My thoughts about opioid therapy for chronic pain

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.

• There aren’t any conclusive long-term studies showing the effectiveness of opioids in relieving pain or restoring function.
• Observational studies have found that treatment with long term opioid therapy is associated with poor pain outcomes, greater functional impairment, and lower return to work rates.
• Extended use of opioids can make people more sensitive to pain – a condition called hyperalgesia – and lead to the chronification of pain.
• Higher opioids doses have been tied to more health care utilization.
• Opioid use come with risks:
  • Side effects – including drowsiness, dizziness, nausea, vomiting, and constipation
  • Tolerance – needing more of the drug over time to get the same benefit 
  • Dependence – not being able to stop the medicine without severe symptoms
  • Addiction – compulsively seeking out the drug
  • Other complications – including anxiety, depression, and respiratory failure

 
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.
 
Sources
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/