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Opioids for Chronic Aches & Pains

The nuclear option: “Hillbilly heroin” (Oxycontin), codeine and other opioids for musculoskeletal problems like neck and back pain

updated
by Paul Ingraham, Vancouver, Canadabio
I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of ScienceBasedMedicine.org for several years. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about memore about PainScience.com

SUMMARY

The infamous opioids are drugs like codeine (found in small does in Tylenol IIs and IIIs) and the more serious “hillbilly heroin” drugs like Oxycontin, Percocet, and Vicodin. They induce deep relaxation and euphoria and make you not care about the pain. Unfortunately, not caring is not a cure, and their efficacy is surprisingly dubious. And of course they also have grim risks like life-altering addiction and death by overdose, which is shockingly common. The danger can’t be overstated: more ordinary Americans have started to die from opioid overdose than car accidents. The CDC declared in early 2016 that opioids should not be an option for chronic musculoskeletal pain: there’s just too much danger, and too little evidence of benefit.

On the other hand, not everyone gets addicted and some people get real relief, so despite “the opioid crisis” — which is all-too real — there’s plenty of grey area here. If you have a good relationship with a cautious doctor who respects the risks, it’s not unreasonable to consider a short term opioid experiment: it could provide some much needed emotional relief from chronic pain, and maybe even break a vicious cycle. But the need for caution and medical supervision is as high as it gets.

full article 2750 words

Opioids are the nuclear option for pain: codeine (more readily available, mostly in small doses in Tylenol IIs and IIIs) and more serious “hillbilly heroin” (Oxycontin, Percocet, etc) are all capable of inducing deep relaxation, euphoria, and making you “not care” about pain.1 All opioids are narcotics, but in health care we like to talk about “opioids” because it sounds better than “Let’s give you some narcotics for your chronic pain.”

Opioids are dangerous. Extremely dangerous. But, as with cars and mountain climbing, some risks are worthwhile, and there is a vigorous ongoing debate about how opioids should be used. For each patient, it depends, and you need to talk to your doctor about it. And some doctors are far more qualified to discuss it than others.2 This article is intended to help patients with chronic body pain prepare for that conversation.

I am not a doctor & this article is not medical advice. It’s just a plain language summary of expert opinion & official guidelines, plus some opinion and interpretation specifically about opioids for chronic musculoskeletal pain. See also the full site disclaimer: Dammit, Jim, I’m Not a Doctor!

It’s official: opioids for chronic musculoskeletal pain are a bad idea

Prescription opioid [DrugAbuse.com] abuse is causing so many deaths by overdose that, in early 2016, the American Centers for Disease Control and Prevention (CDC) decided it had to do something. (Not the FDA, but the CDC!3) They made many recommendations, including that opioids should not be considered an option for chronic musculoskeletal pain,4 which were quickly adopted by many physician colleges around the world.5

The CDC’s position is strongly opposed by pain patient advocacy groups, because opioids obviously do help many people.6 More cynically, perhaps they don’t want to lose funding from the drug companies that make prescription opioids.7

The danger can’t be overstated: it’s been called the “opioid crisis[Google search] repeatedly in recent years, because deaths from opioid overdose have tripled (in the US).8 In fact, since 2014, more Americans have died from opioid overdoses than from car accidents9 — the first time in decades that car accidents haven’t been the number one cause of accidental death.

And a whopping 60% of opioid-related deaths are linked to a chronic pain diagnosis10 — which is a huge problem for the argument that opioids are safer when prescribed for chronic pain.

So, before you try opioids for a condition like back pain, ask yourself the reasonable question, “Do I really want to risk death? Or, if I’m “luckier,” a decade of addiction and rehab hell?”

Opioids are not very effective, either!

As if all the extreme danger wasn’t bad enough, opioids just don’t work all that well. It’s not that they don’t work at all, just not nearly well enough or in the right ways for enough people. As with all drugs, the effects are unpredictable. Some people are actually immune to (oral) opioids: they can’t get high that way at all!11 The scientific literature on this topic is a litany of disappointing results. For instance, in 2016, Shaheed et al concluded:12

For people with chronic low back pain who tolerate the medicine, opioid analgesics provide modest short-term pain relief but the effect is not likely to be clinically important within guideline recommended doses.

And in 2015, reviewing opioids for non-cancer musculoskeletal diseases, Berthelot et al concluded:

…morphine and other strong opioids in dosages of up to 100mg/day were only slightly more effective than their placebos, no more effective than acetaminophen, and somewhat less effective than nonsteroidal anti-inflammatory drugs (NSAIDs).

In other words, opioids are surprisingly unimpressive as a pain treatment at safer dosages. (They probably work better at higher dosages, but then you’re really dancing with the addiction risk.) The questionable efficacy should be a major point of concern when discussing the opioid option with a doctor.

Ripening seed head of an opium poppy.
© Albert Bridge, Creative Commons Licence, image cropped.

What are the opioids? Many opioids are household names, like the oxycodone brands Oxycontin and Percocet, AKA “Hillbilly Heroin,” the most popular narcotic painkiller in America for some time. Other familiar examples, some known better by the brand and others by their chemical names, are fentanyl (the drug that killed Prince), Vicodin (the one Dr. Greg House was addicted to), morphine, codeine (most widely available in Tylenol 2s and 3s), heroin and methadone, Demerol, and Darvon. And, of course, there’s actual opium! Many famous people have infamous addictions to some these drugs, such as Rush Limbaugh’s Oxycontin addiction.

“Opiate” is the older word referring specifically to poppy-derived compounds. “Opioid” refers to any drug with similar effects, opioid-ish. This does not include the infamous benzodiazepines, like Valium.

Should opioids be demonized?

Demonizing an entire class of drugs is usually a bad idea. It might be justified and defensible in this case, given the serious dangers, but not everyone gets addicted and nothing is all bad. Opioids still have a vital place in pain management for some kinds of patients, especially:

But there is still intense controversy about their use for everything else,13 and how to manage the undeniable crisis. For musculoskeletal pain in particular, over the last few years, expert concensus has shifted strongly towards the belief that they should only be used with great caution and close supervision… or not at all.14


For some excellent background on the history of the opioid crisis, listen to Planet Money Episode 711: Hooked on Heroin (17:38). “When we meet the heroin dealer called Bone, he has just shot up. He has a lot to say anyway. He tells us about his career—it pretty much tracks the evolution of drug use in America these past ten years or so. He tells us about his rough past. And he tells us about how he died a week ago.”

What if you’re already on opioids? Should you stop?

No one thinks these drugs are completely useless and dangerous for everyone all the time… just for so many people that it may be unwise to try them in the first place. All medical decisions are about balancing risk and benefit, and if you’ve already opened that door and walked through it, and there seems to be some real benefit and minimal risk as far as you can tell so far… well then, phew. You’re one of the lucky ones: you’re demonstrating that opioids can be used safely.15

But please consider:

  1. The benefits might be a least partially illusory. Opioids have that weird knack for making pain seem more tolerable — suffering reduction — rather than actually reducing it. And suffering reduction is something that can be achieved other ways, and maybe should be.
  2. The risks don’t go away just because you’ve been on the drug for a while. The risk of overdose continues. People can do just fine on opioids for a long time and then still get into trouble.

If you continue on opioids, work closely with your doctor and be wary of increasing your dosage, particularly if it has been stable for some time.

The smart way to ask for a prescription

If you still want to try opioids for your pain, find a doctor who respects opioids as a powerful tool to be used with extreme caution, if at all, and consider refusing a prescription from any doctor who does not show awareness of the risks.

A quick safety note about other pain killers

Over-the-counter (OTC) pain killers are safer than opioids, but they have their own substantial risks, particularly the anti-inflammatories. Beware of taking any of them for long — risks go up over time, and they can even backfire and cause pain. (rebound headaches [Mayo]).

acetaminophen (Tylenol) is good for fever and pain, and is one of the safest of all drugs at recommended dosages, but overdose can badly hurt livers16 and it doesn’t work well17) for musculoskeletal pain.

The NSAIDs (Aspirin, ibuprofen, Advil, etc) are a better bet for common aches and pains. They reduce inflammation as well as pain and fever. As mentioned above, they may actually be more effective than opioids for musculoskeletal pain (Berthelot 2015), and they are modestly effective for sprains, strains, and repetitive strain injuries.18 Unfortunately, at any dose they can cause heart attacks and strokes19 and they are “gut burners”20 — they can badly irritate the GI tract, even taken with food, and especially with booze. Aspirin is usually best for joint and muscle pain, but it’s the most gut-burninating of them all.

Voltaren® is an ointment NSAID, generally much safer because it involves a smaller dose only where you need it. It’s by far the best option for any minor, superficial musculoskeletal pain. And there’s always icing, too!

Article Summary

The infamous opioids are drugs like codeine (found in small does in Tylenol IIs and IIIs) and the more serious “hillbilly heroin” drugs like Oxycontin, Percocet, and Vicodin. They induce deep relaxation and euphoria and make you not care about the pain. Unfortunately, not caring is not a cure, and their efficacy is surprisingly dubious. And of course they also have grim risks like life-altering addiction and death by overdose, which is shockingly common. The danger can’t be overstated: more ordinary Americans have started to die from opioid overdose than car accidents. The CDC declared in early 2016 that opioids should not be an option for chronic musculoskeletal pain: there’s just too much danger, and too little evidence of benefit.

On the other hand, not everyone gets addicted and some people get real relief, so despite “the opioid crisis” — which is all-too real — there’s plenty of grey area here. If you have a good relationship with a cautious doctor who respects the risks, it’s not unreasonable to consider a short term opioid experiment: it could provide some much needed emotional relief from chronic pain, and maybe even break a vicious cycle. But the need for caution and medical supervision is as high as it gets.

Related Reading


About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.

What’s new in this article?

Five updates have been logged for this article since publication (2016). All PainScience.com updates are logged to show a long term commitment to quality, accuracy, and currency. more Like good footnotes, update logging sets PainScience.com apart from most other health websites and blogs. It’s fine print, but important fine print, in the same spirit of transparency as the editing history available for Wikipedia pages.

I log any change to articles that might be of interest to a keen reader. Complete update logging started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.

See the What’s New? page for updates to all recent site updates.

2016Improved footnotes/citations regarding other pain-killers. Added key citations about opioid and NSAID efficacy for musculoskeletal pain. Added more early emphasis on the position of pain patient advocacy groups. Miscellaneous editing.

2016Added citation about opioid non-responders. Added a TL;DR summary.

2016Major update. Added disclaimer (needed more for this article than most). Edited extensively to focus the article more strongly on official guidelines and reporting exerpt opinion and official guidelines, and greater acknowledgement of controversy. Added related reading section.

2016Editing, added several references, and a new section about safety issues with over-the-counter medications for perspective.

2016Transferred and adapted content from a chapter in Trigger Points & Myofascial Pain Syndrome.

2016Publication.

Notes

  1. That is, they don’t actually treat the source of any pain: they simply make you care less about it for a while. They decrease perception of pain, reaction to pain, and increase pain tolerance (all subtly different things). BACK TO TEXT
  2. PS Ingraham. The Medical Blind Spot for Aches, Pains & Injuries: Most physicians are unqualified to care for many common pain and injury problems, especially the more stubborn and tricky ones. PainScience.com. 711 words. Doctors lack the skills and knowledge needed to care for most common aches, pains, and injury problems, especially the chronic cases, and even the best are poor substitutes for physical therapists. This has been proven in a number of studies, like Stockard et al, who found that 82% of medical graduates “failed to demonstrate basic competency in musculoskeletal medicine.” It’s just not their thing, and people with joint or meaty body pain should take their family doctor’s advice with a grain of salt.

    By all means, discuss opioids with your family physician — but it’s really the domain of specialists, preferably a doctor at a pain clinic, or any specialist who deals with a lot of chronic body pain (neurologists, rheumatologists).

    BACK TO TEXT
  3. The CDC usually leaves drug regulation to the Federal Drug Administration, but chose to issue their recommendations because of the rapidly increasing number of deaths from prescription opioids. They saw a dire need, and they stepped up. It was an interesting move. BACK TO TEXT
  4. CDC.gov [Internet]. Centers for Disease Control and Prevention. CDC Guideline for Prescribing Opioids for Chronic Pain; 2016 Apr [cited 16 Jun 22]. “Plainly stated, the risks of opioids are addiction and death, and the benefits for chronic pain are often transient and generally unproven.” (CDC Director Tom Frieden, from March 2016 press briefing about the new guidelines). The FDA quickly responded with “enhanced warnings” about the “risks of misuse, abuse, addiction, overdose and death.” BACK TO TEXT
  5. For example, in Canada: “Physician regulatory colleges in four provinces, alarmed by Canada’s opioid epidemic and frustrated by a lack of federal action, are endorsing new national standards in the United States for prescribing painkillers” (Globe and Mail, May 8, 2016). In recent years, Canadian doctors have been prescribing more opioids than than doctors anywhere else in the world. BACK TO TEXT
  6. Some patients do benefit from opioids, of course — more about this below. It could be a disaster for those patients if opioids become heavily stigmatized and inaccessible. BACK TO TEXT
  7. TheGuardian.com [Internet]. Zalkind S. CDC issues guidelines against opioid prescriptions to treat chronic pain; 2016 July 27 [cited 16 Jul 29].

    This article does a great job summarizing the controversy. Here’s a good excerpt:

    For Bob Twillman, executive director for the American Academy of Pain Management… the CDC’s move is an ominous sign that state and federal lawmakers will take increasing steps to turn CDC’s suggestions to prescribing doctors into a hard and fast rule. “It reflects a lack of experience in treating people with chronic pain,” says Twillman, who also receives funding from pharmaceutical companies.

    Kolodny, says the blacklash from pain advocates — many of whom are funded by pharmaceutical companies — is akin to naysayers of global warming. “It’s a manufactured controversy,” Kolodny says.

    So it’s quite contentious.

    BACK TO TEXT
  8. PSMag.com [Internet]. Gershon L. Five Studies: Understanding America’s Opioid Crisis; 2016 July 27 [cited 16 Jul 29]. BACK TO TEXT
  9. National Safety Council: “Unintentional poisoning deaths in the adult population were not prevalent until the early 1990s. Since then this category has skyrocketed to 1st place, driven by unintentional drug overdose — predominantly from prescription painkillers.” BACK TO TEXT
  10. Olfson M, Wall M, Wang S, Crystal S, Blanco C. Service Use Preceding Opioid-Related Fatality. Am J Psychiatry. 2017 Nov:appiajp201717070808. PubMed #29179577. PainSci #52752. BACK TO TEXT
  11. Tennant F. Why oral opioids may not be effective in a subset of chronic pain patients. Postgrad Med. 2016 Jan;128(1):18–22. PubMed #26635137.

    We tend to think of opioids as potent drugs that are going to make pretty much anyone high, and therefore probably provide some pain relief… but there’s an incredible range of responses to drugs, even strong ones. This paper presents some specific reasons why some people just aren’t much affected by (oral) opioids: “there is a group of intractable pain patients who do not effectively metabolize oral opioids,” mainly because of gastrointestinal disorders and an inherited metabolic problem (cytochrome P450 enzymatic defects).

    BACK TO TEXT
  12. Abdel Shaheed C, Maher CG, Williams KA, Day R, McLachlan AJ. Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med. 2016 Jul;176(7):958–68. PubMed #27213267. BACK TO TEXT
  13. Many doctors now believe that the risk of addiction and other severe complications is just too great. Others — including many chronic pain specialists and patient advocacy groups like the American Pain foundation — believe that the risks of opioid addiction are exaggerated and the benefits of properly prescribed and monitored opioids are vital to many chronic pain patients. Some even argue that there’s essentially a tragic epidemic of treatable chronic pain going untreated because of ignorant prejudice against opioids. BACK TO TEXT
  14. Pro Publica [Internet]. Ornstein C, Weber T. The Champion of Painkillers; 2012 Mar 7 [cited 15 May 23].

    For years I assumed that narcotic pain killers are effective, and I took at face value the American Pain Foundation’s position that the risks of addiction are overblown, and the drugs are stigmatized and underused, resulting in a tragic lack of relief for many patients. This article casts reasonable doubt on all of that, and on the credibility of the APF, who may be serving the interests of pharmaceutical companies better than patients. In the spirit of Dr. Harriet Hall’s skeptical rule of thumb — “Who disagrees and why?” — it is clear that there is a problem here. Politics aside, I am most perturbed by the idea that opiates may not be all that effective in the first place. There is little doubt that these powerful drugs are valuable for some kinds of pain — just try passing a kidney stone without them! — but they may be surprisingly powerless against other kinds.

    BACK TO TEXT
  15. Huber E, Robinson RC, Noe CE, Van Ness O. Who Benefits from Chronic Opioid Therapy? Rethinking the Question of Opioid Misuse Risk. Healthcare (Basel). 2016;4(2). PubMed #27417617. “Harmful, dose-dependent deleterious effects have become clearer,” and yet “many individuals on low doses of opioids for long periods of time appear to have good pain control and retain social and occupational functioning. Therefore, we propose that the question, ‘Who is at risk of opioid misuse?’ should evolve to, ‘Who may benefit from chronic opioid therapy?’” BACK TO TEXT
  16. FDA.gov [Internet]. Acetaminophen and Liver Injury: Q & A for Consumers; 2009 Jun 4 [cited 16 Aug 31].

    “This drug is generally considered safe when used according to the directions on its labeling. But taking more than the recommended amount can cause liver damage, ranging from abnormalities in liver function blood tests, to acute liver failure, and even death.”

    BACK TO TEXT
  17. Machado GC, Maher CG, Ferreira PH, et al. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. BMJ. 2015;350:h1225. PubMed #25828856. PainSci #54220. BACK TO TEXT
  18. Derry S, Moore RA, Gaskell H, McIntyre M, Wiffen PJ. Topical NSAIDs for acute musculoskeletal pain in adults. Cochrane Database Syst Rev. 2015;6:CD007402. PubMed #26068955. BACK TO TEXT
  19. FDA.gov [Internet]. FDA Strengthens Warning of Heart Attack and Stroke Risk for Non-Steroidal Anti-Inflammatory Drugs; 2015 Jul 9 [cited 16 Aug 19]. BACK TO TEXT
  20. Science Based Pharmacy [Internet]. Gavura S. How risky are NSAIDS?; 2015 Jul 25 [cited 16 Aug 18]. BACK TO TEXT