Letter to my patient #3: Opioids

By opioids, I mean all the Morphine-family drugs, from Codeine (weak) to Oxycodone (very strong), via Tramadol (medium) and Morphine itself (strong), and many more beside.  

You might find these drugs helpful. They might take the edge off your pain, they might help you get off to sleep, go swimming, or see friends. OK, they might make you a bit sleepy, and you have to take laxatives to treat the constipation, but on the whole it feels like they help you more than they harm you. 

But your GP doesn’t believe you! 

They’ve read the latest guidelines, they’ve watched “Dopesick”, and are now caught up in the moral panic about opioids. They have started talking to you about de-prescribing, which to you means taking away the one medication that helps. Sometimes it feels like they are treating you as if you were an addict. You feel so desperate that you may have even thought about buying street painkillers, with all the risks and dangers that entails. Why can your GP not understand this? 

Opioids are fantastic painkillers. Our bodies have evolved to respond to them. We even produce our own morphine drugs, the endorphins, which work on the opioid receptors found throughout the body’s pain system – in the spinal cord, the brain, even the gut. The opioids that we take are a lot stronger than the opioids our bodies make, so the first time we take any morphine-family drug the effect is powerful. But…and it is a big but…the second time we take any morphine family drug the effect is a bit less powerful, the third time less still, and so on. 

WHAT IS HAPPENING? 

Our opioid receptors aren’t designed to be bombarded with stronger versions of the pain-regulating chemicals that we produce ourselves, so they respond to this bombardment by becoming a little less sensitive every time we hit them with a bigger dose. You need to take more to get the same effect, leading the receptors to become even less sensitive, and so on and so forth, effectively locking you into an arms race between your body’s own pain regulatory system and the drugs that you are taking to control your pain. 

As with any arms race, there are no winners in this game. We know that taking high doses of morphine-family drugs for more than a few months leads to changes in the endocrine and immune systems as well as the pain system. Hormone regulation is disrupted, leading to decreased levels of testosterone and oestrogen, and changes in stress hormones like cortisol. A weakened immune system results in more colds. The pain system itself starts to change, eventually becoming more sensitive to painful stimuli (a condition called opioid-induced hyperalgesia). 

Chronic pain is horrible. If a drug helps control your pain, you might feel that pain relief today is worth the risk of other medical problems tomorrow. The difficulty of applying this philosophy to opioids is that it is hard to tell just how much they are actually helping. You are on a high dose of morphine, but your pain is still at a level of 8/10. So, you figure it probably isn’t helping and decide to reduce the dose. Your pain levels shoot up to 10/10 – the opioid must be doing something. Well, not necessarily. We’ve talked about tolerance, but the flip side of tolerance is physical dependence; your opioid receptors have adjusted to a certain level of opioid intake, so when this intake reduces they become under-activated, and you feel more pain (alongside other unpleasant withdrawal symptoms). But this is only temporary; over time the receptors will reset and re-adjust to the new, lower level of opioid intake, in a reverse of the tolerance arms race described above. Physical dependence is not a permanent condition. 

Modern medicine should be all about collaborative decision-making. Both patients and prescribers have serious concerns about opioids in chronic pain management, but these aren’t always the same concerns. How then to bridge this gap? What might an effective, sustainable and collaborative approach to opioid prescribing look like? I have my ideas, but they will have to wait for the next issue of Pain Matters, as I’ve run out of space in this column. In the meantime, I’d love to hear what readers think, and if you want to find out more about the issues raised in this column then the websites www.fpm.ac.uk/opioids-aware, and www.painkillersdontexist.com are good places to start. 

Lars Williams

You can write to Lars Williams c/o Pain Matters, email: editorial@painconcern.org.uk.