What are opioids?

Opioids are drugs that activate pain killing mechanisms in your body (by stimulating opioid receptors, strangely enough).  They include drugs like morphine, codeine (this has to get converted to morphine by your body for it to work), oxycodone, hydromorphone, methadone and pethidine.  It also includes tramadol, tapentadol and buprenorphine. All of these drugs can be sold under multiple brand names. For example, “Targin” is oxycodone, “Junista” is hydromorphone.

 

My position on opioids is simple: Its evidence based.

The Faculty of Pain Medicine (FPM) has an excellent summary of the evidence in their professional documents, and its no surprise that opioid management is the very first document of the FPM

Executive summary

There is no evidence for benefit with long term use of opioids. If there was, I’d prescribe them for everyone with pain.

But this is the only thing that helps my pain?

Yes, I know that they help.  If you don’t take them, you feel a lot more pain.

However, they never really make chronic pain go away.  If they did, you probably wouldn’t be reading this right now.

At their best, they reduce pain by maybe 30% with long term use. They help a lot more than this when you first start them, and they also help a lot more than this each time you increase the dose.

But in the long run, they only help a small amount.  Unfortunately, the level of benefit they deliver is not very different from taking a sugar pill.  Its a bit better, for sure, but not that much better.

Pain Scales

You are probably familiar with pain scales. Where 0 is no pain, 1 is just perceptible, and 10 is unbearable or the worst pain you could feel.

How much do opioids help?

If an opioid reduces your pain from, say 7 down to  4.5 (these would be common sorts of average pain scores in clinical trials of opioids), that would sound like a major improvement.

It probably is for most people.

When you look at well designed trials, they tend to have two halves to them. One for the drug, and one as a reference of what happens in comparison if you don’t get the drug.

And here is the problem. To make it a proper trial, the group with severe pain that gets “nothing” has to get a sugar pill (or placebo) that has no drug. Ideally, even the people who give the drugs don’t know which are the sugar pills and which are real.

The investigators know, but the boxes of pills look the same. The only difference is the ID on the front of the box.  The people who know what is what don’t tell the people who give out the drugs which is which, either.

When you look at the group that didn’t get opioids, but instead got sugar pills, their pain scores also reduce.  In comparison, their pain scores might reduce from 7 to say 5.

And that is the problem.

The difference between a sugar pill and an opioid, in long term use, is only about a half a point out of ten.  And most people wouldn’t rate that as being much of an improvement.

What are the alternatives?

Lots of things. Many medications do not lose effectiveness over time.  Anti-inflammatory medications and nerve pain medications (anti-neuropathic agents) both work in the long term. As do a number of novel therapies that are starting to be looked at. This includes procedural options as well as medication

Its not all about medical therapy, either. Managing bad pain involves rehabilitation and coping strategies.

Summary

While opioids certainly have a role in acute pain and cancer pain, their role in long term pain management needs to be limited.  In particular, if you cant get good control of your pain with low doses of the (relatively) safer agents such as tapentadol, buphrenorphine and tramadol, then increasing the dose over time really won’t help.

The first point of call is obviously your family doctor, but if you still have bad pain then you will do far better with a referral to a pain management center than you will with opioids.