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Chronic pain, part 2: opiates.

February 13, 2012

Some people suffering from chronic pain, whatever its cause, don’t get adequate relief from treatments, surgery, or non-opiate medications.  In this case opiates may be required to help a person live their life with some relief from their pain.

There are many misconceptions about the use of opiates.  There are also societal attitudes toward pain and suffering that either prevent people from seeking relief or cause prejudice against chronic pain patients.  Let’s start with what society tells us.  There is a strong belief in American society that you get only what you work for and deserve.  Those who have disabilities preventing them from working as much as other people tend to face a certain amount of derision from others.  Even when I was working a full time job, when I refused to work extra shifts because I knew I would become over-tired and end up missing work, I was looked down upon as not a “team player” or needing to “step it up.”  As a nurse, I was concerned not only for my own well-being, but for the safety of the patients I would care for.  When  a nurse is fatigued or not feeling well, he or she is more prone to making mistakes in judgement and  in administering medications and treatments.  At least where I worked there was no mandatory overtime.  Nurses in some areas are forced to work those extra shifts whether they are physically and mentally able to or not or face losing their jobs.

I think attitudes toward pain are related to our attitudes toward work.  Society tells us we should work through our pain.  “No pain, no gain.”  “Take the pain.”  We’ve all heard these cliches countless times.  How often do you see co-workers show up obviously ill with no regard for the flu virus or whatever they are spewing all over the workplace?  I don’t think they do it because they want to make everyone else sick.  I think they do it  because they are afraid to miss work because they might be considered a sub-standard employee or even lose their job.  This attitude helps no one and hurts many, but America seems to be stuck in this rut.

Moving on to concerns about opiate medications.  First let me define what this means.  There tends to be some confusion about “narcotics” on the part of the public.  A good bit of confusion is caused by the difference between the pharmacological definition and the legal definition.  Originally, the medical definition was any sedating drug that affected the mind.  That became primarily associated with the opiates in time.  The legal definition of narcotic is any illegal or controlled drug.  This confusion in the public eye tends to contribute to the disdain in which opiate medications (and the people who use them legally) are sometimes held.

Let’s clear up some of the confusion.  “Narcotic” is a very imprecise term, thus I do not generally use it.  Opiates are medications that are derived from opium.  Morphine and codeine are naturally occurring alkyloids found in opium.  The semi-synthetic opiates (for example hydrocodone, hydromorphone, oxycodone, etc.) are derived from opium alkyloids through chemical processes.  The opiates as a group relieve pain when taken internally and have similar side effects such as itching, nausea, sedation, constipation, and respiratory depression.  Although people tend to talk about whether  particular opiate is “stronger” than another, I find this terminology to be fairly useless in describing the effects of opiates.  Doses required to achieve a comfortable level of pain relief vary widely depending on individual factors, the type of pain, and the degree of bodily injury.  So one person coming out of a gallbladder surgery may need twice as much medication as another person coming out of the same surgery, for example.  Also, all opiates are dosed to effect.  It doesn’t matter that 2 mg of morphine IV may do the same job as 0.4 mg hydromorphone (Dilaudid).  You’re going to use the amount it takes to relieve pain sufficiently.  Same deal with hydrocodone (found in Vicodin or Norco) and oxycodone (found in Percocet or OxyContin) in which a dose of 10 mg hydrocodone is essentially equal to 5 mg oxycodone.  Due to individual differences in metabolism, some may respond better to one opiate over another, but that does not make that opiate better for everyone.

The side effects of opiates and the risk of addiction are the main reasons people hesitate to use opiate pain medications when they need them for pain relief.  These are also the reasons opiates aren’t used first for aches and pains before other medications like Tylenol or Advil.  Used appropriately, opiates are quite safe.  Of the common side effects, people are most familiar with sedation.  These medications can make you sleepy and impair judgement, particularly when you are not used to taking them.  Nausea and respiratory depression may occur, but this is more common when first starting to take opiates and tend to diminish within a few days of use.  Itching is a known side effect, particularly with morphine.  I have seen many patients who list one or more opiates as an allergy when they experienced itching or nausea.  These are side effects, not an indication of a drug allergy.  Hives and wheezing would indicate allergy, but not itching by itself.  Constipation tends to be the most troublesome side effect over time.  This is easily managed with stool softeners and stimulant laxatives.  Unfortunately the patient is often not instructed regarding a bowel program while on opiates and then suffers needlessly either from constipation or from depriving themselves of needed pain medication to relieve the constipation.

So now we come to the hot button for a lot of people.  People worry about becoming addicted to pain medication or they worry about being labeled as an addict by others.  The plain truth is people do not become addicted when they take pain medication as directed and for PAIN, not to sleep or to feel happier.  Tolerance does develop over time, but this is NOT addiction.  Tolerance is when a larger dose of a medication is needed to achieve the same effect.  People who take opiates for chronic pain may in time need larger doses.  If they have to seek medical care and require pain medication, they will need more pain medication than other people even if the pain being treated is unrelated to their chronic pain process.  It is vitally important to notify care providers of your usual daily dosage of pain medications so that appropriate doses can be prescribed.  Besides tolerance, physical dependence develops with long term use of opiates.  This does not mean someone is addicted.  It does mean that the opiate dose must be tapered when stopping use.  Stopping suddenly will cause unpleasant withdrawal symptoms like nausea, sweating, shaking, agitation.

I am not saying people do not become addicted to opiates.  Lots of people do.  It’s good to keep an eye on your use of pain medications to make sure you are using your medication responsibly.  This means following the doctor’s instructions.  Getting your opiate medication from one doctor, not getting prescriptions from different doctors without telling them who else is prescribing for you.  Keep yourself accountable, especially if you have a history of addictive tendency.

There is a lot more to say here, but I’ll leave it for now.  Please feel free to comment on your own experience.

3 Comments leave one →
  1. Melissa permalink
    February 14, 2012 10:25 am

    Thanks for such an organized and lucid introduction to chronic pain management.
    As a chronic pain and chronic illness survivor, it is a joy to see a health care provider publicly enter the realm of reasonable talk about such a charged topic. You certainly know of which you speak!
    In my career as a Hospice RN, we dealt with chronic and acute pain quite often, in the context of end of life care. I came to realize at some point that we are all hospice patients– we will all die some day– no one escapes their end. If we are able to adopt an attitude toward our lives that we are living until we die, then it becomes a little more possible to improve our quality of life–both for the short and long terms.
    For me, taking care of the constant stress of severe pain made a huge difference to my quality of life and my ability to move forward, to engage more fully in my life, and to lift me out of depression.
    It is good, then, for me to revisit the tenets of pain management and check in with my program of treatment to see if I’m still meeting my goals for quality of life. I involve my pain physician in my personal evaluation process, so that we can fine tune if necessary.
    So far, so good!
    I look forward to your next installation !
    — Melissa

  2. rita permalink
    April 27, 2013 2:28 pm

    i am a chronic patient that has been turned over to pain management as i have been under the same dr. for 12 yrs. but my dr.s firm got scared of the new laws and referring patients over to pain management .but my new nuse practioner told me she was not going to write me all my meds and has prescribed me down in milligrams as well as the amount.i have copd and am dying but she is worried about addition?ihave been on the same meds for over 5 yrs and i had a little quality of life but now i am in such pain that it is hard to enjoy anything.i am mostly bedridden and i am lost,if i wasn’t a christian ,i think suicide would be the answer but i wont but what kind of life can i have and why is she playing GOD?I TRULY AM SCARED AND I PRAY BUT SOMETHING HAS TO BE DONE.i don’t want to be like this for whatever life i have left.is there any hope for me?i pray there is.thankyou for you dounderstand ,MAY god bless you and thank you.

    • April 28, 2013 8:45 am

      I would encourage you to call that office and report the increase in your pain. If you are demonstrating worsening symptoms with the med change likely they will be willing to revisit the issue. Having your doctor who had prescribed the meds the last 5 years call could help also. If you are in end stage COPD, you will be eligible for hospice care. This care provides a nurse to advocate for you whose goal is managing your symptoms so you can be as comfortable as possible for the time you have left.

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