The Human-Opioid Connection
The relationship between humans and opioids goes back thousands of years. From the time we first cultivated Papaver somniferum over 5,000 years ago to the present day, the properties of the opium poppy have been a blessing and a curse. Opioids contain the most powerful pain-relieving molecules known to medical science, but they also carry a heavy, destructive, and deadly potential for addiction and abuse. Blessing and curse dovetail in a quirk of human physiology: the endogenous opioid system present in the human nervous system. Opioids relieve pain by leveraging this naturally occurring system; opioids lead to abuse by hijacking this naturally occurring system. Opioids become problematic because this internal pain-relief network is linked, at the cellular level, to how humans experience feelings of pleasure, satisfaction, and reward. Humans wrestle with this de facto paradox daily. It’s a cruel irony of nature that the most effective pain medication on earth is also the most dangerous; it’s a test of our ingenuity and scientific responsibility to find ways to use opioids without becoming victims to them – and if we can’t, to find alternative methods of managing pain without exposing ourselves to the risks inherent in opioid use. No population has a greater stake in the search for alternative pain management than those who are in recovery from substance abuse disorders. People in recovery work for years to free themselves from cycles of addiction and abuse. Yet when they’re faced with injuries, surgeries minor and major, or develop medical conditions characterized by chronic pain, their options are limited, and they’re often presented with a false dilemma: live with the pain, or risk sabotaging the hard work and progress gained in recovery by ingesting substances that increase risk of relapse or lead to a new substance abuse disorder.
The Problem(s) With Opioids
Setting aside issues related to individuals with a history of addiction and abuse, opioid pain medications have a significant set of limitations and complications that are neither widely known nor publicized. While they’re incredibly effective at relieving acute pain and there are many situations for which opioids are the logical and appropriate choice for pain management, the effectiveness of long term use of opioids for chronic pain management is not supported by medical research. That may come as a surprise to most people, but it’s true. In 2016, the Centers for Disease Control (CDC) released CDC Guideline for Prescribing Opioids for Chronic Pain, a comprehensive and systematic review of existing scientific evidence “to identify the effectiveness, benefits, and harms of long-term opioid therapy for chronic pain.” The study defines long-term as use of opioids for over three months. The conclusion as to the effectiveness and benefits of opioid therapy for chronic pain management is concise and unequivocal:
“…no study of opioid therapy versus placebo…evaluated long-term (≥ 1 year) outcomes related to pain, function, or quality of life. Most placebo-controlled randomized studies were ≤ 6 weeks in duration. The body of evidence…is rated as insufficient.”
Risks and Harms
The absence of clinical support for long-term opioid therapy in chronic pain management may come as a shock, but the complications of long-term opioid use are well-known and broadly publicized in online, print, and television media. The statistics reveal a pattern which, taken at face value, should cause a complete re-evaluation of the long-term use of opioids for chronic pain:
- In the U.S., opioid pain medication overdose caused over 165,000 fatalities between 1999 – 2014. Over 20,000 of these fatalities occurred in 2014 alone.
- In 2013, Substance Abuse and Mental Health Services Administration (SAMHSA) identified an estimated 9 million cases of opioid pain medication dependence or abuse.
- 80% of individuals initiating heroin use report starting with a prescription opioid.
Prescription opioids are big business. Experts estimate the value of the North American opioid market at $12.4 billion for 2015, a figure which quadrupled between 1999 – 2014, and is projected to grow to over $17 billion by the year 2024. This enormous increase occurred even though the amount of pain reported by Americans during the same period did not change. In the January 2017 study “What are the advantages of non-opioid analgesic techniques in the management of acute and chronic pain?” published in Expert Opinion on Pharmacology, Dr. Paul F. White, MD, identifies potential explanations for this counter-intuitive phenomenon:
- Aggressive marketing tactics of the pharmaceutical industry
- Overstated risks of non-opioid analgesics
- Reimbursement issues related to alternative pain-management therapies
- $880 million spent lobbying politicians to block legislation aimed at curtailing the use of opioids.
Rather than collaborate with patients to discover pain-management methods that carry less risk of harm than opioid medications, pharmaceutical companies and groups of vocal physicians did the opposite. White cites an article published in 2007 in which an international group of pain experts advocated for an increase in opioid prescription with this remarkable assertion: “If only we [physicians and nurses] could overcome our ‘opiophobia’, we would improve pain management.” When correlated with CDC data indicating a dramatic surge in opioid prescribing between 2007 – 2012, and the steady increase in abuse, overdose, and opioid-related fatalities since 1999, a clear picture of the past decade and a half emerges. Profit, expediency, and our cultural tendency to trust physicians and the prescriptions they write combined to create a perfect storm in which medication developed to alleviate suffering has arguably done more harm than good, and likely caused more pain than it has relieved.
Chronic Pain Management: Alternatives to Opioids
The Biopsychosocial Model
We’re in the midst of an opioid epidemic – that’s common knowledge. What’s not common knowledge is the existence of safe and effective alternatives for chronic pain management. To date, the most complete and effective approach to the management of chronic pain is the biopsychosocial approach, which entails understanding illness and disease as a result of the active interplay of physiological, psychological, and social factors. In their 2007 article “The Biopsychosocial Approach to Chronic Pain: Scientific Advances and Future Directions”, Gatchel, Peng, et al. conclude “the emergence of the biopsychosocial model of chronic pain has led to the development of the most heuristic approach to chronic pain—the interdisciplinary pain management approach.” The interdisciplinary approach suggests that in order to treat chronic pain effectively, physicians and patients must work together to see the big picture. Since people who suffer from chronic pain show increased risk for a wide range of additional emotional and physical pathologies, treating one symptom in isolation from the others is ineffective. It’s imperative to adopt a multi-modal approach that includes – in addition to physical symptoms – strategies that consider behavior, emotion, cognition, and environment. Viewing chronic pain as more than a physical condition is the first step in managing symptoms without the use of opioids. The second step is the use of non-opioid medications.
Alternative Medications for Chronic Pain
Chronic pain is often the result of poorly managed acute pain, and opioid abuse is often the result of the over-prescription of opioid medications after minor or major surgery. Mounting evidence shows that two widely used oral analgesics, when administered intravenously, are effective for managing acute pain:
- Intravenous (IV) Acetaminophen decreases post-operative pain scores and post-operative opioid usage.
- Intravenous (IV) Ibuprofen also decreases post-operative pain scores and post-operative opioid usage.
In addition, several non-opioid pain medications are effective in treating chronic pain, and thus decrease the risks associated with opioids:
- Anti-convulsant medications such as Gabapentin and pregablin are considered effective, first-line treatments for managing chronic neuropathic (nerve) pain.
- Antidepressant medications (serotonin and norepinephrine reuptake inhibitors) are approved by the FDA for the treatment of chronic neuropathic conditions such as diabetic nerve pain, fibromyalgia, and chronic musculoskeletal pain.
- Tricyclic antidepressants can help manage general nerve pain, diabetic nerve pain, and post-stroke pain. Note: because of the side effects of these drugs, they are not typically advised for elderly patients.
- Topical NSAIDs (Nonsteroidal Anti-Inflammatory Drugs) are an effective treatment for chronic musculoskeletal conditions such as osteoarthritis.
After a change in mindset from a strictly material point of view (diagnose-prescribe-take pill) to a holistic one (biopsychosocial), and a shift from opioid medications to non-opioid medications, the third step in managing chronic pain without opioids is the pursuit of complementary and alternative medical therapies.
Complementary Therapies for Chronic Pain Management
Complementary therapies are defined as treatments that exist outside mainstream medical science but can be effective when used either in place of or in conjunction with traditional therapies. Complementary therapies attract patients struggling with chronic pain who don’t want to use opioid medication for a variety of reasons. Some may avoid opioids because of pre-existing substance abuse disorders; some may have developed substance abuse disorders as a result of prescription opioid use; some may have been unsuccessful managing chronic pain with opioids; some may be averse to physicians and traditional medical science altogether. This list details complementary approaches supported by scientific research for the management of chronic pain:
- Cognitive Behavioral Therapy (CBT) is a type of talk therapy which helps a patient make connections between emotions, thoughts, and actions. While CBT itself does not relieve pain, it’s considered effective in improving mood and decreasing catastrophizing. Pain management experts recommend CBT to address the psychological component of pain within the biopsychosocial model of chronic pain management.
- Physical Exercise improves overall quality of life, mood, physical functioning, and reduces risk of developing co-occurring chronic diseases such as cardiovascular disease, type 2 diabetes, osteoporosis, and obesity. Low, moderate, and high-intensity aerobic exercise, strength training, and flexibility training all have positive impacts on the management of chronic pain. Any exercise plan should be tailored to accommodate individual needs and capabilities.
- Yoga, Tai Chi, and Qigong are low-intensity movement-based physical activities that have positive impacts on chronic pain associated with rheumatoid arthritis and fibromyalgia. Evidence shows these activities also improve strength, balance, flexibility, cognitive function, and help manage symptoms of anxiety and depression.
- Acupuncture is a traditional Chinese medical technique used to treat a wide range of disease and illness. Research verifies acupuncture as an effective treatment for osteoarthritis, neck pain, back pain, chronic headache, and shoulder pain.
- Massage is proven effective in reducing chronic musculoskeletal pain and mitigating associated symptoms such as insomnia, depression, anxiety, and stress.
- Chiropractic therapy – the direct manipulation of the spine – is proven effective for the treatment of chronic spinal pain syndromes.
- Mindfulness and Meditation practices serve as an effective complement to CBT in managing chronic pain, decreasing stress, and treating opioid misuse. Pain researchers assert that these techniques operate by increasing emotional awareness and intelligence, skills which lead to greater self-efficacy and a subsequent decrease in the subjective experience of pain.
Managing Chronic Pain Without Opioids
The relationship between humans and opioids goes back thousands of years – but that’s not the whole story. While it’s true that our relationship with exogenous opioids goes back thousands of years, our relationship with endogenous opioids is deeper. It goes back millions of years, to the very origin of our species, because our opioid system evolved as an integral part of our nervous system. We can neither avoid nor ignore its presence and power in our lives. We can, however, identify when this system works against our overall health and well-being, as in the case of opioid medications used for chronic pain. We can mitigate the negative effects of exogenous opioids by pursuing evidence-based therapies which are equally effective, and in some cases, superior to opioids for chronic pain management. Individuals in recovery and treatment for substance abuse disorders can find comfort in the fact that opioids are not their only option and sidestep the potential for relapse and misuse. They no longer have to fear the effect of injuries or surgeries on the recovery process, or operate under the false notion that living a sober life means they don’t have access to effective pain management strategies or medication that works. Holistic, interdisciplinary approaches, paired with non-opioid medications and the right combination of complementary therapies, empower patients – including those in recovery – to take control of their pain experience and improve quality of life without exposure to the preponderance of risks associated with opioids.