Chronic Pain and Opioids:

Traditional Treatment vs. Alternative Approaches

Chronic pain is an ongoing and persistent pain that can become quite debilitating for those who live with it. People who suffer from chronic pain are often eager to find relief. In most cases, doctors will prescribe opioids as a treatment for patients with chronic pain. While this type of treatment can work for many, in some cases, it can be the onset of an opioid use disorder, which can create more significant problems for the patient.

The use of opioids as a treatment plan for chronic pain can come at a very high risk for some. If you or someone you love struggles with chronic pain, it is essential to gain a comprehensive understanding of chronic pain and its different treatment methods. You should know what chronic pain is, how opioids work as a treatment for chronic pain, the threat and symptoms of addiction to opioids, alternative treatment plans for chronic pain, and treatment for opioid use disorders.

Understanding Chronic Pain

Acute pain is a normal sensation in the nervous system that alerts the body of a possible injury and the necessity of care. Chronic pain is different from acute pain in that it is ongoing and persistent. Someone with chronic pain will experience pain signals firing in their nervous system for weeks, months, and even many years. An initial mishap may cause chronic pain, or there may be an ongoing cause of pain. 1

Chronic pain usually lasts longer than six months and is often accompanied by anger, depression, anxiety, low sex drive, and disability.2 Chronic pain can be quite debilitating and may prevent someone from working and enjoying life. It can also lead to feelings of isolation, anger, frustration, and guilt.3

There is some speculation that psychological issues are the root of chronic pain. However, research suggests that chronic pain is linked to abnormalities between the hypothalamus, pituitary glands, adrenal glands, and the nervous system. Their interaction is known as a stress axis. This stress axis controls the body’s reaction to stress, injury, and trauma. Abnormalities may explain why pain is experienced differently from person to person. 2

Additional studies have found that there are abnormally low levels of endorphins in the spinal fluid of people who experience chronic pain. These endorphins are chemicals in the body that naturally help to control pain the body experiences. 2

Symptoms

Symptoms of chronic pain can vary from person to person.

Usually, chronic pain will include one or multiple of the following symptoms: 2
  • Lower back pain 2
  • Headaches 2
  • Joint pain 2
  • Muscle aches 2
  • Burning or tingling in different body parts 2
  • Jolts of sharp pain 2
  • Weakness 4
  • Fever 4
  • Cancer pain 5
  • Arthritis pain 5
  • Pain from nerve damage 5
Those who experience chronic pain may describe their pain as: 5
  • Soreness
  • Stiffness
  • Stinging
  • Squeezing
  • Throbbing
  • Burning
  • Shooting
  • Dull aches
People with chronic pain may experience different or additional symptoms. They may feel exhausted, have issues with sleeping, or experience changes in their mood. The pain itself can also lead to other unwanted symptoms, including low self-esteem, anger, depression, anxiety, or frustration. 5

Causes

There are a variety of medical conditions or injuries that can cause chronic pain. There may be a continuation of pain after recovering from an initial injury, for example, a back injury. Chronic diseases, such as arthritis or cancer, can also cause chronic pain. It is important to note that there is not always an identifiable cause for chronic pain, but this does not mean that the pain isn’t real. Chronic pain is real and should be treated, no matter what the cause is. 3
A variety of conditions that may be associated with chronic pain, including:
  • Cancer 3
  • Fibromyalgia 3
  • Spinal injury 3
  • Headaches or migraines 5
  • Arthritis 3
  • Nerve inflammation or damage 3
  • Infections 5
  • Back problems 5
  • Previous surgery 5
Depression and stress may cause chronic pain to become worse. 5

Risk Factors

There are many risk factors associated with the development of chronic pain and include the following: 6
  • Severe acute pain
  • Mental health issues
  • Chronic disease
  • Smoking
  • Obesity
  • Old age
  • Female sex
  • Trauma
  • Genetics

Treatment for Chronic Pain

The debilitating nature of chronic pain creates the necessity of treatment for people living with chronic pain. In most cases, doctors prescribe opioids to treat chronic pain. However, some patients may develop an opioid use disorder as a result of opioid treatment. In cases where the risk for developing addiction is high, there are alternative and effective treatment methods that can be used.

Using Opioids for Chronic Pain

An opioid is any compound that binds to opioid receptors in the brain. Opioids have been regarded as one of the most effective drugs for pain treatment for many years and throughout history. Professionals have long considered opioids the standard of care when dealing with acute severe pain and chronic pain. 7

Opioids work by binding to opioid receptors, which are widely distributed throughout the brain. Opioid receptors related to pain are located in the central nervous system and the peripheral nervous system. When opioids are administered and bind to opioid receptors, they help reduce pain and create other side effects. Side effects can include constipation, itching, mental clouding, and respiratory depression. 7

Opioids can also produce mood effects, such as dysphoria or euphoria, and bind to receptors involved in reinforcement and reward. Many individuals who use opioids for pain treatment are not affected by the change in these systems. However, in some cases, powerful reinforcement occurs and can result in cravings and positive mood effects, including euphorigenic or pleasurable effects. These effects could be associated with addiction. 7

The Threat of Addiction

The effects on the reinforcement and reward system in the brain associated with opioids as a treatment for chronic pain can create addiction issues in patients. It is crucial to understand the threat of addiction associated with opioids as a treatment for chronic pain, considering the severity of opioid use disorder.

The American Medical Association estimates that 3% to 19% of people who take prescription pain medications develop an addiction. Patients who develop an addiction to prescription painkillers may seek other forms of opioids, such as heroin, when it is more readily available. Almost 45% of people who use heroin were first addicted to prescription opioids. 8

In 2017, over 72,000 Americans died from drug overdoses. Nearly 30,000 of these overdose deaths involved fentanyl and fentanyl analogs, almost 16,000 involved heroin, and practically 15,000 involved prescription painkillers. Also in the year 2017, the opioid crisis was declared a nationwide Public Health Emergency. 8

Symptoms of Opioid Use Disorder
A chronic pain patient may have developed an opioid use disorder if they are displaying any of the following symptoms: 8
Guidelines For Prescribing Opioids
The guidelines include three main focus areas, including: 9
  1. Determining when to start or continue utilizing opioids to treat chronic pain
    • Deciding whether opioids should be used
    • Establishing the goals of treatment
    • Discussing the risks and benefits of opioid treatment with patients
  2. Selecting the type of opioid, dosage, duration of therapy, follow-up, and discontinuation
    • Selecting immediate-release or extended-release opioids
    • Considering what the dosage should be
    • Deciding how long treatment will last
    • Following-up with patients and discontinuing when necessary
  3. Assessing the risk and addressing the harms associated with the use of opioids
    • Evaluating risk factors and ways to reduce risk
    • Drug testing through urine analysis
    • Arranging treatment for patients who develop an opioid use disorder

The CDC has developed guidelines for prescribing opioids to reduce the number of people who misuse or overdose due to opioid treatment. Part of what these recommendations focus on is the use of opioids to treat chronic pain.

While many doctors may choose to utilize these guidelines, some doctors may have their own methods for prescribing opioids and may not be as thorough in their approach. In some instances, a patient, their family members, or their doctor may find that it is in the patient’s best interest to choose an alternative treatment method, especially if the patient is at risk for developing an opioid use disorder.

Alternatives to Opioids for Chronic Pain

If a patient, their family, or their doctor decides it is best to avoid opioid treatment, they can utilize many alternative methods. Several different medications and therapies can be used as an alternative to opioids when treating chronic pain. 10
Medications
  • Acetaminophen
    • Relieves mild pain
    • Treats headaches, muscle aches, arthritis, and backaches
  • Non-steroidal Anti-inflammatory Drugs (NSAIDS) [Aspirin, Ibuprofen, Naproxen]
    • Relieves mild-moderate pain
    • Reduces swelling and inflammation
  • Nerve Pain Medications (Gabapentin, Pregabalin)
    • Relieves mild-moderate nerve pain
    • Relieves shooting and burning pains
  • Antidepressants (Effexor XR, Cymbalta, Savella)
    • Relieves mild-moderate chronic pain
    • Relieves nerve pain, shooting and burning pain
    • Relieves headaches
  • Medicated Creams, Foams, Gels, Lotions, Ointments, Sprays, and Patches (Anesthetics, NSAIDS, Muscle Relaxers, Capsaicin, Compound Topicals)
    • Relieves mild-moderate pain when applied to the pain source
    • Anesthetics: Relieves nerve pain, shooting and burning pain
    • NSAIDS: Relieves pain associated with osteoarthritis, sprains, strains, overuse injuries
    • Muscle Relaxers: Relieves pain by reducing muscle stiffness and tensing
    • Capsaicin: Relieves musculoskeletal and neuropathic pain
    • Compounded Topicals: Customized to meet a patient’s specific needs
  • Interventional Pain Management
    • Medicates specific areas of the body
    • Includes any of the following:
      • Anesthetic or steroid injections around nerves, tendons, joints, or muscles
      • Spinal cord stimulation
      • Drug delivery systems
      • Permanent or temporary nerve blocking
  • Non-Opioid Anesthesia
    • Safer medications that can be used to block pain during and after surgery
Therapies
  • Self-care
    • Applying cold and heat
      • Ice can relieve pain and reduce inflammation and swelling
      • Heat can reduce muscle pain and stiffness
    • Exercise and movement
      • Regularly exercising and engaging in physical activity can relieve pain
      • Yoga and tai chi utilize breath control, meditation, and movements which stretch and strengthen muscles
  • Complementary Therapies
    • Acupuncture
      • Thin needles are inserted into the body and stimulate specific points
      • Relieves pain in the low back, neck, and knees
    • Chiropractic
      • Includes manual, mechanical, electrical, and natural methods used by chiropractic physicians in a hands-on manner to reduce pain
    • Osteopathic Manipulative Treatment
      • Hands-on techniques are applied to muscles, joints, and other tissues to treat pain
      • Relieves lower back pain
    • Massage Therapy
      • Manual manipulation of muscles, connective tissue, tendons, and ligaments
      • Relieves pain by relaxing muscles, tendons, and joints
      • Reduces stress and anxiety, which could slow pain messages to and from the brain
    • Transcutaneous electrical nerve stimulation
      • Electrical currents are applied through electrodes placed on the skin in different frequencies
  • Rehabilitation Therapies
    • Occupational Therapy
      • Therapeutic use of everyday activities can help relieve pain associated with dressing, bathing, eating, and working
    • Physical Therapy
      • Restoring, enhancing, and maintaining physical and functional abilities to reduce pain
  • Behavioral and Mental Health Therapies
    • Psychiatrists, clinical social workers, marriage and family therapists, and health counselors
      • Through therapy, professionals identify and treat mental disorders or substance abuse problems that can

Treatment For Opioid Use Disorder

If you or someone you love is experiencing symptoms associated with opioid use disorder, it is important to seek treatment. There are various treatment methods that can be utilized when dealing with an addiction.

Counseling

Counseling can help change attitudes and behaviors related to someone’s drug use, build healthy life skills and approaches to everyday life, and encourage alternative treatment methods and medicine.11

Different types of counseling include:

  • Individual counseling: May include goal setting, discussing setbacks, and celebrating progress. Specific behavioral therapies used in individual counseling include: 11
    • Cognitive-behavioral therapy
      • Helps patients to recognize and reduce negative thinking and behavioral patterns
      • Teaches coping skills such as stress management and thought changes that may cause someone to want to use opioids
    • Motivational enhancement therapy
      • Helps patients to obtain motivation to continue a treatment plan
    • Contingency management
      • Gives the patient incentives for positive behaviors, including avoiding opioids
  • Group counseling 11
    • Helps patients to understand that they are not alone
    • Allows patients to experience the difficulties and successes of their peers
    • Helps patients to incorporate new strategies for coping with life situations
  • Family counseling 11
    • Helps to repair and improve family relationships that may have been harmed due to the patient’s opioid use

Residential and Hospital-Based Treatments

Residential programs offer a combination of treatment services and housing. During this kind of treatment, patients live with their peers and support each other, often attending groups that incorporate different counseling methods. Inpatient hospital-based programs offer a combination of health care and addiction treatment. Both treatment types are very structured and include different medications and a variety of counseling and behavioral therapies. 11

Resources:

  1. Chronic Pain Information Page. (n.d.). Retrieved from https://www.ninds.nih.gov/Disorders/All-Disorders/Chronic-Pain-information-Page
  2. Chronic Pain Syndrome. (2020, August 18). Retrieved from https://www.columbianeurology.org/neurology/staywell/chronic-pain-syndrome
  3. Chronic Pain – Causes, Symptoms, Treatment, Diagnosis. (n.d.). Retrieved from https://medbroadcast.com/condition/getcondition/chronic-pain
  4. William C. Shiel Jr., M. (2019, September 10). Chronic Pain: Symptoms, Signs, Causes & Treatment. Retrieved from https://www.medicinenet.com/chronic_pain/symptoms.htm
  5. Staff, F. E. (2020, July 23). Chronic Pain – Treatment. Retrieved from https://familydoctor.org/condition/chronic-pain/
  6. van Hecke O, Torrance N, Smith BH. Chronic pain epidemiology – where do lifestyle factors fit in?. Br J Pain. 2013;7(4):209-217. doi:10.1177/2049463713493264
  7. Rosenblum A, Marsch LA, Joseph H, Portenoy RK. Opioids and the treatment of chronic pain: controversies, current status, and future directions. Exp Clin Psychopharmacol. 2008;16(5):405-416. doi:10.1037/a0013628
  8. Opioid Use Disorder (n.d.). Retrieved from https://www.psychiatry.org/patients-families/addiction/opioid-use-disorder/opioid-use-disorder#:~:text=According to the American Medical,develop an addiction to them.&text=People misusing opioids may try,it is more easily available.
  9. CDC Guideline for Prescribing Opioids for Chronic Pain. (2019, August 28). Retrieved from https://www.cdc.gov/drugoverdose/prescribing/guideline.html
  10. Alternatives to Opioids: Medications Retrieved from http://www.floridahealth.gov/programs-and-services/non-opioid-pain-management/_documents/alternatives-facts-8.5×11-eng.pdf
  11. Opioid Misuse and Addiction Treatment. (2020, August 20). Retrieved from https://medlineplus.gov/opioidmisuseandaddictiontreatment.html