Chronic, Nonmalignant Pain: Why Opiates Aren't the Answer

I answered a post today that is similar to many prior posts– a patient with significant pain is no longer getting good pain relief from the pain pills he has taken for the past three years, and he asked whether it was a good idea to change from one narcotic– let’s say oxycodone– to another narcotic– let’s say Duragesic, the fentanyl skin patch.
I often come across this question in one form or another.  For a person in pain, opiate pain medications are wonderful– at least initially.  The problem is that the medications lose their potency over time through a process called ‘tolerance’.  In order to continue to get relief, the person with pain has to keep increasing the dose of the medication.  This leads to problems; often the doctor prescribing the medication becomes uncomfortable with the dose but wants to avoid confrontation, and the doctor/patient relationship becomes more and more strained… the patient goes to the ER for pain relief and nothing works, and the nurses and doctors treat the person like a criminal…  Read on for one writer’s experience, followed by my comments:
As I mentioned in your forum, it’s refreshing to see someone preaching the realities of non-acute opiate use. This happened to me to a certain degree, with opiate hyperalgesia (which you didn’t address in this post but have mentioned elsewhere) thrown in. Doctor doesn’t explain the limitations of opiates and tolerance, things spin out of control (in my case, thankfully no doctor shopping and only a couple of instances of upping the dose myself slightly and no more out of fear of overdose), I end up on Suboxone to taper off after the source of the pain was finally discovered and properly treated (with my pain receptors still firing improperly for the first few months, albeit not nearly as badly as they did while on the painkillers and during withdrawal. Plus, being ill-informed, after my relationship with my doctor soured for various reasons and I knew that even if it hadn’t, my dose had gotten much too high, I didn’t know that tolerance too high = withdrawal, for WEEKS in spite of visits to ERs, other neurologists, and psychiatrists who, in hindsight, seemed to be playing dumb in some cases so as not to second-guess the original prescribing doctor while I lied there screaming in the worst pain of my life from a combination of opiate hyperalgesia and withdrawal. This was actually the second time that this happened though it was slightly less bad the other time (and for those of you who absolutely have to take opiates while recovering from surgery or for cancer pain, AVOID OPANA ER LIKE THE PLAGUE. The time release doesn’t work properly for many people, including me).
I often see patients who have been destroyed by pain medications. I hear you– you are in pain, and need a way to reduce the pain. But all opiates have the same severe limitation– tolerance.

Duragesic (which is fentanyl), morphine, oxycodone, hydrocodone, hydromorphone (dilaudid)… they all work through the exact same receptor site, and they are all ‘cross tolerant’– meaning that if you are tolerant to one of them, you are tolerant to all of them.

The problem with tolerance is that if you increase your dose, or (as you are suggesting) change to a different medication at a dose that is essentially higher than what you are taking now, your receptors will change to match the increase, and very soon you will have exactly the pain you are having now– only while on a higher dose of medication. I typically see patients who have chased tolerance to extreme levels– people who are taking 600 mg of oxycodone per day or more, and who get nothing from it, because of tolerance.

If you chase tolerance and end up on high doses of pain meds, you face many problems– most doctors will refuse to even consider taking on a patient in that position; if you have surgery it is very difficult to treat the pain, as even higher doses are required; and if you miss a dose, or run out of medication, you are in deep trouble from withdrawal.


The ONLY solution is to avoid chasing tolerance. Don’t interpret this as ‘not caring’ or ‘not believing you’– that is not the issue. Assuming you are having bad pain, and from a standpoint of wanting to help, increasing the narcotic simply does not work.

Some day– maybe soon– we will have a way to prevent tolerance. Studies suggest that tolerance requires actions through glutamate receptors, and so there have been attempts to limit tolerance by using drugs that block those receptors– such as dextromethorphan. Studies that looked at a combination drug called ‘morphidex’ did not show reduced tolerance in humans, but dextromethorphan has been demonstrated to reduce tolerance in animals. There are ‘compounding pharmacies’ out there that make and dispense pills containing oxycodone and dextromethorphan, in an attempt to limit tolerance.

So if you don’t increase the opiate medication, what can you do? I don’t know– maybe nothing! My point is that an increase is ultimately not helpful, and is actually setting you up for worse pain. So keep the opiate dose constant and focus your efforts on every non-opiate pain-reduction technique you can find. Exercise as much as you are able– that will have the greatest effect on your level of disability. Use an SNRI antidepressant. Try the anti-convulsant medications for ‘burning’ pain– medications like ypregabalin (Lyrica), gabapentin, tegretol, or topiramate (Topamax). Use locally-applied heat for tight muscles, and use muscle-relaxants sparingly– medications like cyclobenzaprine (Flexeril), metaxolone (Skelaxin), tizanidine, or baclofen. Benzodiazepines like diazepam (Valium) are potent muscle relaxants, but are limited by sedation and tolerance, and can be addictive in some patients– particularly those with other substance issues including alcoholism. As for pain clinics, be careful. I am Board Certified in Anesthesiology and worked in pain treatment for ten years as an anesthesiologist, so I understand what pain docs can and cannot do. Pain treatment is a huge draw for hospitals, and pain clinics are often a bit misleading (trying not to use the word ‘scam’ here!). Blocks that eliminate your pain for a few hours are fun for the anesthesiologist, and they bring in a grand or two for the hospital… but if your pain returns in six hours, were they worth it?

As prior posts have suggested, the important thing is to find a doc who listens. I would add, look for someone who doesn’t just keep increasing your narcotic dose. That is a fine approach for a person who has a terminal illness, but is a disaster for a person with years to live.

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