Chronic Pain - Opiod Medications

When presented with a patient who has chronic pain not responsive to the medications previously discussed or modalities such as surgery, nerve blocks, physical therapy, a trial of opiate or narcotic medication may be considered. This treatment is still somewhat controversial and is subject to close scrutiny by state and federal authorities. It is gaining wider acceptance in the treatment of chronic, non-cancerous pain. This is logical because there are certain individuals who are unable to adapt to pain. Their choices become one of either severe immobility, depression and some times suicide or aggressive management of their pain.

It has been my experience that an opiate increases an individual’s capacity for physical activity, improve mood and sleep, and decrease reliance on other treatment modalities. Physical dependence on this medication does develop, however, with increasing dose, a plateau is reached where the pain comes under control with very little need for escalation. It is hoped that by gaining control of the pain for a period of time, one will be able to restore normal physiology and withdraw the pain medication without recrudescence of the severe pain that was present previously. This has had mixed results.

Opiate medications that are generally used include Morphine (MS Contin and Oramorph), Oxycodone (Oxycontin). Fentanyl  (Duragesic patches) and Methadone (Dolophine). These  medications have the advantage of being used once, twice or occasionally three times daily. In the case of the Duragesic patch, it is placed once every 72 hours. These medications are long acting, absorbed slowly so that the individual does not experience a sense of euphoria a “buzz,” therefore having less of an addiction potential.

The fact that there is a constant blood level allows the physician to get ahead of the pain rather than trying to catch up to it, and a higher degree of pain relief is achieved. There is no arbitrary upper limit on dose. The patient’s response is used in determining how much medication is required. Methadone has been used for over 40 years in the treatment of heroin addiction. Individuals who have utilized this particular substance have shown no deleterious effects on organs such as liver, kidney, etc.

Furthermore, women on Methadone have actually gone through pregnancies with no increase in birth defects. Percocet. Vicodin, Lorcet, Tylenol #3 in higher doses, greater than six tablets a day, are not suitable because of their acetaminophen component, which can cause liver and kidney damage. Demerol, likewise should be avoided because of a toxic stimulatory metabolite, which can cause seizures with chronic use. The opiate medications work by binding to opiate receptors in the brain and decreasing central transmission and perception of pain.

Common initial side effects include constipation, difficulty urinating, fatigue, sedation, nausea, itching and headache. With time, tolerance to most of the side effects will develop, however some problems are refractory, especially constipation which requires laxatives chronically. Visteril for the puritis, Phenergan for nausea, Ritalin or Dexadrine for sedation. Some patients become "psychologically depen­dent" on opiates, begin to crave it, independently increase their dosage, seek additional drug supplies from other doctors and misuse the drug to control stress, disappointments, anxiety or depression. This is a reason to taper and discontinue treatment.