Over the last few decades, the prevalence of narcotic painkiller (also
referred to as opioids) use in the United States has skyrocketed. This
class of medications suppresses the body’s perception of pain by
blocking signals between the brain and the nervous system. In the past,
usage of opioids for pain relief was mostly limited to short-term instances of severe pain,
such as during the recovery period after surgery, a traumatic injury or
an acute flare-up of an existing condition. Opioids are powerful and extremely
effective at treating pain. But there are also risks associated with their
use. In the short term, the tradeoff (risk vs. benefit) usually makes
sense. The risks range from mild and nuisance-like to severe and include
things like drowsiness, constipation, nausea and vomiting, itchy skin
and even death (usually from respiratory suppression). But initiating
prescriptions at low doses and providing warnings to avoid use of alcohol
or other drugs that can interact with the opioids significantly reduces
these risks.
There are significant benefits to managing acute pain. Gone unchecked,
the pain can cause physiologic complications with cardiac, respiratory,
autonomic, endocrine and inflammatory consequences. Surgical recovery
is certainly aided by aggressive pain control. Patients regain the ability
to move around and walk more quickly, get out of the hospital earlier,
avoid disordered sleep and have a drastically improved quality of life
with good pain control. In addition, for acute and short-term problems,
patients are under a much more watchful eye (and are typically out of
their usual daily routine). Opioids typically make sense for acute, short-term
pain relief. The risks of long-term use of opioids for chronic pain include
all the short-term risks plus the additional risks of overuse and addiction
that can be devastating. Most physicians learned of the duality of opioid
prescription during training (reasonable for acute pain; to be avoided
for chronic pain). Most of us are also aware the studies showing the
dangers of chronic opioid use are infrequently accompanied by benefits of improved function, performance
or quality of life. But somewhere along the way, longer-term use of opioids,
especially for those who suffer from chronic pain, became a much more
prevalent reality, and with it came a host of serious problems.
For patients seeking relief from chronic pain, an initial prescription
for an opioid medication can be the start of a dangerous cycle of addiction
if not carefully monitored by a trusted and knowledgeable physician expert.
Some patients’ pain is so intense and debilitating that relief can
become the only goal, even if that means trading the life-disruptive pain
for other disruptive side effects and complications. Treating the physical
pain, for these patients, may mean knowingly increasing the dose and frequency
of pills without regard for their doctor’s prescribed recommendation.
In other cases, individuals may be “treating” depression,
anxiety or insomnia with opioids (called misuse) rather than seeking appropriate
treatment for these issues – because the opioid “numbs”
them, gives them a high or makes them fall asleep. Still other scenarios
involve individuals who, unknowingly, have genetic differences in how
they metabolize medications, resulting in the need for dramatically higher
doses of a medication to feel any pain relief effect. They may doctor
shop or turn to street drugs because the prescribing physician is unaware
of their peculiar physiologic state and refuses to give them appropriate
treatment for acute pain, thereby exposing them to an increased risk of
chronic pain or inappropriate combinations of medications and street drugs
in search of pain relief. These additional side effects and unintended
consequences can also include withdrawal from friends and family, poor
work performance, malaise, apathy and, ultimately, addiction, as the body
develops tolerance and begins to require increased doses of the drug for
the same level of pain relief. All of this is just to mask the symptoms
(pain) of a condition without focusing on the underlying cause.
As health care providers have begun to realize the consequences of
opioid over-usage, more thorough protocols, deeper evaluation of a patient’s pain
and long-term effects have become a greater focus. In some instances (for
both acute and chronic conditions), prescribing opioids may still be beneficial,
and prescribing doctors hold an immense responsibility to exercise judgment
that will keep their patient free from harm, or in the worst cases of
opioid addiction, death.
So what if you do end up on the receiving end of a narcotic prescription?
The good news is that you as a patient can share in the role of keeping
yourself safe and take control over your own health by staying educated
and asking important questions. Before you begin taking a prescription
for an opioid painkiller, receiving thorough answers to these questions
will help you make the choice that’s safe and most appropriate for you.
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Why am I being prescribed an opioid? (What is the goal and what is the
endpoint?)The reason a physician would prescribe this type of medication
should directly relate to the underlying cause of your pain and how the
resulting pain is being classified. It is imperative that both you and
your doctor understand what is
causing the pain you're feeling. The last thing you want is to become dependent
on pain medications for months or even years without resolution of the
main issue that’s causing the pain in the first place. You may think
this sounds like common sense, and you may even feel uncomfortable questioning
your physician about his/her recommendations, but don’t be afraid
to speak up. It's in your best interest to be firm in expressing that
you don't wish to only cover up the pain, but that you desire an accurate
diagnosis of the cause, too. Furthermore, you and your physician should
understand that pain relief is only part of the goal. You should also
be seeking significant improvement in function. If both aspects of the
goal are not met, the use of an opioid isn’t justified. When both
aspects of the goal are met, an effort should be made to reduce the dose
and eliminate the opioid medication.
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What are the risks of taking this medication? Before taking any medication,
it’s vital to
understand all the risks and benefits, but this is especially true with a more powerful drug such as an opioid.
The general risks are important, but what can be most valuable is to ask
the physician about the risks for you personally. Doing this requires
your physician to have a detailed account of your medical history, including
family history of addiction, mental health status, possibility of pregnancy
or any other medications you're currently taking. Narcotic medication
for short-term pain generally carries little risk, as it can be stopped
before your body becomes tolerant of the medication. In some cases, genetic
testing can be extremely valuable in predicting your response to specific
opioid medications and dosing likely to be necessary for benefit without
undue risk. Keep in mind, some risks are dependent on the duration of
use. Long-term usage for chronic pain can put you at significant risk
for many complications (cognitive, endocrine, etc.) in addition to dependence
and addiction. Make sure you understand from your doctor how long you
should be taking these drugs, and whether there's a stop date already planned.
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Are there alternative treatment options? For most chronic pain patients,
there are a number of effective treatment options – both pharmacologic
and non-pharmacologic. In fact, multidisciplinary treatments have been
proven beneficial for chronic pain. Importantly, they help both pain and
function. Combinations of non-opioid medications,
physical therapy and functional restoration, cognitive therapies, biofeedback, mindfulness
meditation, interventional procedures and neuromodulation can dramatically
reduce and eliminate pain while improving function and quality of life.
Having a discussion with your doctor and expressing your willingness to
try the non-narcotic treatment options first opens the door to other possibilities
that may help you even more.
In the big picture, opioids can be beneficial if used under the appropriate
circumstances and for the right amount of time. To protect your own health
and well-being, investigate and ask all the questions you can before diving
into the “painkiller plan.” As far as pain management goes,
it’s always in your favor to start with the least risky and most
effective treatment option first. Like the old saying goes, “knowledge
is power,” and you hold the power to keep your body functioning
at its best by taking your health into your own hands.