I'm a Believer

I believe that patients living with chronic pain should have only the best treatments. They should have every opportunity to try treatments with a proven track record of improving quality of life for those living daily with chronic pain. I believe their doctors should help them to evaluate treatments that hold promise but are not yet of proven benefit. And most importantly, their doctors should help them to avoid treatments that have been proven to reduce their quality of life. Treatments like opioids.

Wait. What? Avoid opioids? That’s crazy talk!

It certainly sounds crazy. Especially to those who are already taking opioids for their chronic pain. They know that they work. Every. Single. Dose. Reduces. Pain.

Yes, as a doctor, I know this. And this is exactly the problem. Every single dose reduces pain. How can a patient be expected to agree that overall their pain is worse when every single dose reduces pain? Again, as in my previous articles, the answer is complicated. And yet, if you are willing to consider my reasoning, it’s not so complicated.

I have worked in pain management for 15 years. I have prescribed tens of thousands of doses of opioid pain relievers. I have treated. I have observed. And I have learned. Opioids simply do not do what everyone thinks that they do.

It is important that you know that it’s not just me. More and more physicians and other healthcare providers are coming to realize that opioids are not the answer for chronic pain. And those of us who know are no longer willing to allow patients who have newly acquired chronic pain to go down the path of chasing that pain with opioids. But what about those who come to us already on opioids? Maybe they were started on them years ago, long before the current “opioid crisis” that fills the news. What do we do for them – they know that every single dose reduces pain.

If you read my article, “Of Opioids and Pain,” then you know about the brain’s “pain meter.” The brain is a wonderfully complex machine that we are only now, in the twenty first century, beginning to understand. For some reason scientists weren’t interested in studying the effects of opioids on the brain until the opioid epidemic prompted them to take a look. So much of our current knowledge about the effects of opioids in the brain comes from research into the effects of heroin. Heroin is an opioid, just like the pain pills many readers are likely already taking. Heroin, like all other opioids, causes profound changes in the brain. Not only does it break the brain’s “pain meter,” but it also causes a host of other changes that make life more difficult.

We have functional MRI scans and PET scans that show dramatic changes in both the anatomy and function of the brain caused by opioids. We have learned from these scans and from other experiments that opioids modify the function of the prefrontal cortex and the regions of the brain that regulate dopamine. There are also alterations in the hypothalamus and pituitary and thus in the ability of the brain to control sex hormones and the stress response. The consequences of these changes are many:

• Impaired emotional regulation with more depression and anxiety

• Memory impairment

• Reduced dopamine levels causing feelings of punishment and enhanced pain

• Lower levels of testosterone and female hormones

• Impaired stress hormone response

• Diminished flexibility regarding tasks – more easily frustrated

• Diminished reasoning skills – harder to solve problems

• Reduced ability to evaluate one’s own decisions and actions

• Decreased ability to plan for the future

These changes in the brain and in the body explain why addiction can be so hard to treat. But the real kicker here is that you don’t have to be addicted to heroin in order to suffer the above consequences. You don’t have to be an addict at all – in fact most of the patients on opioids never become addicts. But all opioids cause exactly the same set of undesirable results and each of these results leads to a reduced tolerance for pain. But - every single dose still reduces the pain. It’s just that now there is more pain to reduce and even the reduce level of pain is harder to tolerate. Increasingly there are brief periods of relief interspersed with long periods of difficulty engaging with life to the fullest.

There are alternatives to opioids that benefit both those not yet taking them as well as those who have been on them for many years. I’m not talking surgery, needles or other drugs. I’m talking about therapies aimed at the brain and at the mind. Therapies that have been shown in scientific studies to reduce pain by as much as 50% or more. Therapies that have been proven to improve quality of life. More joy, more engagement, more mobility - more. This is what I desire for my patients suffering from chronic pain because I believe that chronic pain patients should have only the best treatments.

If you are someone looking for a better way, it would be my pleasure to point you in the right direction. 

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