Are you now taking pain pills or patches containing opiate medications to deal with chronic pain? Here is some important information for people who have pain that is likely to last months or years from a medical condition that is not life-threatening. If you have been taking opiates every day for a long time, yet you still have a lot of pain, and your everyday life remains out of whack, that’s a sign that opiates may be the wrong treatment for you. Successful treatments relieve distress and restore health, function, and well-being––so life gets back to normal. Why accept a treatment that is failing, especially if it may be making things worse and there are better options? Keep reading so you are ready to talk to your doctor or get a second opinion.

What are Opiates?

Opiates are a family of pain-relieving medications. They may also be called opiates, narcotics, or strong pain relievers.  

• Here are some common names:
• hydrocodone (Vicodin®, Lortab®)
• fentanyl (Actiq®, (Duragesic®)
• oxycodone (OxyContin®, Percocet®)
• morphine (MS-Contin®)
• meperidine (Demerol)
• hydromorphone (Dilaudid®)
• oxymorphone (Opana®)
• codeine (Tylenol #3® and #4®)
• methadone
• and buprenorphine

At the beginning, you probably went to the doctor because you were concerned about a new symptom or because a change in your condition had disrupted your daily life. In your case, your healthcare practitioner’s treatment included an opiate medication. If months or even years have passed since then, it is time to ask: How well is it working for you now? Are you functioning better or worse?

Opiates: A Two-Edged Sword

Many people do not realize that these medications are a two-edged sword. It is true that opiates are remarkable drugs. They are simply the best way to relieve excruciating pain in the short run after injury or surgery – for a few hours, days, or maybe even weeks. And, for centuries they have been easing the agony of ailing people for whom nothing more can be done as the end of life approaches.………… But there is more to the opiate story. When taken on a regular basis for a long time (months or years), these same drugs can end up causing more harm than good. With prolonged everyday use, they have actually worsened pain and disability for many people who should have been able to resume a relatively normal life.

Opiates are simply not capable of taking away painful sensations entirely. The best that opiates can do for you is dull the pain and make it less bothersome. In addition, research has shown that long-term use of opiate drugs, particularly at high doses, is often not the best treatment. Although opiates do help some people, better relief is usually available elsewhere. Studies have shown that the best treatment for chronic pain does not primarily revolve around medication. You are the owner of your body. You need to know what you are putting into it. You also need to know whether a medical treatment is doing what it is supposed to do. Every drug works well in some situations and less well in others. Opiates affect the brain, nervous system, and many other [arts of the body. Prolonged opiate use can actually increase suffering and disability. Long-term reliance on opiates alters the way your brain and nervous system interact, and changes how other parts of your body function, too.

Longstanding Pain Requires Different Treatment Than Short-term Pain

Chronic pain is simply not the same as acute pain from a sudden illness, a new injury, childbirth, or a surgical procedure. Persistent pain changes people: how they spend their days, what they do and don’t do, how they see themselves, how they feel day in and day out, and their view of the future. Unrelieved pain wears you down and alters your life. Successful treatment gives you back your life––and the nervous system heals itself!

Better Ways to Relieve Chronic Pain

Other methods have been shown to work well and are less hazardous––and are more likely to restore a satisfying everyday life. Some methods are medical treatments and some are things you can do by yourself. Suffering can usually be greatly relieved by learning how the nervous system works, and by learning new skills. Multi-disciplinary pain programs and organizations like the American Chronic Pain Association (www.theacpa.org) teach many specific techniques that relieve discomfort. Mastering them will allow you to soothe yourself and minimize the things that often make pain worse: stress, inactivity, uncertainty, feeling powerless, being out of shape, boredom, fear, anger––all the normal human reactions to pain and life disruption. Combining several methods often works the best.

Lack of Relief Despite High Doses Is a Signal It’s Time to Rethink

If your life is still on hold and your pain level is still high after months of opiate use, it’s probably time to think about changing treatments. Your doctor may be able to prescribe other treatments with fewer side effects to help you manage the pain while you learn the self-care approaches that will help you get your life back on track. You can ask your doctor to help you reduce or stop the opiates so you can see whether you feel better overall. It can be dangerous as well as uncomfortable to do this rapidly or without medical supervision, especially if you are on high doses or are taking more than one medication. You may need a specialist in detoxification.

Long-term Opiate Use Can Actually Cause More Pain

Over time, opiates can actually heighten your sensitivity to pain, which makes you feel worse. The brain may even start interpreting normal sensations as painful. The term for this is “hyperalgesia.” This phenomenon has been seen in many people on prolonged opiate therapy. In other words, the drugs have actually become a source of increased pain. Often the best solution is to simply reduce or get off opiates entirely. After a tapering process, people with hyperalgesia end up feeling better with less pain.

Daily Cycle of Withdrawal Symptoms Increases Suffering

If your body has become dependent on a narcotic drug, unpleasant symptoms appear along with an increase in pain near the time of the next dose of your meds. This is called withdrawal. Symptoms can include restlessness, irritability, muscle and bone pain, insomnia, sweating, diarrhea, vomiting, and so on. The daily roller coaster of withdrawal is especially difficult for those who routinely take opiates many times a day. Over time, the frequent dosing schedule may teach the brain to create painful and distressing sensations as a way to make sure it gets the next dose.

Sexual Dysfunction

Research has shown that long-term use of opiates shrinks the glands that make sex hormones. Long term exposure to opiates can cause sexual dysfunction including both reduced desire and performance. Changes in sex hormones (testosterone and estrogen) may cause other effects, including breast enlargement in men, fatigue and depression.

Talk to Your Doctor or Get a Second Opinion

Your doctor is trained to consider your concerns, preferences, and circumstances when planning your treatment ––but can only do so if you talk about them. Take this brochure to your next visit and discuss it. Ask your doctor to choose treatments that will allow you to function as normally as possible and have an active everyday life. And take responsibility for learning the skills needed to reduce your own suffering.

Other Side Effects of Long Term Opiates

Opiates have effects on many bodily functions. They can affect judgment, decision-making and moods. Opiates can cause sedation, drowsiness, and may cause confusion, especially when the medication is being started or the dose has been increased. Opiates can affect balance and increase the risk of falls. They also disturb the quality of sleep. Opiates reduce the natural drive to breathe which can cause apnea (stopped breathing). Overdose deaths are usually caused by this, especially when opiates are combined with alcohol or other drugs. Almost all people on opiates have constipation, sometimes severe enough to need powerful prescriptions to treat it, and often other gastrointestinal symptoms. Many people complain about itching and dry mouth. Liver damage, bone thinning, and weakening of the immune system (immunosuppression) are other side effects.

Impact on Safety and Employment

The side effects listed above can significantly impair performance of safety-sensitive tasks such as operating a motor vehicle or dangerous machinery -– whether at home, at work, or in the community. Opiate users are often unaware of their own impairment even though the consequences may be severe. Those whose jobs are safety-sensitive such as drivers and public safety workers are often denied medical clearance if they are using opiates.

Risk of Death

According to the Centers for Disease Control and Prevention (CDC), the risk of accidental death has risen as the use of opiates for chronic pain has become more common, up from 2,900 fatalities in 1999 to 11,500 in 2007. Prescription opiate overdoses now outnumber deaths due to heroin and/or cocaine, combined. There are several reasons. People on very high daily doses sometimes die without an obvious cause, but most of the time they stopped breathing after an unintentional overdose. There are also deaths among young children who put everything they find in their mouths. There are deaths among teenagers who take some of their parent’s or grandparent’s medications in order to get high. And there are deaths among those who take someone else’s medications, purchase them on the street, or steal them. Death is more likely when opiates are taken with other medications, or with illicit drugs or alcohol. The number of deaths due to all prescription drug overdoses now exceeds deaths due to motor vehicle crashes, long the leading cause of injury death in the United States. Public health officials are calling this an epidemic.

Risk of Addiction

Physical dependence, tolerance, and addiction to opiates are three separate issues. Everyone who uses opiates will soon become physically dependent on them and have withdrawal symptoms if the dose is abruptly lowered or stopped. Tolerance is common but not universal. It means that over time, higher and higher doses are required to get the same effect. But some people also become addicted. No-one can predict for sure who is vulnerable or when the shift to addiction will occur. Addiction is related to physical dependence but is a bit different. Because opiates affect the brain’s reward/pleasure center, a craving develops that goes beyond the relief of pain. It may be subtle. When addicted, people don’t use their drugs the way the doctor prescribes. Patients lose the power of self-control. Worrisome signs include things like running out of medication early, getting opiates from different doctors, and lying about losing a prescription. If a person with a previous substance abuse problem of any kind develops a painful condition, consulting an addiction specialist is advisable. Untreated addiction ruins lives––or ends them. This is why opiates should be used for the shortest possible period and why other methods of pain relief should be chosen whenever possible.

For Safety’s Sake

If you are taking opiates, bring a list of all of your medications to every medical office visit. The list should include both prescription drugs and things you buy at the drugstore without a doctor’s prescription. That means everything: pills, patches, injections, ointments, vitamins, herbals, supplements, etc. You should ask every doctor who prescribes any other medication for you how it might interact with your opiates. If your doctor doesn’t do this, show your list to the pharmacist and ask for counseling about drug interactions and side effects.

To Summarize…

The effect of long-term opiates on the way you think and feel often interferes with normal everyday life. Opiates have a lot of other side effects, including worsening pain in some people, and the risk of addiction. If you are on one of these drugs and your pain is getting worse, or you are not functioning in a way that lets you have a full productive life, then you should talk to your doctor. Ask about getting off the opiates entirely to see how you do. Other methods of relieving chronic pain work better for most people. The best approach of all is for you to take charge of your own recovery –– and use techniques to cope with your pain that will give you back your life. References: http://odg-disability.com/odgopiateflyer.pdf. http://www.acoem.org/Guidelines_Opiates.aspx A Day Without Pain, Mel Pohl, 2008, Central Recovery Press. Franklin, et al, Am J Ind Med 48:91-99, 2005 Eriksen, J, Pain 2006: 125: 172-179 Franklin et al, Clin J Pain, Dec, 2009 Dunn et al, Ann Int Med 2010; 152: 85-92 Angst and Clark, Anesthesiology 104:570-87, 2006 Sources: Jennifer Christian, MD, MPH (occupational medicine / disability prevention & management), President of Webility Corporation in Massachusetts, led the development of this document and is its primary author. Substantive contributions were made by Melissa Bean, DO, MBA (family medicine/occupational medicine in Missouri); Marianne Cloeren, MD, MPH (internal medicine/occupational medicine in Maryland); Marjorie Eskay-Auerbach, MD, JD (orthopedics/spine surgery in Arizona); Steven Feinberg, MD (pain medicine/physical medicine and rehabilitation in California); David Hanscom, MD (orthopedics/spine surgery in Washington state); Ralph Jaffe, MSW, PsyD (social work/psychology in Pennsylvania); Maja Jurisic, MD (emergency medicine/occupational medicine in Wisconsin); Michael Levine, MD, MPH (internal medicine/occupational medicine in Virginia); William Nemeth, MD (orthopedics/pain management/ addiction medicine in Texas); Suzanne Novak, MD, PhD (anesthesiology/health outcomes/pharmacy practice in Texas); and Mel Pohl, MD (family medicine/pain management/addiction medicine in Nevada). Helpful comments and suggestion for improvement were received from six additional reviewers in family medicine, internal medicine, occupational medicine, pain education, and pain medicine. Minimal changes were made to this document by John Dreyzehner, MD, MPH, FACOEM, Commissioner of the Tennessee Department of Health, and Mitch Mutter, MD, Medical Director of Special Projects for the Tennessee Department of Health.