Opioids still have place in pain control
Potentially addictive drugs can be crucial for some patients with chronic discomfort
A 70-year-old woman takes six Percocet pills a day to control her arthritis. Yes, she may be dependent on opioids. But those pills allow her to live her most active life — going out to meet friends for coffee, enjoying her grandchildren and indulging her love of cooking.
Many believe opioid addiction is a crisis, and there’s no question the problem is heartbreaking. As a pain specialist, I see it up close every day, and I won’t downplay the role doctors have played in the mismanagement of people that we were trying to help. Many believed that opioids like OxyContin would be effective long-term, so they were widely prescribed for chronic conditions like back pain.
But as medical authorities react to the crisis by imposing strict restrictions on opioid prescribing, the challenge is to avoid throwing the baby out with the bathwater. There’s still a place for opioids — even in managing chronic pain — for some people some of the time.
That 70-year-old woman is a poster child for the responsible use of opioids to manage chronic pain. First, and most importantly, she has been on the same prescription for years, never asking for higher doses. Like two-thirds of people, she doesn’t get a rush of euphoria from the pills.
If someone is coming back to me every few weeks asking for a higher prescription, I know we’re going to have a problem. There are new guidelines on safe dosing (for example, keeping prescriptions under 90 milligrams a day), and these should clarify for patients the path forward right from the start. But physicians need to recognize the red flags associated with early misuse of opioids.
For example, do you have underlying issues making you more susceptible to addiction? Our poster patient has no history of depression or anxiety, or substance abuse of any kind, nor do any of her close family members. It’s important to maximize nonopioid strategies and monitor for opioid misuse in people who have a personal or family history of addiction. If you’re considering opioids to manage pain, discuss your personal and family history with your doctor.
And finally, our sample patient’s attitude toward the pain is realistic. She doesn’t expect a drug to take away all of her pain all of the time. Like everyone, she deserves to live with as little pain as possible. But unfortunately, it’s a myth that doctors can take away all pain in all cases.
For acute or moderate-to-severe pain, opioids continue to be important medications, however even in our 70-year old arthritis patient, they should not be the first treatment tried.
The first step to managing pain is to create a non- opioid pain plan targeted toward the specific type of pain. Anti-inflammatories usually work on arthritis. For nerve pain, there’s very good evidence that specific anticonvulsants (pregabalin and gabapentin) work better than opioids, but not all family doctors start with these.
There’s a difference between how much pain you objectively feel, and how much you’re bothered by it — and both are crucial to living well with chronic pain. With opioid addiction, there are usually underlying issues such as anxiety, depression, or a history of abuse that make the experience of pain worse. It’s amazing how much a simple antidepressant medication can help people with pain. I work with mental health providers to ensure that these issues are identified and treated.
Mindfulness meditation, offered by many hospitals, is also a crucial tool that should be in everybody’s arsenal, whether they’re trying to manage pain without opioids or weaning off them. Clinical psychologists at my hospital developed a version of this powerful practice that specifically helps people withdraw from opioids. It’s called Acceptance and Commitment Therapy. We found that patients who used this therapy reduced their opioid use more than those who didn’t use it, had pain interfere less with their life — and were less depressed.
There are many ways to ease pain, and most are great for your overall health: Physiotherapy, swimming, acqua-therapy, and breathing exercises, acupuncture and massage. Holistic therapies increase your body’s pain-fighting endorphin hormones, and stimulate a pain-control area in your nervous system called the endocannabinoid system.
If money is tight, it’s worth exploring student massage clinics and community acupuncture, which offer affordable and sliding scale treatments. They are easy to find in Toronto through a simple internet search. Workplace benefits can be used for physiotherapy, and mindfulness meditation is sometimes reimbursed by OHIP with a doctor’s note.
Responsible pain regimens can continue to include opioids, but only after careful consideration. And there should always be an “exit plan” for opioids discussed before you take your first pill.
If you are currently functioning well on your safe dose of opioid medication, your primary care physician should not be weaning you from a medication which is helping you to live your life. If however you’re on high levels of opioids (more than 200 — 300 milligrams a day) for chronic, non-cancer pain, you need an effective and humane plan to gradually reduce your use while maintaining your level of functioning. You should experiment with more holistic ways to deal with your pain and any of the underlying issues that led to such heavy use. It’s a time-consuming process that can be hard emotionally and physically, but many patients feel very grateful once they achieve a new balance in their life. Dr. Clarke is an assistant professor in the Faculty of Medicine’s Department of Anesthesia, and serves as director of pain services at the Toronto General Hospital. Doctors’ Notes is a weekly column by members of the U of T Faculty of Medicine. Email doctorsnotes@thestar.ca.