“It is easy to get a thousand prescriptions but hard to get one single remedy.”
– Chinese Proverb

Nobody likes to hurt. It’s why moms give kids a kiss and a bandage for scuffed knees, and the reason we go to the medicine cabinet for everything from a headache to arthritis pain. If we live with chronic illness, our dilemmas and options can be complex. Besides the pain, we may have stressed family relationships, emotional drain, and fears of never getting better.

In the last 100 years, pain control has advanced enormously. If over-the-counter medications don’t provide enough relief from pain, we can ask for something stronger. Our physicians have two groups of medications they usually choose from first: analgesics and adjuvants.

Analgesics, drugs specifically used to treat pain, include opioids, non-opioids, and combinations of both. Doctors often recommend starting pain treatment with topical formulas (lidocaine or diclofenac patches, capsaicin), non-opioids (aspirin and acetaminophen), and nonsteroidal anti-inflammatory drugs (NSAIDS) to address the inflammation that adds to many types of pain. Their generic names include ibuprofen, naproxen, anaprox, and celecoxib; and they block prostaglandins, a chemical that produces pain at the site of injury or inflammation. Adjuvants are substances that can be used to enhance pain medications even though their primary purpose is for something other than pain (i.e., antidepressants, muscle relaxants, and anticonvulsants).

Another category of pain control includes opioid-containing drugs. Opioids first came from opium—a strong, habit-forming powder made from poppy flower seedpods. Since the mid-1900s, they have been used to provide relief from pain due to cancer and other life-ending diseases. For patients who were dying, the worry about dependence or addiction seemed a moot point.

With more attention given to pain control came the practice of prescribing opioids for patients whose pain couldn’t be alleviated. It worked like magic because opiate compounds have very effective pain-relieving properties. This may be your experience.

But for many people, opioid use has complicated life with dependency, tolerance issues, addiction, and overdose. Many people also lose social connections and the ability to participate in life. Heads are fuzzy, and controlling the pain is all that matters. This may be your experience.

There isn’t necessarily a right or wrong when it comes to pain control. What matters is whether or not you are living a life that satisfies you. What matters to your family and friends is that you aren’t taken away from them—mentally or physically. While Take Courage Coaching® doesn’t evaluate or advise client medication use, oftentimes the knowledge and skills of self-managing pain spur clients to reduce or eliminate the use of narcotics.

Long-term studies and patient observations offer good statistics on opioid use. While much of the data casts a shadow on this magic pill, the value of knowing how a drug works is priceless.

Just a few things medical scientists and physicians have learned about opioid use:
The term dependence is widely used to identify the need for a drug for improved function (physical dependence); whereas addiction signifies dependence without functional improvement. Patients with chronic illness on long-term use of opioids often experience tolerance issues and increased pain, emotional dependence, and strong withdrawal symptoms.

Many physicians concur that evidence is weak for the long-term effectiveness of opioids in relieving pain and improving functional status. This conclusion comes from studies showing that long-term use of opioids confuses the body and brain, in a sense—interfering with the body’s production of natural pain killers.

This is especially the case for patients who develop hyperalgesia (more pain)—a common response to opioids where the brain becomes more aware of and more sensitive to pain. Patients who experience this side effect to opioids are caught in a never-ending cycle of increased pain and heavier drug use.

While hyperalgesia can be a horrible complication of opioids, other negative effects are also common—blurred vision, reduced respiratory rate, nausea, constipation, itching, and anxiety. Some patients practice the dangerous use of opioids in combination with other substances such as alcohol, sedatives, sleeping pills and stimulants. Many patients develop “tolerance” to a drug—an adaptation to a drug which necessitates heavier and heavier doses to get the same amount of relief.

What’s new to this topic since this lesson was written in 2014? In 2016, the CDC published findings and guidelines on opioid prescribing to reduce medication-related complications and deaths from overdose. Researchers at Veterans Affairs (VA) and Kaiser Permanente health systems reported at the end of 2016 on a study based on dosage and patient-reported effects of opioid use—pain perception and intensity, anxiety and depression, function, beliefs and behaviors related to misuse of pain medication. Researchers Dr. Morasco and his colleagues found patients in the higher-dose group reported greater pain intensity, more impairments in functioning and quality of life, poorer self-efficacy (effectiveness) for managing pain, greater fear avoidance, and more health care utilization. Physicians have responded to the study by pointing out the need for multidisciplinary treatment methods, rather than reliance solely on pain medications for the chronic pain patient.

Patients who don’t adapt well to opioids or who are on heavy doses may no longer be doing what they once enjoyed, feel fuzzy-headed, appear to be in a stupor, and miss out on interactions with family and friends. Instead of being helped by these magic drugs, they have become prisoners of the medication(s). The solution has become the problem.
If you are taking opioid-containing medications for pain, you or a family member may be able to judge whether the drugs are helping you cope with pain or whether you have moved to a dependent state. Ask yourself these questions and have a supportive family member answer them, too:

• Is my life dictated by my medication—what I do, when I do it, or if I do it?
• Am I frequently in a “fog”?
• Am I constantly thinking about the next time I can take my medication?

Questions that can shed light on addictive states include:

• Do I take my medication to feel euphoria?
• Do I take my medication before the scheduled dose when pain levels are low or absent?
• Am I taking someone else’s medication in addition to mine?
• Do I frequently run out of medication before my next scheduled doctor’s visit?

In his book, A Day Without Pain, Dr. Pohl acknowledges that millions of people are started on opioids for chronic pain with no plan for stopping them. While these medicines can provide relief as patients learn other coping mechanisms, they also cause physical dependence after a month or two. This means the longer a person takes an opioid and the higher the dose, the worse withdrawal will be—uncomfortable sensations when a substance is abruptly stopped or decreased.

In addition to physical addiction, opioids can create an emotional dependence because they diminish emotional pain. If you find you are also using your medication as a “chemical coper”—to relieve feelings of anxiety, irritability, fear, or depression—this can be an added signal of addiction. You have probably also noticed that when the “good feeling” wears off, you are in a worse state than before you took the pill. Those who are dependent or addicted to opioids often stay on them when they would like to stop, because they fear withdrawal.

Dr. Pohl, Medical Director of the Las Vegas Recovery Center, suggests three questions that can help you know if opioids are working for you. If the answer to any of these is “no,” there may be better options for you:

• Is your pain totally or mostly relieved, or at least significantly better?
• Is your function maintained or improved?
• Are side effects absent or tolerable?

“If your medications are making you feel worse,” Dr. Pohl advises, “you may benefit from a discussion with your prescribing doctor about the pros and cons of continuing or stopping your medication.” Should stopping opioid use be your choice, withdrawal symptoms can be mild to severe. Although withdrawal is not likely to present physical danger, having a plan for medical attention is a good idea.

1. Withdrawal can start just hours after the last dose.
2. Restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, and other symptoms can be experienced.
3. Medical attention may be required.
4. Heavy withdrawal may last 3-4 days. Typically, major withdrawal symptoms hit their worst point within 72 hours, and gradually subside over the next 5-7 days (varying from person to person and with different drugs and formulations).
5. Low energy, depression, or irritability may be experienced for a week or longer.

If your physician feels opioid-containing medication is indicated for your pain, ask what the “exit strategy” is if the prescription doesn’t work or if side effects exceed the benefits. Dr. Pohl advises doctors to “prescribe opioids where needed but always with an eye to stopping them in the future.”

You may be a long-time user of opioids and wish you could be free of side effects or dependencies. If so, seek your physician’s guidance and the support of your coach. One possible positive is that knowing how to manage chronic pain may be extremely helpful as your body releases its hold on opioid substances.