What Physicians Need to Know About Chronic Pain and Opioids
To begin with, medical science now recognizes three types of pain. The most common is the pain you feel when you hit your thumb with a hammer. Such basic “nociceptive pain” arises when sensory neurons (nociceptors) experience damaging or potentially damaging stimuli. The cause may be a misguided hammer or a malignant tumor, but the pain-processing mechanism is essentially the same: healthy nerves respond to a stimulus by sending pain signals to the brain.
Neuropathic pain, on the other hand, is generated by damage to the nerves themselves, which send pain signals to the brain regardless of any external stimulus.
In addition to these two well-established types of pain, researchers now believe that there is a third type, triggered by emotionally traumatic experiences, such as child abuse. According to a 2016 article in The Journal of Family Practice (JFP), “Research demonstrates through objective means that it is possible for a person to feel real pain in response to purely psychological factors that have sensitized the nervous system over weeks and months, in the absence of tissue injury.”
Opioids help relieve basic chronic pain safely and effectively. While neuropathic pain is often adequately treated by non-opioid medications, such as gabapentin (with the addition of opioids if needed), opioids are well suited to treating chronic nociceptive pain. The goal of such treatment is two-fold: to relieve the pain and improve the person’s ability to function. Opioids are often very effective at relieving the pain, says Schneider, which allows patients to engage in other types of treatment—physical therapy and exercise, for example—that can help them meaningfully improve their functioning.
Schneider, who teaches a PBI course on Prescribing, tells those in her class that once most legitimate pain patients understand the importance of the non-opioid therapies, they are usually compliant. Doctors need to follow up to make sure, but since the patients’ goal is to improve their quality of life, not get high, they are more than willing to do what they need to. In fact, some patients are so worried about becoming addicted to opioids that they resist not the physical therapy and exercise, but the medications themselves. That’s a mistake based on the common misperception that physical dependence and addiction are one and the same.
Physical dependence is very different from addiction. A person is considered physically dependent on a drug if stopping it abruptly causes withdrawal symptoms. People become physically dependent on a wide range of substances, not just opioids. If you regularly drink a lot of caffeinated coffee, for instance, and suddenly stop, you’re likely to suffer a number of withdrawal symptoms, including, headache, sleepiness, irritability, lethargy and lack of concentration. The way to end physical dependence on caffeine without suffering withdrawal is to taper off gradually. The same is true of most physical drug dependency. Whether the drug is caffeine, an antidepressant, a corticosteroid or an opioid, patients whose dosage is carefully reduced generally avoid the hardship of withdrawal.
Addicts, too, could avoid the pain of withdrawal by tapering off their drug of choice. The problem is they can’t. That’s part of what it means to be addicted. In fact, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, defines addiction as a cluster of three basic behaviors. People who suffer from “Substance-Related and Addictive Disorders” (1) lose control over their drug use, (2) are unable to stop using their drug despite increasingly severe adverse consequences and (3) become obsessed with obtaining and using the drug, and increase the amount they take over time.
This last characteristic gets to the heart of addiction. Addicts use opioids not to relieve pain but to gain a sense of euphoria. Since tolerance to this mood-altering effect develops rapidly, addicts have to keep using more of their drug to achieve the same high.
The process is very different among pain patients. To minimize unpleasant side effects, such as sedation or nausea, these patients are generally started on a low dose of an opioid. Their bodies quickly develop a tolerance to the unwanted side effects. As the nausea or sedation fades, the dosage is gradually increased until their pain is sufficiently relieved. At this point, the legitimate pain patient is generally content to level off, which is why, studies show, addiction is rare among people who take opioids for pain.
In short, for the vast majority of chronic pain patients, the use of opioids leads to improved functioning not addiction. And properly managed by a trained physician, these drugs are safe. In fact, the American Geriatric Society has said they are safer than nonsteroidal anti-inflammatory drugs (NSAIDs) for geriatric patients.
Opioids help relieve emotionally-induced pain in two ways. Once someone has suffered serious emotional trauma, whether in childhood or as an adult, explains Schneider, “Their nervous system can be viewed as being ramped up.” These patients have become more sensitive to pain, as if their bodies are on high alert for signs of danger. Their physical pain is heightened by their often unrecognized emotional pain.
Such emotionally traumatized patients are often convinced that that they are benefiting from opioid treatment, in part because some opioids are also effective in treating psychological issues such as anxiety and depression (Oxycodone, for example, is an effective anti-anxiety drug). Schneider cautions, however, that such patients often resist including other forms of therapy along with their use of opioids. These other therapies, which are important to the patients’ long-term recovery, might include a home exercise program to strengthen their muscles, physical therapy, counseling, Eye Movement Desensitization and Reprocessing Therapy (EMDR) and antidepressant or anti-anxiety drugs. While it can be challenging to persuade such patients to participate in a comprehensive treatment plan, once they do, it is sometimes possible to scale back their use of opioids or even stop it altogether.
Better still is diagnosing the emotional component of a patient’s chronic pain upfront, before they become accustomed to the emotional/physical relief opioids offer. The authors of the JFP article suggest that physicians include assessments of anxiety, depression and developmental trauma as a regular part of their initial assessment. Schneider advises physicians in her Prescribing class to have patients fill out the Adverse Childhood Experiences (ACE) questionnaire, which helps identify different types of abuse and neglect patients have suffered, as well as other hallmarks of a rough childhood.