How opioids can increase chronic pain

In this article, we describe concerns of painkiller abuse in patients and effects of overusing painkillers. One effect especially worrisome is that painkillers can cause more pain for chronic joint and back pain patients.

The surgeon general’s letter

In late August of 2016, United States Surgeon General Vivek Murthy, MD took the unprecedented step of personally contacting every physician in the United States by letter to warn of an epidemic killing tens of thousands of Americans every year:

Research July 2016 

Doctors at the University of Washington had this to say:

“Musculoskeletal conditions are common, and there are many options for pharmacologic therapy. Unfortunately, there is not strong evidence for the use of many of these medications. Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are generally first-line medications for most musculoskeletal pain, but there is more evidence these medications are not as safe as once thought. “1

Should painkillers be the first response to pain?

Many medical conditions that affect people’s lives involve some type of chronic pain, whatever it may be. In today’s medical society, the prescription of drugs, more specifically painkillers, has almost become the first response to any and all conditions no matter the severity.

This mentality of the pharmaceutical industry and some traditional medicine practitioners has unfortunately hurt the public by the immense volume of pain medication pills it has pumped into the medical community. Not only is it easier to get them but just as easy to get higher dosages as well. This current purge of drug supplement and drug usage is very quickly escalating into a very big societal problem; bigger than it ever could have been imagined by the creators of these drugs.

Researchers want to know why patients are turning away from painkillers

People in pain know that painkillers are not the answer and they are rebelling. Research published in the Journal of the American Geriatrics Society studied the use of painkillers in older adults with knee pain. Researchers were looking to describe the prevalence of pharmacological and non-pharmacological pain management approaches used by older adults with persistent knee pain. They also sought to identify characteristics associated with use of these approaches.

The study followed 599 adults aged 64 and older in urban and suburban communities of Boston. They conducted a home interview and clinic examination with the patients. The interviews showed

• 37.5% reported using both pharmacological and non-pharmacological pain management modalities.
•  31% percent reported use of non-pharmacological modalities alone
•  11.5% used pharmacological modalities alone

Other results showed

• Non-pharmacological modalities (68.4% – over the counter) were reported more frequently than pharmacological modalities (49%).
• Women, individuals with knee osteoarthritis, and individuals with moderate to severe pain were more likely to report combined use of pharmacological and non-pharmacological modalities.
• Only one-third of older adults with persistent pain reported pain management strategies consistent with current guidelines.

The article concludes that further research is required to understand reasons behind choices, barriers to adherence, and the benefits of multiple modalities that older adults with persistent pain use.

Additionally, not only are the patients non-compliant with the use of pharmacological pain relief, but their doctors themselves are confused as to how to medicate them.

On top of the ineffectiveness of painkillers to cure chronic pain, there is an underlying fear of side effects. Many patients would rather live with the pain than risk prescription pain medication for their side-effects, addiction risk, and fear of accidental overdose. A stern warning was issued in Journal of Safety Research:

“Overdoses involving prescription drugs in the United States have reached epidemic proportions over the past 20 years,” and that one of the problems is an “incomplete understanding of prescription overdoses,” that impedes prevention efforts. In other words – confusion by the patient and confusion by the doctor.2

It is no wonder that patients are actively seeking “natural painkillers,” these include simple movement and exercise. Or they are asking their doctors for  painkillers without acetaminophen (tylenol, APAP)

In May 2016, researchers made an amazing discovery

Less than 1 in 5 patients in Portugal with chronic low back pain were taking painkillers.

In the study of 1,487 subjects with active chronic low back pain, only 18.7% were using analgesic/pain-relief drugs.

Estimated prevalence was:

• anxiolytics (anxiety medication) 14.1%;
• nonsteroidal anti-inflammatory drugs (NSAIDs),12.3%;
• antidepressants, 10.1%;
• analgesic, antipyretics, (fever, inflammation) 6.6%;
• anticonvulsants, (these are anti-seizure and anti-convulsion medications prescribed for Neuropathic pain) 3.4%;
• central muscle relaxants, 2.6%;
• and analgesic opioids, 1.6%. 3

Chronic low back pain is one of the most common reasons why older adults go to the doctor and get painkillers

A recent study in the journal Neurology shows that pregabalin – a nerve pain medication – is not effective in controlling the pain associated with lumbar spinal stenosis, the most common type of chronic lower back pain in older adults.

“Chronic low back pain is one of the most common reasons why older adults go to the doctor and lumbar stenosis is the leading indication for surgery in this age group,” said John Markman, M.D., director of the Translational Pain Research Program in the University of Rochester Department of Neurosurgery and lead author of the study.

“While physicians have increasingly looked for medication alternatives to opioid pain medication like gabapentin (a neuropathy pain medication) and pregabalin to help these patients manage their pain, until now there has been no credible evidence as to whether or not these treatments are effective for this problem.”

“Given the cost and potential side effects associated with pregabalin, it is critical that we understand the efficacy of this drug,” Markman said. “This study convincingly demonstrates a lack of relief with pregabalin for the walking pain associated with lumbar spinal stenosis.”

Doctors are not sure how to treat SYMPTOMS of chronic pain

Recently researchers at Indiana University had this to say:

“We learned that sufficient clinical research doesn’t exist to show physicians how best to treat chronic pain in adults, many of whom suffer from multiple health problems,” said the founding director of the Indiana University Center for Aging Research and Regenstrief Institute investigator Christopher Callahan, M.D., who served on an independent panel convened by the National Institutes of Health to discuss these concerns and issue a report.

While opioid painkillers are frequently prescribed for chronic pain, the panel noted the absence of pain assessment and treatment guidelines. The panel also reviewed reports that suggest insufficient data exists on drug characteristics, dosing strategies and tapering options.

“Are opioids the appropriate treatment? And, if so, at what dose and for how long? Could other, less dangerous treatments work for some people?

The panel found that, in spite of what many clinicians believe, there is no evidence that pain narcotics — with their risks of dependency, addiction and death — are an effective long-term pain treatment. More research is needed to guide effective care for chronic, often debilitating, pain,” Dr. Callahan said.

Yet painkiller prescriptions continues despite limited evidence to support the long-term benefit of this pain treatment approach. It has been found in women that painkillers expose women to unique risks, including endocrinopathy, reduced fertility, neonatal risks, as well as greater risk for polypharmacy, cardiac risks, poisoning and unintentional overdose, among other risks.4

• Painkillers are linked to erectile dysfunction.5
• Patients still take over-the-counter pain medications despite the risks.6,7
• Prescription overdose rate reaches epidemic levels in NYC. 8

Signs and symptoms of opioid toxicity may include:

• altered mental status,
• hypoventilation,
• decreased bowel motility,
• central nervous system and
• respiratory depression,
• peripheral vasodilation,
• pulmonary edema,
• hypotension,
• bradycardia (a slow heart),
• and seizures. 9

 Incomplete understanding of prescription overdoses

On top of the ineffectiveness of painkillers to cure chronic pain, there is an underlying fear of side effects. Many patients would rather live with the pain than risk prescription pain medication for their side-effects, addiction risk, and fear of accidental overdose. A stern warning was issued in Journal of Safety Research:

“Overdoses involving prescription drugs in the United States have reached epidemic proportions over the past 20 years,” and that one of the problems is an “incomplete understanding of prescription overdoses,” that impedes prevention efforts. In other words – confusion by the patient and confusion by the doctor.10

Prescription painkiller abuse in women

Since 1990, painkiller overdoses have more than tripled, but even worse than this is the five-fold increase in women. The Center for Disease and Control (CDC) said, “The deaths due to opioid drugs have skyrocketed in women; mothers, wives, sisters, and daughters at rates we have never seen before.” In 2010, there was an emergency department visit by women for the misuse or abuse of opioids at a rate of about 1 every 3 minutes.

• To add fuel to this fire, recent research has shown that women are more likely to have chronic pain, be prescribed painkillers, be prescribed higher doses and use them for longer periods of time than men.

On average, women weigh less than men so these drugs have much higher effects on them than the average man. The correlation between the amount of pain medications available and the increased deaths of everyone, not just women, almost go hand in hand.

Despite this knowledge, doctors still to continue to freely give away prescriptions to these dangerous drugs without regarding the individual taking them. Many aspects of the person should be taken into account before giving them the prescription and, if nothing else, they should at least be told of the dangerous affects they can have on individuals. A holistic and curative approach is the best way to prevent, treat, and protect patients from abusing their medications.

Painkillers are a common treatment option for people battling chronic knee pain. While many other treatment options exist, both conservative and non-conservative, prescription drugs rank high as a main course of knee pain treatment.

Facts about Narcotics

The term narcotic is derived from the Greek word for stupor. At one time, the term applied to any drug that induced sleep, but most refer to drugs that have strong analgesic properties. Narcotics are medications that are morphine-like, whereas a similar analogy is NSAIDS, which are aspirin-like. There are numerous NSAIDs available because each NSAID company believes that their product is safer and more effective than the others are. The same is true with the various narcotics. Each pharmaceutical company producing narcotics tries to develop an even stronger pain reliever with fewer side effects. By definition, narcotics, which act in a manner similar to morphine, are immunosuppressive.

Here is a list of some of the most commonly prescribed drugs with their generic names:

• Tylenol with codeine (Tylenol #3, Tylenol #4) A combination of narcotic pain reliever and a non-narcotic pain reliever.
• Duragesic (fentanyl patch)
• Fentanyl a very potent synthetic painkiller more potent than morphine.
• Morphine (Avinza, Kadian, Oramorph SR, Rescudose, Roxanol)
• MS Contin
• Oxycontin (Oxycodone)
• Demerol (meperidine)
• Vicoden (hydrocodone, Dolorex Forte, Hycet, Liquicet, Lorcet Plus, Lortab, Lortab Elixir, Maxidone, Norco, Stagesic, Vicodin, Vicodin ES, Vicodin HP, Xodol, Zydone )
• Darvon (Propoxyphene)
• Dilaudid (hydromorphone hydrochloride)
• Lortab (hydrocodone bitartrate and acetaminophen)
• Percocet (Oxycodone and acetametaphen)
• Tylox (acetaminophen and oxycodone)
• Percodan (oxycodone with aspirin)
• Lyrica (pregabalin) [not a narcotic like others in this list, however]

Known Effects of Narcotics on the Immune System:

• Depress the function of all cells of the immune system
• Suppress the cytotoxic activity of natural killer cells
• Enhance the growth of implanted tumors
• Increase incidence of infections
• Depress T-Lymphocyte responsiveness to stimulation (immune problems)
• Abate delayed hypersensitive skin response (rash or rashes, itching)
• Cause spleen atrophy
• Cause thymus gland atrophy
• Decrease T-Lymphocyte numbers
• Decrease T-cell function
• Inhibit B-cell activity
• Decrease levels of interferon

Pain typically indicates that some structure is weakened and/or damaged. If there is no pain there is no need for painkillers. Prolotherapy treats the root cause of the problem, looking past the symptoms to the cause of the symptoms. It is a cost-effective and conservative alternative to painkillers for joint pain.

Ask us your questions about this article

1 Loveless MS, Fry AL. Pharmacologic Therapies in Musculoskeletal Conditions. Med Clin North Am. 2016 Jul;100(4):869-90. doi: 10.1016/j.mcna.2016.03.015. Epub 2016 Apr 20. Review. [Pubmed]

2. Paulozzi LJ. Prescription drug overdoses: A review. J Safety Res. 2012 Sep;43(4):283-9. doi: 10.1016/j.jsr.2012.08.009. Epub 2012 Aug 25.

3. Gouveia N, Rodrigues A, Ramiro S, Eusébio M, Machado PM Canhão H Branco JC. The Use of Analgesic and Other Pain-Relief Drugs to Manage Chronic Low Back Pain: Results from a National Survey. Pain Pract. 2016 May 21. doi: 10.1111/papr.12455.earchers  [Epub ahead of print]

4. Darnall BD, Stacey BR, Chou R. Medical and psychological risks and consequences of long-term opioid therapy in women.Pain Med. 2012 Sep;13(9):1181-211. doi: 10.1111/j.1526-4637.2012.01467.x. [Pubmed]

5. Richard A. Deyo, David H. M. Smith, Eric S. Johnson, Carrie J. Tillotson, Marilee Donovan, Xiuhai Yang, Amanda Petrik, Benjamin J. Morasco, Steven K. Dobscha. Prescription Opioids for Back Pain and Use of Medications for Erectile Dysfunction. Spine, 2013; 38 (11): 909

6. Koffeman A et al., Use of over-the-counter non-steroidal anti-inflammatory drugs in the general population and in patients with a high risk of adverse drug events [abstract]. EULAR Annual European Congress of Rheumatology; 12-15 June 2013; Madrid, Spain. Abstract nr. OP0202-PC.

7.Warlé-Van Herwaarden MF, Kramers C, Sturkenboom MC, et al. Targeting outpatient drug safety: Recommendations of the Dutch Harm-Wrestling Task Force. Drug Saf 2012; 5 (3): 245-59

8. Columbia University’s Mailman School of Public Health. Public release date: 3-Feb-2013

9. Cobaugh DJ, Gainor C, Gaston CL, et al. The opioid abuse and misuse epidemic: Implications for pharmacists in hospitals and health systems. Am J Health Syst Pharm. 2014 Sep 15;71(18):1539-54. doi: 10.2146/ajhp140157.

10. Paulozzi LJ. Prescription drug overdoses: A review. J Safety Res. 2012 Sep;43(4):283-9.

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• Surgery
• NSAIDs
• Cortisone Shots
• R.I.C.E.