biofeedback, chiropractic, cognitive behavioral therapy, hypnotherapy and massage to help relieve chronic pain.”
Biofeedback is a method of increasing awareness of physiological responses to pain stimuli and altering individual responses that many doctors are looking at more closely as an alternative to opioid prescriptions. It takes some training, but Buvanendran says it can be a powerful way to harness the body’s own ability to deal with pain.
In addition, he says it’s also important to “set expectations” with patients about what’s going to happen when they’re headed for acute pain, as is often the case with surgery. “I tell patients that surgery is going to hurt, but we can control it.”
Staying on top of pain while it’s still acute is important to the patient’s quality of life and for avoiding other problems later on. Acute pain can tip into chronic pain, and how and when exactly this transition occurs is an active area of study. Finding the right combination of techniques and medications to control acute pain before it becomes chronic will require collaboration with your doctor.
If your doctor prescribes an opioid pain reliever, be sure to discuss your concerns and any alternatives that might be applicable. One strategy Buvanendran suggests is asking for a reduced course. Instead of your doctor writing a prescription for 30 pills, see if he or she will write it for 10 or 15 doses instead. You can contact your doctor for more later if you find you need the rest of the typical course, and having fewer drugs lying around can help reduce the chances that someone else will access them.
Similarly, if you have a known issue with addiction or have previously overdosed on opioids, he suggests talking to your doctor about naloxone (Narcan), a drug that counteracts the effects of opioids and can be used to reverse overdoses. Some doctors are prescribing naloxone alongside opioids for certain patients. “Some high-risk patients are candidates for that, so ask whether you need it,” Buvanendran says.
If you have comorbidities such as sleep apnea, a high BMI or liver or kidney disease, opioids may not be a good option for you. “Most of these drugs are metabolized in the liver and kidney. If you have any of those conditions, the drug sits in the body differently,” and could lead to serious complications, Buvanendran says.
The key in all discussions surrounding opioid use is to be open and honest with your doctor. Discuss all your options and the benefits and risks of any and all medications before filling a prescription.