“My back hurts so much that I can hardly get out of bed on some days. I have tried everything; including, Bufferin, Tylenol, heat, music, et al; and nothing works. What about Morphine? Would this help me?”
Morphine is an opioid, much like Oxycodone, Roxicet, Percocet, Vicodin, Codeine and others. For the past twenty years or so, opioids have been seen as helpful to people who suffer from chronic pain; especially when all other alternatives have been tested and failed. Physicians have been urged to follow the patient’s lead. If the patient was still complaining of extreme pain, then the dosage should be increased. The sky was the limit. However, there are problems associated with this mode of therapy; unlike when managing acute or terminal pain.
In some studies, people have discontinued opioid therapy due to the side effects; principally constipation. Contipation has been severe and very resistive to the usual treatment methods. Some patients report drinking a whole bottle of Phillips Magnesia per day, without any effect. Some people may have a bowel movement once a week, or even less. The stool is hard, dry, and very difficult to pass. So needless to say, this side effect is not inconsequential. Other side effects which are hard to tolerate are a ‘brain numbing’ effect. People complain that they don’t ‘think as quickly, but seem to have a hole or vacuum in their brain cells’. To be noted, however, is that cognitive studies which look at patient’s ability to continue to drive or operate machinery indicates that no difference is seen (at least when the dose remains stable over time). Other side effects associated with opioid use, such as nausea, itching, sedation usually subside, and are considered temporary.
In other studies, as opioid doses are increased, the pain increases. This paradox is very confusing to the prescribing physician as well as the person being treated. However, we now know that hyperalgesia (i.e. more pain) can exist along with analgesia (no pain). A particular nerve receptor, NMDA accounts for this analgesic failure. These people seem to improve when opioids are weaned.
There are some studies to suggest that the Hypothalmus-Pituatary-Adrenal Gland may be impacted by long term opioid therapy. This may, over time, decrease the immune response. Consideration needs to be given to this potential, especially in people who are already immune compromised, such as with HIV, but require pain control. Paradoxically, chronic pain also impacts the immune system; so again, the prescribing physician is challenged to be particularly astute when caring for these people.
Interesting to note is that, although they physician should only prescribe opioids if the person's ability to function or quality of life improves, there are no studies which look at either.
Perhaps the most significant affect, or at least the one most discussed, is the potential for addiction. It is apparent, that the risk for addiction is much higher than initially thought. Addiction to prescribed opioids is a growing concern in our society. Unfortunately, there are no tools which can discern which people will become addicted, and who will not. However, there are some tools which can help the physician decide which people are at a higher risk for addiction. If these high risk people are to be treated with opioids, closer monitoring is required to assure that the opioids are being used judiciously.
To summarize, opioids are no longer the panacea for chronic pain which was once hoped for by pain specialists. Future directions indicate that an improvement is desired in both the types of studies conducted, and the medications which are used. Until then, chronic pain will continue to be a challenge both for the person who experiences it, as well as the prescribing physician.
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