Long-term opioid therapy for chronic pain is an approach that not every healthcare professional can safely take.
While opioids are more potent than any other pain medicine out there, making them practical for patients with chronic pain, opioid therapy always carries the risk of opioid addiction. That’s why doctors always think twice during opioid prescribing,
Let’s discuss extended opioid therapy for chronic pain, weigh the benefits and risks, and understand whether the risk of substance abuse is worth taking.
What Is Long-Term Opioid Use?
Opioid analgesics are a class of drugs used to treat severe pain. They include morphine, oxycodone, hydrocodone, and fentanyl.
These drugs are often more effective than other pain medications, but they also have a fair share of risks, primarily the risk of dependence.
Long-term opioid therapy is defined as using opioids to treat conditions of severe pain or other medical conditions for more than three months. Long-term opioid use could also be applied to obtaining and using opioids illegally for more than three months.
Why Do Doctors Prescribe Long-term Use Opioids?
Pain relief is the reason why doctors prescribe opioids for long-term conditions, like a back injury or chronic migraines.
Opioids directly bind to the opioid receptors in the brain, providing a strong sense of pain relief and a “high feeling” that leaves some patients craving more. Unfortunately, the high feeling is why those patients may sometimes get too dependent on the substance. Some people also illegally seek and inject opioids, leading to opioid abuse.
Is Long-Term Opioid Therapy Effective?
Science is yet to provide a definitive answer to this question. The evidence of long-term opioid treatment of chronic pain is mixed. Some studies showed that using opioids can be effective in managing chronic, non-cancer pain over long durations.
However, other studies couldn’t find strong evidence that opioids can provide relief over extended periods. If anything, the pain might get worse over time because of how the body becomes tolerant to the effects of opioids.
Because of the potential addiction risks associated with long-term opioid therapy, many doctors are cautious when they prescribe opioids for pain relief. Instead of prescribing opioids, they may start by trying other analgesics that could be effective, like NSAIDs and acetaminophen.
However, if the patient is to be prescribed opioids, the doctors would conduct regular assessments and closely monitor their patients, especially if they are to be on opioids for a long time.
What Are the Risks of Using Opioids for a Long Time?
Opioids come with a long list of risks. Here are a few of them:
The primary fear that both doctors and chronic pain patients have when opioids are in the picture is addiction.
Typically, the body secretes natural, endogenous opioids. These include dynorphins, endorphins, and enkephalins. These natural opioids are secreted during periods of pain, stress, exercise, social interactions, and various other scenarios.
Their job is to regulate our body’s responses to the situation, whether by pain relief or the feeling of happiness or reward.
Exogenous opioids have a similar but more substantial effect on the body. If the patient takes these opioids for a long time, the body will reduce its endogenous opioid secretion because it’s getting what it needs from outside.
Once the patient stops taking exogenous opioids, the body can’t utilize the endogenous opioids effectively.
It takes time for it to readjust and secrete adequate amounts of endogenous opioids again, which manifests physically and mentally in the patient as withdrawal symptoms.
The human body has a fantastic degree of adaptability. This adaptability may take generations to manifest, but it can also be seen within the lifespan of a person.
Regarding opioid usage, this adaptability comes in the form of tolerance. When the patient uses opioids for a long time, their brain starts to adjust to the drug.
With time, the patient will need larger drug doses to achieve the same effect.
In drug addicts, this shows when the person fails to acquire the high feeling they seek from their regular dose. That forces them to uncontrollably take extra doses, which can lead to a fatal opioid overdose.
In medicine, this manifests as a reduced analgesic effect. The same dose that the patient has been using to control pain is no longer effective.
4. Withdrawal Symptoms
At one point, the patient will need to stop using opioids. That’s when withdrawal symptoms start to appear, especially if the patient has been using opioids for a long time.
Assuming that the patient has abruptly stopped using opioids and that they’re not using partial agonists like buprenorphine to transition out of opioid usage gradually, the patient might experience the following:
- Nausea and vomiting
- Abdominal cramps
- Sweating, chills, and fever
- Sleepiness and yawning
- Muscle aches
- Dilated pupils
- Cold symptoms like pain in the joints and runny nose
- Anxiety and depression
- Extreme irritability and opioid craving
- Restlessness and lack of sleep
- Difficulty to concentrate on a certain task
4. Limited Effectiveness
Opioids are strong painkillers, and they’re arguably the strongest in medicine. However, they’re not that effective in all cases of severe pain.
For example, chronic non-cancer pain arising from fibromyalgia or lower back pain is better treated with antidepressants or anticonvulsants.
Opioids might have an analgesic effect for these conditions, but it’s not ideal here. In these cases, the risks of opioids will outweigh their benefits, especially if the patient is to use them for a long time. This renders opioids a poor choice for treating such cases.
5. Individual Variation in Efficacy
The effect of using opioids (both in the short and long term) can vary from person to person. Some people may require higher doses of opioids to feel the pain relief. Such people are at a higher risk of opioid dependence and/or opioid tolerance.
On the other hand, some people can quickly get the pain relief they seek from minimal doses. Such people are often better candidates for opioids since the risk of addiction is somewhat lower.
Science has yet to find a permanent solution to the different responses people may have to opioids. This is why individual variety can dramatically change the prognosis of long-term opioid therapy.
6. The Side Effects
Opioids have many short and long-term side effects. Some of these effects are bearable, like drowsiness and constipation. However, long-term side effects are considerably more dangerous.
These include but aren’t limited to:
- Small eye pupils
- Extreme sleepiness, which can sometimes cause sudden loss of consciousness
- Faint heartbeat
- Breathlessness that can lead to choking
- Pale skin, lips, and fingernails
Additionally, there’s the risk of developing Opioid Use Disorder or OUD, a condition where the absence of opioids can seriously affect the quality of your daily life.
Is Long-Term Opioid Use Worth It?
Science and doctors can’t fully answer this question yet, as the answer is highly dependent on the patient’s condition and the opioid used.
For example, long-term usage of opioids with a patient who has a terminal disease can cause a lot of controversy. While some people believe it’s unethical, others believe the patient deserves the maximum pain relief in their last days.
The argument point here is that the patient has bigger problems to worry about than being addicted to opioids. Besides, would it really be considered long-term if the patient’s life expectancy is already limited?
On the other hand, many other chronic non-cancer pain conditions can be handled without opioids if the patient and the doctor are willing to put the effort into using therapy and lifestyle modification.
Yet, some of these patients may not have the luxury of being able to alter their lifestyles because of reasons beyond their control, like socioeconomic or disability-related factors.
There are many points of contention while weighing the risks and benefits of long-term opioid usage. Ultimately, it all falls to the doctor’s judgment and the patient’s ability to follow the instructions.
What Are the Alternatives for Long-term Opioid Use?
If the condition allows it, multiple classes of medications can be prescribed instead of opioids.
They may not be as strong as opioids, but they don’t have the risk of addiction, abuse, or misuse. Some of these medications include:
Non-steroidal anti-inflammatory drugs are valid replacements for opioids. They are widely used to treat moderate to severe pain. They can also reduce inflammation, making them popular analgesics.
Mode of Action
Since the mechanism of action doesn’t involve opioid receptors, there’s no addiction risk with NSAIDs. Their action method involves inhibiting the cyclooxygenase (COX) enzyme, which produces prostaglandins.
These prostaglandins are responsible for the body’s inflammatory response. Having them inhibited reduces inflammation, making NSAIDs highly effective against inflammation-based pain.
NSAIDs are often safe to use by most people, but they may cause some of the following side effects:
- Stomach upset associated with nausea
- Skin rashes
Note: The severity and duration of these side effects depend on the type and dose of NSAID used.
Antidepressants are primarily designed to help with mental conditions like anxiety and depression. However, they’ve proved effective in handling moderate pain in certain situations.
Mode of Action
Antidepressants work by increasing the levels of serotonin and norepinephrine in the brain. These neurotransmitters are involved in regulating the mood of the patient. Their increase can improve sleep, energy levels, and the overall positive attitude of the patient.
Antidepressants are often safe to use as long as they’re used according to the doctor’s instructions. Still, even by following these instructions, the patient might experience:
- Dry mouth
- In rare cases, they can cause sexual dysfunction
Steroids are also among the common medications used to treat pain. Topical steroids are popular in handling pain because of their efficacy and safety. However, systemic steroids should be used with caution.
Mode of Action
Corticosteroids reduce pain by combining two mechanisms.
First, they reduce the natural response of the body to injury and/or infection. A significant part of that natural response is inflammation. Steroids would suppress the immune system, which is a major contributor to the inflammatory response.
With reduced inflammation, the pain will be a lot more bearable.
Second, corticosteroids block pain signals from reaching the brain by inhibiting the release of neurotransmitters responsible for the pain signal transmission.
Steroids cause body fluid retention and weight gain.They can also cause the following:
The patient should be aware of and expect those side effects. Should any of them arise, the patient should inform their doctor.
Despite being made for epilepsy, anticonvulsants are sometimes given to non-epileptic patients who suffer from pain to help them cope with the pain.
Mode of Action
The primary effect of anticonvulsants is inhibiting abnormal electrical signals in the central nervous system, which reduces the chances of epileptic seizures. This “calming” effect doesn’t just affect the brain; it also affects the body in general.
This reduces the body’s overall response to pain and makes the condition more bearable for the patient.
Anticonvulsants aren’t OTC medications that can be easily purchased from a pharmacy. They need careful dosing, timing, and administration to reduce the risk of side effects.
Some of the well-known side effects of anticonvulsants are:
- Blurred vision
- Sudden mood flips
To Wrap Up
Chronic opioid therapy is a controversial topic among patients and doctors alike. Some argue that it’s an effective way to handle severe pain over long periods, while others tend to minimize opioid prescriptions.
Opioids are effective; there’s no question about it, but the more they’re used, the more susceptible the patient will be to addiction and other side effects.
Careful assessment and monitoring are vital to ensure the safety of a patient undergoing long-term opioid use.