Which Came First, the Chronic Pain or the Opioid Use?

By Pat Matuszak

A recent publication by the National Institutes of Health discusses the high co-occurrence of chronic pain and substance abuse disorders and sees a trend where “the prevalence of chronic pain among persons with opioid and other substance use disorders is substantially higher than the pain prevalence found in the general population.”1 The question that arises is: Do opioids cause an increase in chronic pain or does chronic pain lead to substance addiction? This possible connection calls for more investigation in the healthcare community surrounding substance use disorders.

What Is Chronic Pain?

Pain that falls under the category of chronic pain is different from pain that arises from a one-time event or temporary illness. In an interview with Recovery Unscripted, Dr. Melissa Lee Warner of residential treatment center Black Bear Lodge defines chronic pain as anything that causes ongoing pain not relieved by surgery or other medical treatment.2

“The idea is that this is going to be an ongoing situation for someone in which case the treatment of chronic pain tends to be more about increasing function and participation,” Dr. Warner explains. “It would be unrealistic to think that for someone with chronic pain that what was going to happen is their pain would go away.”

Recovery Unscripted Melissa Lee Warner

Want to hear more from Dr. Warner about the intersection of chronic pain and addiction? Listen to her full interview  on the Recovery Unscripted podcast.

The National Institutes of Health explains chronic pain this way: “pain that has persisted for at least one month following the usual healing time of an acute injury, pain that occurs in association with a non-healing lesion or pain that recurs frequently over a period of months.”1 People who suffer from cancer, arthritis, migraines, fibromyalgia and injuries or surgeries that permanently cause inflammation may be in chronic pain.

US Patients Want Quick Pain Solutions

Although it is a worldwide problem, Americans seem to report it more frequently than people in other countries, according to an article by Olga Khazan for The Atlantic. One researcher visited doctors in six countries to get opinions on what to do about chronic pain from an old shoulder injury.

His American doctor recommended surgery that would replace his joint with a titanium implant. A French doctor told him surgery was unnecessary unless he was in constant pain. In the UK, his doctor agreed with the French opinion, saying if he could live normally with the pain, he should do without surgery. The Canadian doctor told him that he would have to wait 18 months to be treated under their national healthcare system. The US system was the most aggressive in treating the injury — and the most expensive.3 Some doctors are now saying it also puts the patient at the most risk.

The Pain Scale and the Emergence of Opioids

Male patient with back pain visiting doctorIn the early 1990s, there were calls for US doctors to respond more assertively to pain management in patients, partly in response to legal cases asserting pain management was a right of every patient. Assessments were developed by litigation-shy hospitals and nursing facilities to track how well pain was kept at bay.4 The most popular test, still widely used today, asks patients to rate their pain on a scale of one to 10. These responses are logged while a patient is in the hospital, being treated as an outpatient and during follow-up visits.

Administrators assumed that patients with serious surgeries needed prescriptions, but physical therapy or other care that would mitigate pain was often overlooked because the metrics called for a quick improvement in pain reporting. Medication, especially opioid compounds, delivered immediate positive results. Physical therapy was, and still is, considered effective but more expensive and time-consuming. Surgical procedures to correct a problem caused by surgery are more common in the US, and when these procedures did not relieve a patient’s pain, the solution was most likely to be found in more painkiller prescriptions.5

The question this system posed to doctors was, “Did they track and take notice of their patients’ pain level?” And, “Did they relieve it?” When physicians responded to metrics applied to their treatment and prescribed opioids, they were following best practice according to a 1986 report from the National Institutes of Health that counseled them not to fear using the compounds for chronic pain: “We conclude that opioid maintenance therapy can be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients with intractable non-malignant pain and no history of drug abuse.”6

They were also following insurance companies’ policies as they had dropped reimbursement rates — or eliminated them completely — for physical therapy and other alternatives to further surgery or drug treatments.7

Opioid Prescriptions May Have Actually Resulted in Increased Pain

Anna Lembke, MD, chief of addiction medicine and an assistant professor at Stanford University School of Medicine, wrote the book Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop. She told NPR that doctors were willing to believe the 1986 NIH recommendation because “doctors began to feel that pain was something they had to eliminate at all cost. …Doctors were told that opioids are not addictive as long as you’re prescribing them for a patient in pain, as if there was some sort of magic halo effect with the prescription. That also is obviously not true.”8

So patients who were already suffering chronic pain were burdened with dependency on opioids that often led to addiction. Because doctors were rightfully cautious about over-prescribing opioids many withdrew prescriptions from their dependent patients or would not increase dosage as their tolerance grew. Some of those who were still in pain turned to other opiate drugs, such as heroin. An estimate by the CDC says that three out of four people addicted to heroin started on a prescription opioid.8

Furthermore, the opioid itself may have created an added pain cycle that is just being discovered. The NIH has issued new research and warnings in 2018 about the heightened sensitivity to pain opioids can cause called hyperalgesia: “The neurophysiology of physical dependence and tolerance are closely related to each other and to the phenomenon of opioid-induced hyperalgesia. The possibility that opioid administration, particularly at relatively high doses, may lead to increased pain has contributed to the controversy about opioid therapy for non-cancer pain.”1

The Goal of Pain Management Is to Increase Function and Social Interaction

There are traditional and new alternatives to opioid treatment for pain. Physical therapy was the tried and true method used before the 1986 NIH directive for opioid prescriptions and is still effective today.

Christine Herman of NPR interviewed pain experts for her article “For Chronic Pain, a Change in Habits Can Beat Opioids for Relief.” She learned that a “multidisciplinary approach” was the standard treatment for chronic pain before 1986. Her interview with therapists at a pain center described non-opioid methods being used for pain:

“The approach includes a combination of physical and occupational therapy, massage and nutrition counseling. Patients also participate in Cognitive Behavioral Therapy to address the psychological issues that often accompany pain — such as overcoming fears of letting go of medications they’ve become dependent on. A nurse coordinator oversees all the moving parts and does follow-up assessments after the program is completed.”7

Dr. Warner gave Recovery Unscripted a list of other non-addictive recommendations:
  • Optimize sleep
  • Apply ice to painful areas
  • Use e-stim electronics to relax muscles
  • Practice mindfulness meditation2

The Canyon agrees that mindful meditation can treat pain and may be one way to avoid opioid painkillers. According to our article on using mindfulness in treatment, “A daily mindfulness practice will not alter the physiological causes of pain. However, mindfulness practice can alter the way the brain perceives pain and possibly help alleviate the need for dangerous opioid painkillers.”

The human brain produces natural painkillers within itself, and opioid drugs were designed to act like these natural painkillers. Over time, the use of opioid drugs causes the brain to stop producing its own natural painkillers. Dependence and addiction begin once the brain requires only the constant use of opioid drugs to feel any relief from pain. Mindfulness meditation treats pain without interfering with the body’s natural opioid-producing system.9 A promising recent study by Wake Forest University found that patients were able to reduce their pain levels by 21 percent using meditation alone.10


Sources

1 Rosenblum, Andrew; Marsch, Lisa; Joseph, Herman; Portenoy, Russell. “Opioids and the Treatment of Chronic Pain: Controversies, Current Status, and Future Directions.” National Institutes of Health, April 24, 2018.

2 Condos, David; Warner, Melissa Lee, PhD. “Navigating Detox, Chronic Pain and Addiction with Melissa Lee Warner.” Recovery Unscripted, April 4, 2018.

3 Khazan, Olga. “America Experiences More Pain Than Other Countries.” The Atlantic, December 20, 2017.

4 Rich, Ben. “Physicians’ Legal Duty to Relieve Suffering.” National Institutes of Health, 2001.

5 Shapiro, Ari; Menaka, Wilhelm. “Questions and Answers About Opioids and Chronic Pain.” NPR, March 9, 2018

6 Portenoy, R.K.,Foley, KM. “Chronic Use of Opioid Analgesics in Non-malignant Pain: Report of 38 cases.” PubMed.gov, May 25,1986.

7 Herman, Christine. “For Chronic Pain, A Change In Habits Can Beat Opioids For Relief.” NPR, April 6, 2018.

8‘Drug Dealer, M.D.’: Misunderstandings And Good Intentions Fueled Opioid Epidemic. NPR, Dec 15, 2016.

9 Millán, Kathryn Taylor, MA, LPC/MHSP, “Is Mindfulness an Effective Alternative for Treating Opioid Addiction, Chronic Pain and Mental Health Issues?” The Canyon Malibu, 2018.

10 Zeidan, Fadel, et al. “Mindfulness Meditation-Based Pain Relief Employs Different Neural Mechanisms Than Placebo and Sham Mindfulness Meditation-Induced Analgesia.” Journal of Neuroscience, November 18, 2015.


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