Opiates and chronic pain

Hi Everyone,
Forgive me if this is already well known on the forum.

I have been doing a bit of research lately and came across some interesting information on how opiates make chronic pain worse and I thought I would pass it along in case anyone is in a similar situation.

Basically, after a time, opiates screw up the way that our brain processes pain. The medical term for this is opoid induced hyperalgesia. Opiates activate cells in our brain and spinal cord called glial cells that have been found to be a key component in chronic pain. These glial cells cause neurogenic inflammation and greatly sensitize the nervous system to pain. Often, people will notice that not only are the opiates no longer helping their pain but they are making their pain worse. When the person attempts to increase their dosage to deal with the increasing pain their pain actually increases. The only way out of this cycle is to get off the opiates.

I began researching this because I learned that a few Tmsers I knew were having their breakthrough either after they were completely off the opiates or as they were weaning off. I also noticed in myself that the meds seemed to be increasing my pain.

Also, opiates make it so our brains do not produce the natural pain relieving endorphins. Obviously, after a time without the meds our brains heal. Exercise is said to be very helpful in the healing process.

Here is a quick read on the phenomenon:
http://www.medscape.com/viewarticle/811033 (Medscape: Medscape Access)

How this all relates to the mechanism of TMS I am not entirely sure. There could certainly be a component of conditioned responses involved. For myself, it is pretty difficult to reach a point of outcome independence when I am watching the clock for my next dose of medication. This clock watching keeps me in the cycle of pain.

Opiates also act as a safety net for me. Leaving the house for a long time without medication initially created a great deal of fear and anxiety. But just like everything else, as I reconditioned myself, it became much easier.

I do not regret taking opiates. For a time they helped me to work, function as a father and allowed me to begin exercising again even if the pain relief was a conditioned response.

 

I agree about the dangers of opiates and have stayed away from them most of my 85 years. Most of my life, I have gotten along without them. Here is another take on opiads and how bad they are for everyone, especially young people who are prescribed them and are hooked on them.

http://www.cnn.com/2016/05/11/health/sanjay-gupta-prescription-addiction-doctors-must-lead/index.html (Prescription addiction: Doctors must lead us out - CNN.com)

Instead of opiates, I too like exercise, and also meditation.


Meditation is a time-honored way of relaxing the mind and relieving anxiety, mental stress, headaches, and even physical pain. There are many ways to practice meditation, but many consider the most successful to be a technique called the Relaxation Response (RR).


It is a wonderful way to practice TMS Mindbody Healing because it changes harmful thinking in the subconscious mind which Dr. John Sarno says causes pain in many people.


The RR, practiced daily for a few minutes has a profound positive effect on the subconscious mind, relieving or curing everything from inflammation and pain to headaches, stomach problems, insomnia, high blood pressure, to even aiding in recovery from cancer.


RR is like Tanscendental Meditation which is taught by TM specialists who charge hundreds or thousands of dollars. But the RR is free and you can do it yourself.


It is done 20 minutes once or twice a day, before a mealand works best if not practiced within two hours after a meal. I do it in bed before arising in the morning and again in bed before falling sleep. Often, I only do it 5 or 10 minutes and it works to calm me and put me to sleep.


Just sit in a chair (or lie in bed in the morning or at bedtime), close your eyes, don’t listen to any music, and try to avoid outside noises. Let your mind think of a word such as "One " which has no real meaning or association. Or say a calming word such as “Peace,” or add the faith or spiritual element by saying a favorite religious word. Breathe in through the nose, hold the breath for a few seconds, then say the word when you exhale.


Say the word silently over and over. At the end of the 10 to 20 minutes, picture and feel yourself as you were when you felt your best, and in a place where you felt that way.


When distracting thoughts arise during the RR, as they will, just tell yourslf, “Oh, well,” and go back to repeating your chosen word. Transcendental Meditation teachers will charge hundreds of dollars to give practitioners a word, but the word you choose yourself in the RR works just as well.


There are several free videos on Youtube about the Relaxation Response. I especially recommend these two by Dr. Benson:


https://www.youtube.com/watch?v=nBCsFuoFRp8

 

Very interesting mc1986.

I healed 9 months after I discontinued opioids.

To me there were 2 parts:

- I discovered afterward that opioids completely numbed my emotions (a well understood phenomenon). TMS healing is to reconnect with your emotions in a healthy way. I certainly could not connect with my emotions while on opioids.

- I worried constantly about what may happen. We are well aware that discontinuing opioids abruptly is absolute torture and your body goes into a state of shock.
What happens if my doctor leaves...? Who will prescribe my refill? What happens if my doctor is busted by the DEA? What happens if my doctor changes his mind? What happens if they find another substance during my drug screening test because of tainted equipment or OTC medication that may give a false positive? (it can happen). What happens if my meds. are stolen? What happens if my meds. are confiscated entering a foreign country? What...if? What...if?

 

Great points Ezer. For me, there was always the anxiety of making sure the medication lasted until my next refill. The week leading up to my refill my pain was always much worse.

The tipping point for me was realizing how little the medication actually did for me and then meeting with a well educated physician who explained to me that not only was I likely dealing with the same pain levels I would if I stopped the meds but the meds were likely making it worse. His words were "if you want your doctors to make a lot of money stay on the Percocet".

Obviously, my inability to function in the capacity needed to get back to my career was also a big factor in my decision to begin tapering.

 

Interesting thread. I did not understand the way that opiates interfere with the processing of pain. Thanks for the info.
Way to go, mc, for realizing that although opiates were helpful to you at one point, they have ceased to be helpful--and for taking action.

 

I read a statistic in a business magazine last month that people in the U.S. take 80% of the prescription opiates used worldwide.

 

We are a country inflicted with TMS...why isnt the medical community opening up there eyes, I live in in the medical hub of the world...Boston Ma and the tms concept is not even heard of...its a embarresment

 

As Pog said, "We have met the enemy and he is us". MOST people don't want to hear that "It's all in their head". They want their pain killers and if a doc won't deliver the rx, they will shop around until they find a doc, or a source who will. Read the news story by Prince's long time LA drug dealer, about his twenty year $300 a day Dialudid and Fentanyl addiction-- add some Percosets and Tylenol to the mix and walla. The culture overuses pain killers because they can afford them--follow the money. But, when I had that kidney stone, and they gave me the morphine in the ER, the speed at which the pain disappeared was amazing. The overuse of opiates has been in the news lately with congressional hearings, but it sounds like they will substitute one drug for another and more programs that have been around for decades, that a lot of addicts just walk away from.

 

The opioid epidemic in the US is a difficult subject that requires a nuanced approach. Please remember that 20 years ago, doctors were blasted for being insensitive to chronic pain sufferers and were asked to offer opioid therapy on a long term basis to their patients.

I am personally appalled by the 2016 CDC guideline that pretty much forces doctors to limit opioid prescription to chronic pain patients.
That is okay but they need to suggest a valid alternative. They suggest exercise, NSAIDs etc. Please!

I suffered for 12 years. I was on opoids for 8 years. I truly don't know what I would have done without.
Even for the TMS believers:It is not that following the TMS path has a guaranteed outcome, so what do you do meantime when you have to keep a job?

 

Ezer, that was essentially what I was going to say. Opiates can aid in a tms recovery plan and for honest chronic pain patients who are just trying to hold down a job they can be very necessary. I would not be employed if I hadn't had them to get through the day

 

An RX I'm playing around with, based on a recent article I received a google alert on appearing in the "LANCET", is diclofenac (Voltaren), an NSAID. I'm finding it giving me noticeable relief for my hip arthritis.

http://www.medscape.com/viewarticle/860579 (Medscape: Medscape Access)

Medscape Medical News
For Arthritis Pain: Diclofenac Best, Acetaminophen Worst
Janis C. Kelly

March 17, 2016

• Oral Opioids No Better Than NSAIDs for Knee OA Pain
• Knee OA: Corticosteroid Shot Does Not Boost Exercise Benefit
• Knee Osteoarthritis: Acetaminophen Least Effective Choice

My Alerts
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• Nonsteroidal Anti-Inflammatory Drug (NSAID) Classes
• Pathology of Reactive Gastropathy
• Osteoarthritis

Diclofenac 150 mg/day was the most effective nonsteroidal anti-inflammatory drug (NSAID) for improving both pain and function in knee or hip osteoarthritis (OA), and acetaminophen (paracetamol) was least effective and should not be used in this setting, according to a new network meta-analysis published online March 17 in The Lancet.

"On the basis of the available data, we see no role for single-agent paracetamol for the treatment of patients with osteoarthritis irrespective of dose," write Sven Trelle, MD, University of Bern, Switzerland, and colleagues. "We provide sound evidence that diclofenac 150 mg/day is the most effective NSAID available at present, in terms of improving both pain and function. Nevertheless, in view of the safety profile of these drugs, physicians need to consider our results together with all known safety information when selecting the preparation and dose for individual patients."

This study reinforces data previously reported by other researchers that showed similar lack of efficacy for acetaminophen in this setting.

The new report, which includes substantially more patients than the previous network meta-analysis, is likely to increase calls for reconsideration of OA treatment guidelines that position the drug as a first-line treatment. Guidelines in which acetaminophen is recommended as first-line treatment include those from the American College of Physicians, the American Pain Society, the European League Against Rheumatism, the American College of Rheumatology, the Osteoarthritis Research Society International, and the UK National Institute for Health and Care Excellence.

Dr Trelle and colleagues used network meta-analysis in an attempt to fill in some of the blanks left by previous NSAID efficacy studies, most of which reported only on NSAID pain relief vs placebo "and therefore are only of restricted use for clinical practice," the authors write. The network meta-analysis approach integrates data from all randomized controlled trials (RCT) that compared different doses of NSAIDs either head to head or with placebo while respecting randomization, and thus allows for comparison between active agents.

Moreover, the authors used an extension of multivariable Bayesian random-effects models for mixed multiple treatment comparisons, which allowed for comparison of all available treatments across trials and accounted for multiple comparisons in trials with more than two treatment groups.

Studies eligible for inclusion were RCTs of patients with knee or hip OA that had at least 100 patients randomized to each treatment group. Treatments examined included acetaminophen, rofecoxib, lumiracoxib, etoricoxib, diclofenac, celecoxib, naproxen, and ibuprofen.

The primary outcome was pain, assessed at 1 week, 2 weeks, 4 weeks, 6 weeks, 3 months, 6 months, and 12 months. The researchers defined minimal clinically significant difference as a decrease of 0.37 units, corresponding to a 9-mm difference on a 100-mm visual analogue scale.

The secondary outcome was physical function, assessed at 1 week, 2 weeks, and at end of treatment.

The authors initially identified 8973 manuscripts, of which 74 RCTs comprising 58,556 patients were ultimately included in the analysis. Continue Reading

Among approved maximal daily doses, diclofenac 150 mg/day and etoricoxib 60 mg/day were the most effective at reducing pain, both with 100% probability of reaching the minimum clinically important difference.

Four other treatments had a 95% probability of reaching the prespecified threshold for clinically significant impact: etoricoxib 30 mg/day and 90 mg/day, and rofecoxib 25 mg/day and 50 mg/day. The authors noted that etoricoxib is less available than diclofenac because it has marketing approval in fewer countries.

Five treatments were not superior to placebo using the data available: acetaminophen < 2000 mg/day and 3000 mg/day, diclofenac 70 mg/day, naproxen 750 mg/day, and ibuprofen 1200 mg/day.

"The magnitude of treatment effect estimates varied greatly across different NSAIDs and doses," the authors write. "Whereas paracetamol had nearly a null effect on pain symptoms at various doses (effect size of –0.17, corresponding to 4 mm difference on a 100 mm visual analogue scale), diclofenac 150 mg/day had a moderate to large effect size of –0.57, corresponding to difference on a 100 mm visual analogue scale of 14 mm. This is 1.5 times the minimum clinically important difference for chronic pain of –0.37."

NSAID efficacy generally varied with dose, but acetaminophen was ineffective at all doses tested.

In contrast, diclofenac 150 mg/day was the most effective treatment for both pain and physical disability, and was superior to the maximum doses of ibuprofen, naproxen, and celecoxib.


In a press statement, Dr Trelle said, "NSAIDs are usually only used to treat short-term episodes of pain in osteoarthritis because the side-effects are thought to outweigh the benefits when used longer term. Because of this, paracetamol is often prescribed to manage long-term pain instead of NSAIDs. However, our results suggest that paracetamol at any dose is not effective in managing pain in osteoarthritis, but that certain NSAIDs are effective and can be used intermittently without paracetamol."

In a linked Comment, Professor Nicholas Moore and colleagues from the department of pharmacology at the University of Bordeaux, France, wrote that one limitation of the study was that widely used NSAIDs were not included in this meta-analysis, probably because no recent trials have been done of these drugs or because any recent trials that did assess them were too small.

Dr Moore and colleagues concluded, "The most remarkable result is that paracetamol does not seem to confer any demonstrable effect or benefit in osteoarthritis, at any dose. This finding is not entirely unexpected. Paracetamol has been on the market for as long as most of us remember. Its efficacy has never been properly established or quantified in chronic diseases, and is probably not as great as many would believe. Its safety is also questioned, not just in overdose."


The commentators suggested that patients might be suffering needlessly because of perceived NSAID risks and apparently nonexistent acetaminophen benefits.

Dr Moore and colleagues write, "Shorter-term intermittent use of NSAIDs with gastroprotection might also explain why upper gastrointestinal bleeding risks derived from full-dose long-term trials without gastroprotection are not found in patients in real-life settings."

Study coauthor Peter Jüni, MD, has received research grants from AstraZeneca, Biotronik, Biosensors International, Eli Lilly, and The Medicines Company, and serves as an unpaid member of the steering group of trials funded by AstraZeneca, Biotronik, Biosensors, St Jude Medical, and The Medicines Company. Coauthor Simon Wandel, MD, is an employee of Novartis Pharma AG, Biometrics and Data Management, Novartis Oncology, and was previously an employee of and currently holds shares in Cogitars GmbH Switzerland. All other authors have disclosed no relevant financial relationships. Dr Moore has received grants for studies at the University of Bordeaux and personal fees for work related to nonsteroidal anti-inflammatory drugs and paracetamol from Boots, Reckitt Benckiser, Novartis, Pfizer, Roche, Rhône-Poulenc, Sanofi, and Helsinn. All other authors of the Comment have disclosed no relevant financial relationships.

Lancet. 2016. published online March 17, 2016. Abstract