Narcotic Drugs for the Treatment of Chronic Pain: A Double Edged Sword

Over the past 10 years, the use of narcotic pain killers to treat chronic pain - in particular chronic low back pain - has risen steeply.

Narcotics Drug Image

In the past, usage of narcotics was limited to acute situations of severe pain (i.e. trauma or post-surgical pain) because of the potential risk of addiction.

However, over the past decade, it has been felt that the risk of addiction was overstated, and that the pain relief for patients suffering from chronic pain was more important than the potential risks.

Morphine Prescriptions Image
Change in mg of Morphine per Person (see reference 1)

Narcotic medications have, however, continued to be a double edged sword, and although they work well as a painkiller, they are usually only effective for short durations of time (weeks).

Rising Prescription Pain Medication Deaths

The consequence of this sea change in medical practice has been nothing short of disastrous. Recent estimates are:

  • 6 million Americans a year abuse prescription pain medication
  • Deaths from overdose have risen to 15,000 people a year2

To put this in perspective, more people are dying every year from prescription pain medications than from heroin and cocaine combined.1

While the recent deaths of 28 patients (and counting) from fungal infected steroid injections is tragic, the overall societal impact of tainted steroids pales in comparison to the larger consequence of this ongoing epidemic of narcotic abuse.

We can make the steroid supply safe again, but pulling back from widespread narcotic abuse will be much tougher.

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Painkiller Tolerance and Addiction

To be certain, not everyone who takes narcotic pain medications is an addict.

Most patients will develop some tolerance to the medications if they use them for more than 2 to 4 weeks, and if taken on a daily basis for any longer than this time period, most patients will also develop some habituation (urge to continue taking the medication on a daily basis).

In patients who have developed a tolerance and habituation, they will have withdrawal symptoms when they discontinue taking the narcotics. This withdrawal process is a natural consequence of taking the medication and does not mean that the patient is addicted to narcotics.

Pain medication addiction is a more complicated process. It involves manipulative behavior to obtain narcotic medications and a refusal to discontinue a medication even though it is no longer being used for a medical purpose. Some, including those at significant risk of overdosing, will go to multiple doctors to get medications.1

Many addicted patients will go through a cycle of needing more and more medication in order to keeping getting the desired effects of the medication.

Abuse of narcotic medications defined as taking more than the prescribed amount and although all addicts are abusers, not all abuse is done by addicts (i.e. one time use of someone else's medication for recreational purposes).

Many patients fall into the trap of assuming that if a medication is prescribed by a physician it is therefore safe to take. Physicians themselves often are responding to a request by a patient to get a prescription to relieve their symptoms. The process often starts off innocent enough, but then spirals into a never ending circle.

How Painkillers Work

Narcotic medications work in a very similar manner to heroin, and even bind to the same receptor (the Mu receptor) in the brain. Our bodies make our own narcotic-like molecules (endogenous endorphins) that can bring about a feeling of well-being. An example of this is the "runners high" that people get after a hard workout.

Taking narcotic medications causes a "down regulation" of the Mu receptors, and with less receptors it takes more narcotic-like molecules, either endogenous or in pill form, for patients to get the same feeling.

Increased Tolerance

Taking narcotic medications may paradoxically cause patients to feel more pain as the loss of receptors does not allow the body to regulate the feeling of pain as well. This process is known as hyperalgesia.

It is this down regulation that leads to tolerance and a need for increased narcotics over time to get the same levels of pain relief.

Patients Should be Aware of the Risks

While prescription pain medication does play a key role in helping patients through periods of severe, acute pain, patients need to be acutely aware of the risks.

Narcotics for short term pain carry little risk as they can be stopped before the patient becomes tolerant or habituated. However, if taken for long term chronic pain, tolerance and habituation can be expected, and puts the patient at significant risk for developing addiction and abuse.

References:

  1. "CDC Grand Rounds: prescription Drug Overdoses – a U.S. Epidemic," Centers for Disease Control and Prevention, published Jan. 13, 2012, , accessed Nov. 5, 2012.
  2. Catan T, Barrett D, and Martin T, "Prescription for Addiction," Wall Street Journal Online, published Oct. 5, 2012, accessed Nov. 5, 2012.
Article written by: Peter F. Ullrich, Jr., MD