Before I begin, let me clarify I’m not a trained clinician nor a pain expert. I share my experience as a pain patient (I tapered off opioids while attending the Mayo Pain Rehabilitation Center – it’s an expectation when you start the program) and my research. My treatment approach may or may not be right for everyone else. I don’t mean to dismiss anyone’s beliefs or experience. If opioids work for you, so be it. Treatment is a decision between patient and doctor.
Opioids are a hot topic. In the 1990s, they became the quickest and least expensive treatment option for chronic pain. Then came the opioid crisis and a hard push to reduce opioid use. More recently, there is a movement to de-stigmatize opioids.
Bottom line for me
While opioids are appropriate for acute pain, there’s no quick fix for chronic pain. While some chronic pain patients report short-term improvement with opioids, there is a question of when do the risks exceed the rewards.
It isn’t fair to ask chronic pain patients to lower or stop opioids with little or no tapering and no alternative treatments. If the decision is to reduce or stop opioid therapy, tapering should be done with oversight and alternative treatment. Chronic pain patients shouldn’t be expected to abruptly stop opioid therapy.
If used, opioids should be prescribed at the safest lowest dose and be used as part of a comprehensive pain management plan, including non-opioid medicines and non-biomedical therapies like ACT, CBT, relaxation training, exercise, and other coping strategies.
More research is needed about all sorts of pain treatment.
Barnett, M. L. (2020). Opioid Prescribing in the Midst of Crisis — Myths and Realities. New England Journal of Medicine, 382(12), 1086-1088. doi:10.1056/nejmp1914257 https://www.nejm.org/action/showPdf?articleTools=true&fbclid=IwAR0k_gaCI6MDzN8r-N33UwWqyIC8IqmPEjRwdnzl3LGbO2UAbHLFHIBw880&downloadfile=showPdf&doi=10.1056/NEJMp1914257&loaded=true
Busse JW, Wang L, Kamaleldin M, et al. Opioids for Chronic Noncancer Pain: A Systematic Review and Meta-analysis. JAMA. 2018;320(23):2448–2460. doi:10.1001/jama.2018.18472 https://jamanetwork.com/journals/jama/fullarticle/2718795
Chou R, Deyo R, Devine B, Hansen R, Sullivan S, Jarvik JG, Blazina I, Dana T, Bougatsos C, Turner J. The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain. Evidence Report/Technology Assessment No. 218. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2012-00014-I.) AHRQ Publication No. 14-E005-EF. Rockville, MD: Agency for Healthcare Research and Quality; September 2014. https://doi.org/10.23970/AHRQEPCERTA218. https://effectivehealthcare.ahrq.gov/products/chronic-pain-opioid-treatment/research
Morasco BJ, Yarborough BJ, Smith NX, et al. Higher Prescription Opioid Dose is Associated With Worse Patient-Reported Pain Outcomes and More Health Care Utilization. J Pain. 2017;18(4):437-445.doi:10.1016/j.jpain.2016.12.004 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5376359/
Khomula EV, Araldi D, Bonet IJM, Levine JD. Opioid-Induced Hyperalgesic Priming in Single Nociceptors. J Neurosci. 2021 Jan 6;41(1):31-46. doi: 10.1523/JNEUROSCI.2160-20.2020. Epub 2020 Nov 17. PMID: 33203743; PMCID: PMC7786210.
Stannard C. Where now for opioids in chronic pain? Drug and Therapeutics Bulletin 2018;56:118-122. https://dtb.bmj.com/content/56/10/118
Turner JA, Shortreed SM, Saunders KW, LeResche L, Von Korff M. Association of levels of opioid use with pain and activity interference among patients initiating chronic opioid therapy: a longitudinal study. Pain. 2016;157(4):849-857. doi:10.1097/j.pain.0000000000000452 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4939796/
There's still a core you despite the pain.
What you can do
People with chronic pain often do too much when they’re having good days and not
enough when they’re having bad days.
Pacing/moderation has become a common tool for people living with pain to help provide them with balance. It includes setting time limits, slowing down (start low, go slow), breaking up tasks, and taking frequent short breaks.
But be careful not to let pacing become an excuse for not being active or avoiding pain. Doing so can add more focus to the pain, worsen symptoms, and reduce physical stamina.
Pain doesn't mean harm. It's the result of an overly-protective system trying to protect itself. Our bodies become over-sensitized.
Pacing should instead be used to gradually increase what we can do, despite the pain.
The difference is in the goal and execution. Keep moving forward!
Learn more and do more
What is the biopsychosocial model of medicine and why is it important to pain treatment and recovery?
We’re more than our bodies. Yet, we’ve been typically treating chronic pain only from a biological perspective – potentially missing two-thirds of potential pain treatment.
Enter the biopsychosocial (BPS) model introduced by Dr. George Engel in 1977.
This model of medicine stresses a holistic look at the experience of chronic pain. It not only looks at the biological factors (injury, tissue damage, etc.) but also how our emotional well-being and our social situation influence how we’re affected by chronic pain.
Learn more about the biopsychosocial model:
If you have chronic pain, the answer is probably yes.
Central sensitization has been tied to a variety of chronic pain conditions including fibromyalgia, whiplash, shoulder pain, neuropathic pain, chronic fatigue syndrome, non-cardiac chest pain, irritable bowel syndrome, temporomandibular disorders, complex regional pain syndrome, low back pain, osteoarthritis, pelvic pain, and headache.
What is it
Central sensitization, also called centralized pain, is a phenomenon of the nervous system associated with the development, maintenance, and amplification of chronic pain.
The official definition by the International Association for the Study of Pain is, “Increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input.”
Chronic pain is an abnormal response and doesn’t improve over time. It can happen long after an injury or illness heals. It can be due to a degenerative disease, like arthritis. It can be neurological. It can also have no known biological cause, as in the case of fibromyalgia and many common low back pain conditions.
Once it becomes chronic, pain loses its warning function and becomes its own disease/condition. It changes how the brain processes pain – misfiring nerve signals and continuing to tell the body it hurts. Just like an alarm that goes on and won’t turn off. An overreaction or amplification, of sorts. It gets stuck on high alert and the body learns the pain.
And it can happen in all chronic pain conditions, no matter the underlying cause. We may feel it when only lightly touched or bumped. The pain can move around to different areas of the body other than the spot of the original injury. It can even change the type of feeling we may have like achiness, stabbing, tingling, or burning, for example.
The good news is that central sensitization can be reversed by changing how we manage pain, think about pain, and react to pain.
Best treatment is a biopsychosocial approach, including pain education, exercise, cognitive behavioral therapy, sleep management, and dietary management. I got a heavy dose of all these at the Mayo Clinic Pain Rehabilitation Center.
Chronic Pain Champions is an information resource/blog/support group to help chronic pain patients, their families, and friends, as well as healthcare professionals. Learn more about this site and the author.
Chronic Pain Champions