Opioids' effects are caused by activating receptors located throughout the brain and spinal cord. The two important effects of opioids are pain relief and enhanced mood. Once an opioid medication reaches these receptors, it activates the opioid receptors and produces an effect of relieving pain. It also causes mood enhancement in the form of stress reduction and euphoria, for some. The brain produces many natural endorphins that activate opioid receptors and relieve pain. As discussed in Chapter Three, these chemicals have been linked to many functions of the brain including pain relief, GI activities, respiration, mood, and hormonal regulation.

When you take an opioid, it encourages your brain to release greater amounts of dopamine, which causes a brief, intense sense of well-being, followed by a relaxed state. Opioids help ease pain by interfering with the pain messages traveling to your brain. Pleasure and relief from pain are closely connected in your brain.

Unfortunately, in addition to the desirable pain-relieving qualities of opioids, the drugs can have negative effects. Some of the side effects reported by those who take opioids include difficulty concentrating, blurred vision, reduced respiratory rate, nausea, vomiting, constipation, itching, sleepiness, insomnia, low energy, fatigue, anxiety, and depression. Another problem with opioid therapy, as with Paul and Sam, is that it is often combined with other habit-forming medications such as sedatives, alcohol, sleeping pills, and stimulants. The net effect is that many people are maintained on several long-term prescriptions, with significant consequences and no end in sight.

Many millions of people are being started and continued on opioids for chronic pain with no plan for stopping them in the future. According to Doug Gourlay, MD, Director of Pain and Chemical Dependency, Wasser Pain Management Centre, Mount Sinai Hospital, Toronto, Canada, and Howard Heit, MD, internist, gastroenterologist, and chronic pain specialist in Fairfax, Virginia, a management consideration when beginning opioid treatment should include an "exit strategy" for those in whom the opioids are not working or where side effects exceed benefits. Doctors should prescribe opioids where needed, but always with an eye to stopping them in the future, especially if they aren't successfully treating the chronic pain. Herb Malinoff, MD, often says, "Don't take off if you don't know how to land. Plan an exit strategy before starting these medications."

Physicians see large numbers of people who, though on large doses of opioid medications, continue to have significant levels of pain. Furthermore, they suffer because of the side effects of the medications. Even worse, they notice they're not doing the things they used to. They aren't playing with the kids, going out with friends and family, performing at work or school, and generally feeling well enough to participate in life. For some, the pain is the same or only slightly decreased after a dose of medication, and their function is worsened. Instead of being helped, many find themselves prisoners of these medications. Sam kept increasing the dose in an attempt to gain some pain relief, but he found the medications to be less and less effective. Sam had developed tolerance.

Tolerance, according to the Liaison Committee on Pain and Addiction (LCPA), is "a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time," meaning it requires more of the medication to have the same effect as it did when the individual first started taking it. The person's body adapts to the presence of the drug and he or she needs more of it to feel the same amount of pain relief. This often can lead to more pill taking and less relief and comfort. One might increase the dose, and doctors might prescribe more potent medications to overcome the tolerance.

What is even worse for many people is that when they try to stop these medications, they can't. Many people who take opioids for longer than a month or two develop physical dependence and have some degree of withdrawal discomfort if they stop. Generally speaking, the longer a person takes the opioid and the higher the dose, the worse the withdrawal will be.

According to the Liaison Committee on Pain and Addiction of the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine, "physical dependence is a state of adaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist." Dr. Gourlay and Dr. Heit point out that many different types of nonaddictive drugs, including corticosteroids, antidepressants, and others, can also cause dependence in a person. A person who is dependent on a drug will experience uncomfortable sensations if he or she abruptly stops taking it or decreases the dose. This is called withdrawal, which Sam experienced when he tried to stop his medications on numerous occasions. It is the avoidance of withdrawal that drives some people to continue taking these medications even when they want to stop them.

Excerpted from A Day without Pain (Revised and Updated) by Mel Pohl, MD, FASAM of Las Vegas Recovery Center.