According to the CDC, chronic pain, one of the most common reasons adults seek medical care. It has been linked to restrictions in mobility and daily activities, dependence on opioids, anxiety and depression and poor perceived health or reduced quality of life. Population-based estimates of chronic pain among U.S. adults range from 11% to 40% with considerable population subgroup variation.
Opioids are narcotics that act on opioid receptors to produce morphine-like effects. Medically they are primarily used for pain relief, including anesthesia. Other medical uses include suppression of diarrhea, replacement therapy for opioid use disorder, reversing opioid overdose, suppressing cough, and suppressing opioid induced constipation. Extremely potent opioids such as carfentanil are only approved for veterinary use. Opioids are also frequently used non-medically for their euphoric effects or to prevent withdrawal.
Opioids act by binding to opioid receptors, which are found principally in the central and peripheral nervous system and the gastrointestinal tract. These receptors mediate both the psychoactive and the somatic effects of opioids. Opioid drugs include partial agonists, like the anti-diarrhea drug loperamide and antagonists like naloxegol for opioid-induced constipation, which do not cross the blood-brain barrier, but can displace other opioids from binding to those receptors. Because opioids are addictive and may result in fatal overdose, most are controlled substances.
Physical dependence is the physiological adaptation of the body to the presence of a substance, in this case opioid medication. It is defined by the development of withdrawal symptoms when the substance is discontinued, when the dose is reduced abruptly or, specifically in the case of opioids, when an antagonist (e.g., naloxone) or an agonist-antagonist (e.g., pentazocine) is administered. Physical dependence is a normal and expected aspect of certain medications and does not necessarily imply that the patient is addicted.
The withdrawal symptoms for opiates may include severe dysphoria, craving for another opiate dose, irritability, sweating, nausea, rhinorrea, tremor, vomiting and myalgia. Slowly reducing the intake of opioids over days and weeks can reduce or eliminate the withdrawal symptoms. The speed and severity of withdrawal depends on the half-life of the opioid; heroin and morphine withdrawal occur more quickly than methadone withdrawal. The acute withdrawal phase is often followed by a protracted phase of depression and insomnia that can last for months. The symptoms of opioid withdrawal can be treated with other medications, such as clonidine. Physical dependence does not predict drug misuse or true addiction, and is closely related to the same mechanism as tolerance. While there is anecdotal claims of benefit with ibogaine, data to support its use in substance dependence is poor.
In talking about addiction, there is physical addiction that encompasses the physical dependence, but also the emotional struggle attached to the stigma of being an addict.
Isolation is prevalent among addiction. People affected by addiction typically find they are shamed for their condition and isolated from those who can help. One of the most underemphasized aspects of dealing with addiction is coming together and finding support. People suffering with addiction often feel pain, shame and isolation in combination with physical dependence. Coming together and supporting those facing addiction is an essential part of the treatment and recovery process.
Drug addiction is a complex set of behaviors typically associated with misuse of certain drugs, developing over time and with higher drug dosages. Addiction includes psychological compulsion, to the extent that the sufferer persists in actions leading to dangerous or unhealthy outcomes. Opioid addiction includes insufflation or injection, rather than taking opioids orally as prescribed for medical reasons.
In European nations such as Austria, Bulgaria, and Slovakia, slow release oral morphine formulations are used in opiate substitution therapy (OST) for patients who do not well tolerate the side effects of buprenorphine or methadone. In other European countries including the UK, this is also legally used for OST although on a varying scale of acceptance.
Tamper-release formulations of time-controlled preparations of medications are intended to curb abuse and addiction rates while trying to still provide legitimate pain relief and ease of use to pain patients. Questions remain, however, about the efficacy and safety of these types of preparations. Further tamper resistant medications are currently under consideration with trials for market approval by the FDA.
The amount of evidence available only permits making a weak conclusion, but it suggests that a physician properly managing opioid use in patients with no history of substance dependence or substance abuse can give long-term pain relief with little risk of developing addiction, abuse, or other serious side effects.
Problems with opioids include the following:
All of the opioids can cause side effects. Common adverse reactions in patients taking opioids for pain relief include nausea and vomiting, drowsiness, itching, dry mouth, dizziness, and constipation.
The discussion about the opioid crisis and the approaches to address it are too often siloed by industry or geographic region. We want to band together to crank up the volume on solutions. Addiction is complicated and so is the pathway out of it. We want to band together with all those affected to pull them out of isolation and to put a spotlight on shame and stigma. As a group, we can rock much stronger and louder.
“We talk about living well, about misdiagnosis, healthcare and insurance costs, addiction and recovery, and who is to blame. But we don’t talk about living with the pain. Nor do we acknowledge that every person and every affected industry must step up to help. ”