Opioids and Chronic Pain
This is the second in a series on opioids & chronic pain. If you know someone with a painful chronic illness, please share this article.
Opioids chronic pain debate: cause of epidemic or proper pain relief?
In 2003, Nursing Times argued the evidence for treating “chronic non-malignant pain” with opioids (Chronic pain and opioids: dispelling myths and exploring the facts). The pendulum has swung far in the other direction since then. Now, articles frequently link opioid chronic-pain prescriptions to the “national epidemic of opioid overdose deaths and addictions” in the US.1 According to the New England Journal of Medicine, “opioid analgesics are widely diverted and improperly used.”
Since drug-related abuse and deaths have increased, many say that restricting prescriptions for opioids in non-cancer pain such as rheumatoid disease (RD) is the solution. Meanwhile Centers for Disease Control & Prevention (CDC) has published new guides stressing that opioids are not effective in chronic pain anyway.
Let’s consider two critical questions raised on opioids / chronic pain:
(1) Are opioid prescriptions responsible for the epidemic?
(2) Is chronic disease pain the same thing as chronic pain?
1. Are prescription opioids for chronic pain responsible for the opioid epidemic?
Some claim a large percentage of opioid abuse in the US is due to drugs “diverted” from legal prescriptions. However, many reports show illegal drugs transported across the US southern border are responsible for most so-called “opioid deaths.” NIH graphs seem to show that about half of opioid overdose deaths are actually heroin related. According to CDC, fewer than half of opioid deaths involve prescription opioids.2
It is hard to sort out the facts because most media reports combine statistics for illegal heroin and fentanyl and legal opioid medications. Compare the images from a National Institutes of Health (NIH) page created with CDC statistics. And according to a CNN report, “Epidemiologists in several states blame the increasing number of drug-related deaths on greater use of heroin and synthetic opioids, such as fentanyl.”
In Florida, most illicit opioid use has been linked to illegal activities of “pill mill” doctors. While the state has worked hard to shut down the operations responsible, patients have also endured new and severe medication restrictions that even leave them unable to fill legitimate prescriptions.
Yet, most who abuse opiates obtain them illegally. And there is evidence that treating chronic pain patients with opioids is associated with a very low risk of addiction.3 In a study treating veterans for pain for at least 3 months, only 2% developed opioid abuse.3
“The clinical studies referred to above indicate that opiate addicts and pain patients are largely separate populations and that opiate addiction due to appropriate medical management of pain is rare.”3 Patients who properly used opioids for pain are likely to continue doing so, as CDC reports seem to suggest. It is doubtful whether restricting access to legal medicines will have much effect on illegal drug use.
Opiate addicts & pain patients are separate populations. Addiction w/pain management is rare @CDCgov Click To TweetOpioids: chronic pain versus acute pain
2. Is chronic disease pain actually the same thing as chronic pain?
As we have discussed, there are several reasons pain from chronic diseases like RD does not actually meet definitions for “chronic pain.” The CDC says chronic pain is “pain that typically lasts >3 months or past the time of normal tissue healing.” But with active RD, various immune cells attack a joint, causing repeated damage without chance for recovery as with injury.
Pain from chronic diseases like RD is mostly acute pain that appears with disease activity. Disease activity is variable in some diseases, so pain can reappear during relapses (flares) or be longer-term if disease activity is persistent. This is an important distinction because CDC has attempted to ease public angst over its campaign for opioid restrictions by establishing that opioid pain relievers are ineffective in chronic pain.
CDC took the lead on new opioid guidelines, but FDA pursues change
In the US, it is Food and Drug Administration’s (FDA) role – not CDC – to label medicines for various “indications” (diagnoses). FDA decisions result in what consumers call “package inserts” which list indications, possible side effects, etc. Indications in inserts for medicines containing opioid pain relievers say they treat “severe pain.” However, FDA is fully cooperating with CDC’s campaign to restrict opioid pain relievers. We might expect updates to inserts that change the indication to exclude using opioids for chronic or longer-term pain.
Neither CDC nor FDA can tell people with chronic disease pain that opioid pain medicines don’t work. Many patients know for themselves that they do work. When pain is too much to bear, people with RD and other chronic diseases find opioid pain relievers effective.
Personally, my RD pain is extremely severe. It is not less severe because it is frequent or because I have every joint involved. It is not chronic pain and does not correlate with definitions of chronic pain. It is sharp and acute, reactive to specific joint movements, and the result of specific ongoing destructive disease activity in my joints.
Neither @CDCgov nor @US_FDA can tell people w/chronic disease pain meds don’t work. We know they do Click To Tweet
You might also like to read:
- Opioid Restrictions Versus Patient Needs
- Chronic Pain vs. Recurrent Acute Pain in Rheumatoid Disease
Cancer pain, chronic disease, and opioids
The elaborate CDC opioid chronic pain guidelines published in 2016 specifically separate “pain outside of cancer treatment.” Medical literature commonly differentiates between “malignant” and “non-malignant” pain. Restrictive opioid guidelines do not apply when people have cancer.
But I wonder whether the current distinctions are correct. Just as recurring pain from a chronic disease may not necessarily be “chronic pain,” so cancer pain may not always be unrelenting severe pain requiring continual opioid use. There is no contest over who has more severe pain because, as I always say, there is no prize. However people with cancer do not necessarily hurt more than people with RD.
Pain from RD is very severe. Not less severe because it’s frequent or has more joints involved #rheum Click To TweetOriginally, there was a distinction between cancer and non-cancer pain because natural time limits were more likely to exist for people with cancer than other diseases, i.e. they would likely die sooner. However, according to the American Cancer Society, cancers are often considered chronic diseases, since patients now are able to live with them for years. “So is it becoming a chronic condition like rheumatoid arthritis or insulin-dependent diabetes?” says the Stanford University blog.
This is one more area where models should be updated to correspond to current knowledge about diseases and how they are managed. It is more challenging to consider context, but it would produce more appropriate guidelines. For example post surgical pain is usually treated around the clock for a few days, but people with diseases that cause severe pain on a regular basis do not necessarily take opioids every time they have pain. Usually, they develop several strategies to deal with symptoms, and opioid pain relievers are only one part of that.
We’ll look at some of those strategies next in this opioids – chronic pain series: Are there workable opioids alternatives for pain?
This post is Part 2 in a series on opioids chronic pain. Click here to read Part 1.
Click to watch Local WESH 2 news video interview with Deb Houry from CDC defends her position on opioids & chronic pain. Some officials disagree.
Recommended reading
- Can Bones Hurt? Bone Pain and Rheumatoid Disease
- The Role of Pain in Rheumatoid Arthritis
- What Causes Rheumatoid Arthritis Pain?
FOOTNOTES:
1 Volkow ND, McLellan AT. Opioid abuse in chronic pain — Misconceptions and mitigation strategies. N Engl J Med 2016 Mar 31 [cited 2017 May 28]; 374:1253-1263. doi: 10.1056/NEJMra1507771
2 CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016 [cited 2017 May 28]. Available at http://wonder.cdc.gov
3 Fields HL. The Doctor’s Dilemma: opiate analgesics and chronic pain. Neuron. 2011[cited 2017 May 28];69(4):591-594. doi:10.1016/j.neuron.2011.02.001
What we need are pain medication that are specific for different types of pain with less side effects. Same as prednisone, opiods were a great discovery, but due to side effects they should be used as a model to build better things.
I was dx with RA 5 yrs ago, however, my Rheumy has determined I’ve had this since a teenager…ie: Juvenile RA that went undiagnosed. She determined this through piles of blood work and the fact my disease was so far advanced at such a young age. What a lot of people on the outside of RA don’t realize, this disease is an auto immune disease and doesn’t just affect our joints…it affects tendons, ligaments and organs. Case in point, I have a condition called nutcracker esophagus and gastroparesis…RA is now affecting my gastrointestinal system, the pain when this flares is unbelievable…without going in to all the ins and outs of this…I really just wanted to remind people that RA is not merely a disease of the joints, it’s a disease of the whole body…and you never know what or where it will affect next…be kind to yourselves out there…because sometime you have to be your own warrior with no army to back you up <3
I wonder at times if I’m opiate intolerant. They don’t seem to help the pain. I just had surgery for a ruptured tendon in my foot due to RA/RD. I had to stop orencia and prednisone for the surgery. Now my hands, shoulders, wrists… are flaring. The oxycodon did nothing for the pain. I have had norco, vicodin, and tramadol and nothing seems to help. I wish I knew of another pain med to try.
I get really frustrated with rheumatologists that won’t give out pain meds (other than tramadol) because they are being monitored. I have to get my DO to help me. Don’t understand why someone managing a disease with chronic pain won’t help manage the pain. They say see a pain management doc but the last thing you want during a flare is another doc visit.
People need quality of life!
But don’t opioids impair people’s mental abilities?
I was treated like a criminal at the pharmacy when filling my opioid script , this was hurtful and demoralizing in a way I didn’t expect. I literally cried later that day. We have so much to fight for already–just in hopes of some sense of normalcy.
I am not a patient with RA but I have been following this topic and I have seen a marked change in treatment for pain. I have had increasingly frequent trips to the ER followed by week long stays in the hospital due to bowel obstructions caused from scar tissue after ovarian cancer surgeries. On my last two events (separated by three months) there was an insulting deliberation over whether or not I should be given pain meds (Dilaudid) after a few doses. I was astonished and enraged to have a doctor mansplain the epidemic of pain med abuse and suggest that bags of liquid Tylenol may be suitable for the excruciating pain which, at the same time, could save me from spiraling me into a life of drug addiction. Thankfully, my family was there to advocate for me. This is misguided and scary. Patients in pain today are tomorrow’s drug addicted social miscreants? Dangerous and wrong thinking.
does anybody how i could get steriod injection on my elbow for my elbow bursitis around Los Angeles, CA area and for free maybe? Ive tried going to urgent care but they won’t help me because its RA and for rheumatologist i have to wait for an appointment plus authorization
I was diagnosed with RA 4 years ago and recently CPPD. I have been using opioids just to maintain living half way normally. I have so much joint pain from RA and I also have degenerative discs in L1-5 and C2,3,5,7. I’m on my second rheumatologist and since the start of RA from the beginning I am on my 3rd biologic. Enbrel first then Cimzia, and now acterma infusions for the past 5 months and no relief at all. I take prednisone, methotrexate injections and minocycoline currently with the actemra and have been on plaquenil and Azathioprine in the past and have had no relief at all. I currently use tramadol, Norco as well as diazapam for leg spasms. The Dr’s, especially my primary keep wanting to cut my doses and I keep making a plea not to, I think they are more worried about their licenses instead of patient needs. I take only as directed and don’t abuse my drugs but like I tell them since the actors,singers people in the spotlight etc.. overdose is no reason to cut my pain medications. I’m tired of pain and fatigue and I get somewhat vocal when they try to cut my medication. I have been looking for some correspondence with other people that are in the same boat as I am to see what they do for relief other than drugs and see which drugs have worked for them. My Rheumy tells me if this next infusion of actemra doesn’t work that he’s going to try orencia on me. that will be my 4th biologic, I hope something starts working soon.
Hi I need help I’ve been diagnosed with stenosis
Disk disease also arthritis in my hip sciatica been to several pain management doctors they all stigmatize you as a dope head I just what quality of life which means not laying in bed all day in pain I’m currently taking norco 10 325 not working like it used to I guess with age condition got worse had surgery two years ago on spine eased some of the sciatica I was taking morphine which now I realize it helped but stopped when the pain doc attacked me told me taking to much medicine I’m tired of this I’m fighting depression pain doctors I need a doctor that understands my condition I’m not proud to take the meds my only option I live in Tulsa okla any suggestions what I need to to desperate for help thanks
I have just been recently diagnosed with RA, ( 2 months in ) and was started on Meloxicam. Having issues with the Meloxicam, and requested to use tramadol for the pain until I get started on another RA medication. They made me feel like I was just trying to get drugs. Very humiliating on top of a new diagnosis, feeling depressed and trying to find a way to cope.
Brad,
I can relate to your frustration. I’m newly diagnosed with RA, and I’m confused at how my doctor office handles my requests for tramadol when I’m in pain. They make me feel like I’m doing something wrong…..but yet RA is extremely painful so why is it such an issue when it’s a legitimate request?
Jen
Jen, I agree with you on them making you feel guilty when you ask for pain medications, I say that they make me feel like a criminal..My Friends Dr. made him take a urine test before he would subscribe any pain meds. I agree with Kelly, Disease pain is different than chronic pain. I think they could see that if a person doesn’t ask for a new script before time has lapsed that one isn’t abusing the pain meds. My Rheumatologist won’t prescribe any pain meds other than 800mg ibuprofen, He says “Your Primary Doctor is responsible for your opioids.”
I can feel for you being newly diagnosed with RA, very painful and the only relief for me is in tramadol and diazepam(they wont give me Norco anymore, the swelling and pain especially in the hands is hard to handle and the fatigue and flu like symptons are the worst. I hasn’t improved in 4 years and I just had an appt with my Rheumy on Monday and he said the Actemra IV infusions aren’t working(had 6 months worth) which I could of told him so. On the 30th of this month I will start taking Orencia IV infusions, this is my fourth different biologic. I hope you find some type of relief Jen and the Doctor’s respect your pain and try to help you. Brad
I have been dx with RA/RD for 6 years. By the time I was dx, I was severe and in huge pain. My dr immediately referred me to a pain specialist. Yes I have to pee in a cup every couple of months but my pain has been control very well. Being ignorant about opiods, at first I was prescribed too much and was a walking zombie. I was on Opana 120mg daily. That is a lethal dose and I was taking it for 4 years. Now the FDA recommended removal of Opana and now I am on Morphine. We are working on lowering it in hopes that we will determine my real pain level. It is important to find a good pain doc. I thought about finding a new one after the over precribing but realized the dr was just to my complaints about my pain. I have also realized I can tough it out a bit more and have less drugs in my system.
Brad, I forgot to tell you, I was on Orencia for 7 months and my cholesterol went up to 420. So watch it carefully.
Thanks for sharing
I have a fairly new prescription for Tramadol after trying Diclofenac, celebrex & meloxicam. It works the best for pain thus far but it makes me too drowsy – so I only take it when I know I can stay put!
I went undiagnosed for 3 years before I found a smart doc. I was on the verge of suicide from the pain. I went thru 3 internal med docs and 1 ortho doc. All thought I was pain med seeking, which was denigrating since I am a highly skilled RN. On my first they visit I was automatically given pain narcotic pain pills ( without asking) 45 hydrocodone 5/325 every 3 months which I only take when needed (pain of a 5 to 6 or more) at bedtime due to the fact I have a physically active job with long hours on my feet. That was 3 years ago and my pain med dosage amount has not increased, but at my docs visit i was treated like a damned drug addict and asked to sign a pain contract due to insane enforcement of these guidelines. Again I felt humiliated. At 62 doing strenuous work with a diagnosis of ra, I should not be treated like this. I struggle thru pain during the day daily without pain meds, Nobody knows my Pain but me, and I’m about as far from addiction as I can be, knowing the signs. I have 3 more years before retirement and want to work without going on disability but I worry that the physicians ate not going to support my pain relief. The main point is thru my 6 years of ra pain NO ONE HAS EVER GIVEN ME A PAIN ASSESSMENT according to American pain association standards. I am considering going to a pain doc so I can get the care I deserve.
No, but the constant, chronic pain from RA/RD impairs your mental ability and causes depression, among other things. The 24/7/365 pain from RA is very much like torture. Well really, it is torture when the government is restricting my ability to get a proper opioid dosage. I’m in Mississippi and today, for the first time, my Pain Management doctor has refused to up my pain medication to help me during a debilitating flare that is now 10 days old. This sucks and we need to form an organization to lobby the government to make exceptions, give exemptions, to doctors who treat chronic pain patients so the doctors can prescribe opioids as truly needed without fear of losing their license.
It is time for medical science to redefine the treatment guidelines for the various natures of pain. As many of you have experienced first-hand, pain presents as many beasts, sometimes more than one attacking you at a time. Doctors don’t learn this in medical school. You can’t even begin to understand it until you’ve experienced it. We need some solid qualitative studies on people like us, thoroughly describe the different types of pain, and develop treatment guidelines for each. There can be no one-size-fits-all standard for treating those who are chronically in pain.
I saw my rheumatologist on Tuesday. After I told him how bad my pain had gotten (happens with winter), he told me that my insurance (Medicare) has decided that people with RA only need opiate pain medication for one week out of the month and I will be getting a notice that they will only pay for one week’s medication each month.
As I cried, he said not to worry, they would fight it and I would have my medication. He told me he has one patient who will definitely suicide and that will be his first and it’s really difficult. (It won’t be only one) He also told me they are trying to require him to see patients once a month if they’re on opiates. (My husband has to take a day off work to take me to the doctor)
This is how they’re dealing with the epidemic of narcotic addiction, by punishing the people who use legally-obtained medication because they really need it.
Unless someone has RA, there is not a person on the planet who would understand the intensity of RA pain. Period. Pain for RA is underrated. It is extreme. It is endless. It morphs daily.
Unless someone has RA, there is not a person on the planet who would understand the intensity of RA pain. Period. Pain for RA is underrated.
I just read an article at Slate.com that addresses women and chronic pain “Prescribing Mindfulness Allows Doctors to Ignore Legitimate Female Pain”, written by Sarah Yahm. While nothing in the piece is new to RD patients, it was empowering to read confirmation of what has been an all too frequent experience of mine. I encourage all of you to check it out.
Six weeks ago I got really sick. I had acute pain in my chest cavity and throughout my body. Thought I was having a heart attack, since I have CAD history. I wasn’t. The heart checked out. I live in Mississippi and there are no doctors that I see that prescribe pain medication any longer. I was in so much pain one day I could not even roll over in my bed. I went to my RA doc and she checked all my labs and according to the labs my RA was stable, but my pain was off the charts. I went to the pain doctor to ask him about possibly being prescribed norco, but apparently that’s not even an option. I didn’t get a chance to ask and he gave me trigger point shots in my back for fibro. Fibro was really not the problem at the time, but I was having a hard time describing my pain. I went to my endocrinologist who tentatively diagnosed me adrenal insufficiency, which causes terrible pain. No pain meds for me though.
I can do PT… doesn’t really help. I can do massage… Massage is painful for me. It helps about a day and then I’m in pain again. So my question is this… When all those other options are exhausted.. accupuncture, massage, behavioral modification(pyschiatric help to manage stress), PT, and OT what are those of us with chronic pain left with? NSAID’s? I can’t even tell I’ve taken tylenol or advil when I’m in the kind of pain I’ve been in for 6 weeks.
So there’s nothing to get us over the hump while waiting to see if 6 weeks down the road the new RA meds we’ve been given will work. Nothing to help us sleep comfortably at night. I have never felt so frustrated and so desperate as I have these past weeks knowing that I wasn’t going to get any relief. It increased my stress (doesn’t help pain), and decreased my sleep (doesn’t help pain). Today is the first day in nearly 6 weeks I’ve felt like a functioning human being.
The doctors don’t know what’s causing all the issues. I think it’s RD more than anything. That and the steroid shots for the fibro depressed my adrenal function causing a lack of cortisol which is a hormone that helps deal with pain. But I do know that this pain meds debacle is almost like a punishment for those of us who have chronic pain. It makes me deeply angry and I despair for people who will be having surgeries and who will be having chronic pain.
Has anyone asked the question that if cancer patients have terrible pain and the opioids work, why would it not be considered for chronic pain patients? What makes it less of a choice for them? Addiction? That’s ridiculous. As my husband says… they’ve taken the tools out of the box.
I know this was long. So sorry. I’ve been so upset lately about my condition and the fact I can’t get any relief.
Jennifer
I was dx’d 4 yrs ago and don’t feel like I have ever been actually in remission until recently (saying that VERY tentatively!). Before the dx I had a knee injury which requires multiple surgeries, including an emergency op to treat an infection after one of the surgs. Several years later I hyperextended it again &finally found an ortho Dr that identified the real problem (torn posterior cruciate ligament & popliteal tendon) which required a final major & very painful reconstruction of my left knee just months before getting hit with the first crippling indication that something was very wrong (I.e. Totally out of the blue, no warning signs, woke up one morning & had to roll out of bed & crawl along the floor into the bathroom) I was on norco & something stronger after the surgery & with the exception of a couple months the opiate treatment continued post op right into the episodic (at the time) RD symptoms. Wow! Painful as all of the treatment was on my knee, it paled in comparison to the full blown rheumatoid stuff when it kicked into gear. I thought I had a high tolerance for most pain, but I don’t describe myself as such anymore. Eventually I was put on tramadol & norco both & when that wasn’t effective was sent to a pain clinic where I was prescribed Opana(sp?). Definitely controlled my pain, but only because I couldn’t stay awake long enough to feel anything. I think I might have taken 3 doses, the last one left me asleep in my company vehicle which was running & parked in my driveway in an uber wintery cold mid-December. Woke up wondering how I got from work to house & I gave the rest of the bottle back to the pain clinic. I am still on norco, which I can take 4 times per day if I need to. Rheumy took away the tramadol 2 weeks ago in the hopes i would be less likely to be a “red flag pole” for the opiate police & it has been okay. I know I would not be able to say that if I wasn’t able to fall back on the norco for pain control. I am still able to work because I am helped by taking an opiate medication & I can’t afford not to work right now (on many levels besides financial. Having to give that up would def cause some serious emotional/mental/depressive/UglyUglyUgly setbacks :(. However, having seen my PCP this week he painted a pretty grim picture which he ended with telling me if my rheumy doc decides he can’t write it anymore, he (PCP) won’t be able to help either. Then he gave me a lecture on CBD & MM treatment as viable options (obviously he A] Has never had a RD flare of any kind and B] Is quite probably a product of the 60’s “Summer of Love” or maybe a commune child growing up weaving hemp baskets and smoking the left over?). Lol! I’m kidding of course, but he does have some similar damning characteristics. 🙂 Anyway, Medical ganja (or otherwise) didn’t help me with inflammatory pain. The couple of times I tried it I actually felt like it was exacerbating the inflammation. If anyone has any successful experience with either product please share. Maybe I was puffing from the wrong end of the pipe or something?! ;). Sorry abt my long, windy diatribe, but this is my 1st post after several years of membership. I am hoping if considered in that light & supported by a sincere promise to refrain for another year (or so) it’ is slightly more tolerable!
Have an awesome day all-
Where is the compassion anymore? No, RA isn’t cancer or cancer pain, but, it does share similarities: Dysfunctional immune system which leads to cell destruction, fatigue and increased infection rates; drug treatment involving medications which can lower the effectiveness of the immune system and lead to death from septicemia; decreased ability to perform activities of daily living due to debilitation from joint and bone destruction and fatigue. Complete remission is rare. The government is worried about RA patients getting a narcotic for pain relief? How about worrying about the heroin and crystal meth coming into our country, rather than RA patients needing pain meds? The CDC would be better served by treating and focusing on people who feel the need to get drugs illegally to escape their mental and emotional pain, or, simply to get high with their peer groups. Oh, that was the WAR on DRUGS that we never won in the 80’s. Now, it’s pain meds? Our government is treating us like we don’t know what real pain is. Really? Hope it doesn’t take the CDC and entire government getting an immune system disorder before they figure out that RA is hell, and guess what? IT HURTS. Thank you.
In our Province, BC, the focus is on supplying the drugs to the druggies with permanent and movable injections sites. So a druggie can go there and shoot himself up. No charge. General Practitioners can no longer prescribe opioids ,like morphine, to their patients. So if I have RA pain/flareup, all there is are standard painkillers. Unfortunately they don’t kill RA pain.
Also the druggies are supplied with free needles. When I do require a package of needles to inject methotrexate, I have to pay.
Those people who run our health system have absolutely no clue as to the patients who do need and use opioids responsibly. We have fallen thru the cracks of a political correctness system. World gone mad.
Yes it does seem upside down.