Opioids may seem like the panacea for all pain. Take a pill and it goes away. But time and so much heartache and loss from the opiod epidemic has proven that’s far from the truth. Just like they used to think laudanum was a cure-all before the devastating effects of morphine was finally discovered, opioids are no different. It was actually sold over the counter until it was recognized as addictive and regulated under the Harrison Narcotics Tax Act of 1914, which restricted the manufacture and distribution of all opiates, including laudanum and coca derivatives in the U.S. It was finally made a “schedule II” drug by the Controlled Substance Act passed in 1970.
According to this act, drugs are sorted by their potential for abuse, legal status and medicinal uses,
- Schedule I: Marijuana, ecstasy, heroin, LSD, and peyote
- Schedule II: Methamphetamine, cocaine, fentanyl, Vicodin, oxycodone, and Adderall
- Schedule III: Anabolic steroids, testosterone, and ketamine
- Schedule IV: Xanax, Ambien, Ativan, and Valium
- Schedule V: Cough suppressants
Yes, they have their use in limited cases. But in most they not only don’t work, they’re harmful.
I’m constantly asked why I won’t give anything at my disposal to help pain.
The simple answer is I’m trained to do no harm.
Study after study shows why opioids aren’t the answer most think it is.
A new study published in The Lancet showed opioids yielded no difference for low back pain or neck pain compared to a placebo.
After six weeks, there was no difference in the reported pain between the opioid and placebo groups. But there was a significant difference in the mental health scores favoring the placebo group at 6 and 12 weeks.
This study is important in reaffirming prescribing recommendations that were updated in 2022 by the CDC for acute, subacute and chronic pain. Especially since data shows between 2019-2020 36.4% of patients were prescribed opioids when they had acute back pain.
As the new research showed opioids are not only not helpful but actually detrimental in acute pain settings with their impact on mental health as well as their abuse and addiction potential.
Pain is debilitating, but offering another potentially debilitating treatment isn’t the answer in most cases. Especially when we remember these medications were initially created to ease the excruciating pain felt in the end stages of cancer. They were never intended for daily life until the pharmaceutical company lied to the government, providers and patients. Nearly 75% of overdose deaths in 2020 involved opiates, almost 92,000 lives lost.
Chronic pain can be debilitating, insidiously invading every aspect of life. Wanting it to end becomes our only focus. But opiates are not the panacea we had been told they were. Mislead by the pharmaceutical industry as safe and harmless, they became the go- to answer for many providers. Decades later we are all paying the price.
Opioid induced hyperalgesia
Our bodies are set up to constantly maintain a stable internal environment or homeostasis. We naturally breathe, pump blood, digest food, walk, and talk without thought. Pain regulation is no different. The brain manages it through our endorphin and endocannabinoid systems. But when we use opioids they are much better at occupying the receptors than our own endogenous endorphins and this entire system gets disrupted. The brain perceives the level of circulating endorphins is too high and does its job by making less of its own and at the same time, the receptors system senses too many are occupied so it produces more receptors. The pills become less effective over time, creating a tolerance and higher doses are required to achieve the same level of relief. It can even cause or exacerbate pain in other areas.
They can mask the emotional component of pain
Pain is real. Whether the inciting event is still apparent, if you hurt, you hurt. But there’s no question how we feel emotionally clearly impacts how we feel physically and vice versa. And the longer we hurt the more frustrated we become. As discussed in past posts, pathways for both sensations reside in the same area of the brain. That’s why distraction can be such a powerful tool. Chronic pain puts us in a perpetual fight or flight mode. As a result, opioids are often taken to reduce that heightened state of anxiety not just for the pain itself. Not meant for this purpose it can escalate the doses required to “feel better” and make decreasing more difficult. Dealing with the ramifications chronic pain causes is the only way to stop this cycle and eneusre all treatments options are considered.
They inhibit resilience
This is the ability to endure difficult life experiences and adapt to all its challenges. The best way to achieve this is by honoring the feelings as they occur and then learning to deal with them appropriately. Opioids artificially elevate mood. But this only lasts for a short period of time. As the rise dissipates, mood crashes. Then another rise is needed to elevate it again. This cycle actually reinforces anxiety. Learning ways to recognize when we are tense, stressed and anxious so we can learn healthy ways to relax is imperative. Then we release our own feel-good hormone that protect us from illness, and pain, improving immunity so we recover faster.
Worsens sleep problems
We’ve discussed in numerous posts how important getting at least seven hours of sleep a night can be in reducing weight, pain, cardiovascular disease, depression. There’s no question it’s harder to sleep when we hurt. Just finding a comfortable position can be daunting. Opiates were once thought to aid in sleep by giving pain relief are now known to suppress breathing and can contribute to sleep apnea disorders. They also disrupt sleep architecture by blocking access to rapid eye movement (REM) sleep and to the deeper restorative stages of non-REM sleep that impact restorative sleep. Researchers found those prescribed opiates were 42% more likely to have insomnia.
Discourage movement
Immobility is our number one enemy, yet opiates can discourage movement by causing sedation, GI upset, and depressed breathing. But the best treatment for pain is to move. It surges oxygen and needed nutrients to sore muscles and joins, removes inflammation and toxins, decreases spasms and tension, improves strength and flexibility, help us to de-stress and release feel good hormones from the endorphin and endocannibinoid systems. The last thing we need is a medication that inhibits this.
Withdrawal symptoms between doses
Long term use of opiates can cause a daily withdrawal cycle that actually increases pain. As the dose wears off restlessness, anxiety, irritability, muscle aches, and gastrointestinal complaints may appear. Often this encourages shortening the time between doses which increase the amount required. This roller coaster can even train the brain to create painful and distressing sensations as a way to get its next dose.
Sexual dysfunction
Long term opiate use can actually shrink the glands that make and secrete sex hormones as well as reduce desire and performance. Changes in circulating levels of hormones such as estrogen and testosterone can cause breast enlargement, premature ejaculation and erectile dysfunction in men, fatigue, depression, and decreased libido.
Can affect balance
Opiates can increase the risk of falls by causing impaired psychomotor function or the slowing down or hampering of mental and/or physical activities. This can result in slower reflexes and alertness. By causing sedation and light headedness or even orthostatic hypotension- impaired blouse pressure response to an upright position. Meaning it drops rapidly when standing up causing dizziness, general weakness and even loss of consciousness.
Suppresses breathing
Opioids suppress our natural drive to breathe. This is particularly important in those who have underlying pulmonary issues from smoking, asthma, or chronic obstructive lung disease. It can even lead to periods of apnea (moments when breathing stops altogether) and worsening of already diagnosed sleep apnea disorders.
Gastrointestinal issues
Almost everyone who takes opioids has constipation due to its decreased motility effects in the GI nerves and muscles. Some require powerful prescriptions to counter act this effect. It also causes nausea, vomiting indigestion, gas, impair the gut barrier and microbiome function.
They act as an Immunosuppressant
Studies show an increased risk of serious infection when using opioids. This is thought to be due to their affinity for binding to mu opiate receptors found on T lymphocytes, macrophages and immature immune cells. It’s also linked to the disruption of our natural killer activity through the production and migration phagocytes. Their primary role is the destruction and removal of foreign material and dead cells within the body.
Bone health
Long term opioid use is associated with bone loss due to a number of factors, including direct interference with bone formation by lowering serum calcium levels, inhibiting osteoblasts which produce bone. They also contribute to the development of androgen and sex hormone deficiencies by suppressing the hypothalamus- gonadal axis which then decreases the level of gonadal hormones.
Liver and kidney issues
Opioid medications also include Tylenol or aspirin, usage of both can become excessive with daily doses. These can impact the liver and kidneys leading to liver and renal issues such as NASH and CKD. Since opioids are cleared through the liver those with reduced function can increase the levels circulating in the blood stream and increase the potential for toxicity.
Risk of death
The numbers of death attributed to opioid use has risen from 2,900 in 1999 to 82,998 in 2022. Prescription opioid overdoses now outnumber those from heroin and cocaine combined. Deaths due to all prescription drug overdoses now exceeds deaths from motor vehicle accidents, which had been the long-standing leader of deaths in the US. That’s why public health officials are calling this an epidemic.
Opioids may seem like the answer, but we now have confirmation they are no better than placebos in treating neck and low back pain. Yet they are still the go-to med for emergency rooms and practitioners alike. That has to change. Both patient and provider perceptions they are a quick fix is wrong. This misrepresentation is causing devastating issues to this day. If you’re taking opioids daily and still not functioning the answer isn’t to continue or increase the dose. Pain wears us down and alters our lives. Successful treatments restore health, activity and well-being. Maybe it’s time to discuss safer and better options with your provider.