Pain Management with Opioids

Pain management has become a national issue with the opioid epidemic. Deaths from opioids have been on the rise; especially, synthetic opioids (fentanyl). According to the Centers for Disease Control and Prevention (CDC), the age-adjusted overdose death rate with synthetic opioids (not including methadone) increased from 0.3 per 100,000 people in 1999 to 9.9 per 100,000 people in 2018.

Opioid Use Outside of the Hospital

Despite this growing concern, opioids still have a place in pain management. For chronic or nerve pain, opioids should only be considered after other options including lifestyle changes, exercise, and other medications.

Acute Pain

Acute pain, or short-term pain, can occur from sudden damage or risk of damage to tissue. For example, a minor surgery or a sports injury would be considered acute pain. The risks of using opioids in acute pain is generally considered to be low.

In most cases, addiction and psychological factors will not be a major concern, and opioids can be prescribed for a short course of pain treatment in severe cases. The expectation of treating this pain with opioids would be a single short course of opioids; less than 14 days.

Chronic Pain

Chronic pain, or long-term pain, can occur from permanent or lasting damage to tissue.  This type of pain is often described as burning, throbbing, or aching. It includes conditions like arthritis and back pain. Chronic pain may or may not have an identifiable cause, and it can last indefinitely. This type of pain usually results in long term increased sensitivity in the area where the pain is, and it can be difficult to treat.

Opioids are generally not preferred for treating chronic pain, and the goals of treatment are different from acute pain.  The expectation of fully relieving the pain or healing back to full health can be unrealistic.  Instead, we try to achieve a “functional” level of control for that individual. Exercise, lifestyle changes, and other medications should all be considered prior to long term opioids. Other medications used are anti-inflammatories (e.g. ibuprofen, naproxen, Celebrex), Tylenol, and many others.

Nerve Pain

Nerve pain and be closely related to chronic pain. Permanent damage to nerves can result in pain that feels like burning or tingling. This type of pain is common among diabetics and as a side effect of some medications. Nerve pain is often managed with medications like gabapentin (a medication that can decrease nerve pain signals), or other medications that can modulate nerve signals, like duloxetine.

Opioids are very rarely used to treat nerve pain. For patients with certain medical conditions, like diabetes, lifestyle changes can be effective for treating or preventing nerve pain. Attaining a healthy weight, getting regular exercise, eliminating smoking, and limiting alcohol are some of the recommendations from the CDC for nerve pain.

Key Takeaways

Various types of pain are caused by different processes within the body, and opioids are not effective treatment for all of them. Opioids are commonly used after severe acute pain and are only used for a few days. Opioids should mostly be avoided in chronic or nerve pain, and if they are used, should be at the lowest possible dose.

References:

1. CDC, “Prevent Complications.” Centers for Disease Control and Prevention, 1 Aug. 2019.
2. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49.
3. Hedegaard, Holly, et al. “Drug Overdose Deaths in the United States, 1999–2018.” NCHS Data Brief No. 356, CDC, Jan. 2020.
4. Herndon, Chris M., et al. “Pain Management.” Pharmacotherapy: A Pathophysiologic Approach, 10e Eds. Joseph T. DiPiro, et al. New York, NY: McGraw-Hill.
5. Schumacher, Mark A., et al. “Opioid Agonists & Antagonists.” Basic & Clinical Pharmacology, 14e Ed. Bertram G. Katzung. New York, NY: McGraw-Hill.
6. Yaksh, Tony, and Mark Wallace. “Opioids, Analgesia, and Pain Management.” Goodman & Gilman’s: The Pharmacological Basis of Therapeutics, 13e Eds. Laurence L. Brunton, et al. New York, NY: McGraw-Hill.