Imagine taking a ‘pain’ medication that may actually intensify the person’s suffering.
Add to that frequent side effects such as respiratory distress, constipation, sexual dysfunction, and depression and you’ve described opioids. We increasingly hear about the potential for dependence and addiction to opioids; yet medical providers continue to prescribe them for non cancer, non acute conditions for which they were not intended, especially chronic pain.
Both the New York Times and Washington Post recently published stories on preliminary data each compiled about the latest opioid-related death rates. Arizona’s governor is the latest to declare a public health emergency surrounding the use of opioids. And the Federal Food and Drug Administration in a first-of-its-kind mandate ordered the manufacturer of Opana ER to remove the drug from the market.
Opioids clearly have a place in the nation’s healthcare system; but not as a first line treatment for chronic pain. Stakeholders in the workers’ compensation system might be less inclined to prescribe and approve use of the drugs for injured workers if they truly understood exactly what opioids are and how they affect the body.
Opioids and the Brain
In their purest form, opioids are derived from opium, such as morphine and heroin. There are also synthetic and semi-synthetic varieties, such as hydrocodone, oxycodone and fentanyl — among the biggest sellers in the workers’ compensation system.
Opioids are a class of drugs that interact with opioid receptors on nerve cells. Their chemical structure mimics that of a natural substance in the body. The drugs go to the pleasure center of the brain and release ‘dopamine,’ a neurotransmitter that causes a variety of things to happen, including slowed breathing, blood pressure and alertness; and decreased pain. It also produces a sense of euphoria.
While the body’s naturally occurring dopamine can give great pleasure, the flooding of dopamine from opioids has the effect of turning off the body’s own pleasure response system and instead overstimulates the regions of the brain that control movement, emotion, cognition, and motivation.
The depressant effect of opioids on various bodily systems stimulates a noradrenaline response to combat those effects and keep the person alive. An organic chemical that functions as a hormone in the brain and body, noradrenalin is like the rock star drink of the body. It increases arousal and alertness, and produces the fight-flight response during times of stress or danger. While the opioids create a depressive effective, the noradrenaline creates an anxiety effect.
The brain begins to associate the pleasure response of the opioids with pain control, an effect neuroscientists refer to as ‘what gets fired together, gets wired together.’ The drugs move from the primal part of the brain to the thinking, evolved part of the brain. Eventually, it creates a demotivation, a compromised ability to regulate unsafe or risky behaviors.
Over time, the body becomes tolerant and can become dependent on the drugs. The injured worker has increased pain near the time of the next dose of the meds. He finds he must keep taking the drugs to avoid a variety of unpleasant withdrawal-related symptoms; such as restlessness, irritability, muscle and bone pain, insomnia, sweating, diarrhea, and vomiting. The injured worker may also become addicted to the opioids, meaning he has intense cravings and compulsively uses them.
This tolerance, dependence and addiction are due to brain changes caused by chronic opioid abuse. However, even someone using opioids for the first time may experience life-threatening side effects, such as respiratory arrest.
In addition to changes to the brain, opioid use can also result in a variety of physical ailments, including the following:
- Hyperalgesia. A fairly common effect of opioids, this is where the brain starts to interpret normal sensations as painful. In such cases, the opioids can actually heighten the person’s sensitivity to the pain he is trying to relieve.
- Sexual problems. The glands that make sex hormones are reduced by long term use of opioids, which can cause reduced sexual desire and performance, breast enlargement in men, fatigue and depression.
- Sedation, drowsiness and confusion may occur, especially when the medication is being started or the dose has been increased.
- Balance can be affected, increasing the risk of falls.
- Sleep quality is often affected by opioids, largely because of the reduced drive to breathe, which causes apnea. This is one of the main causes of overdose deaths, especially when opioids are combined with alcohol or other drugs.
- Depression is often seen in long-term opioid users. Research has suggested patients using narcotics for more than six months have more than a 50-percent greater chance of having a depressive episode.
- Constipation is fairly common among long term opioid users, due to the drugs’ effects on the muscles of the digestive system. Users may be more at risk for small bowel obstruction or perforation.
Injured workers with chronic pain have a variety of strategies available to help. A competent, trained professional in cognitive behavioral therapy (CBT) can teach many techniques to help the injured worker soothe himself and reduce his own pain, without the use of these often dangerous medications.
Integrated Medical Case Solutions (Ascellus) is a national network of Health Providers in Psychology that delivers cognitive behavioral therapy (CBT) for chronic pain, trauma and insomnia across the country for the workers’ compensation industry.
Ascellus bridges the gap between mental and physical health to accelerate recovery for our nation's workforce. By connecting the workers' compensation industry with our expert behavioral care and evidence-based treatments, we deliver high-quality outcomes, helping injured workers reemerge with increased strength, purpose and resilience in the workplace.