The problem of pain: Relief without opioids?
by Bronwyn Duncan
Globally, the use of prescription opioids is on the rise, and not all these scripts are used by people who would prefer to use illicit drugs such as heroin. In fact, opiates play a significant role in relieving pain. And if you are unfortunate enough to have both an opioid dependence and chronic pain, the issue of pain relief becomes especially challenging.
In the November issue of Of Substance we explore the topic of pain management. Following is an extract. For the full article, visit www.ofsubstance.org.au.
In the last two years there have been global moves to make pain management a high priority within health care policy and practice, driven by both human rights and economic concerns. Professor Michael Cousins, Chair of Australia's National Pain Strategy (NPS) states, 'Pain is Australia's third most costly health problem and arguably the developed world's largest "undiscovered" health priority.'
A 2007 report by Access Economics and the MBF Foundation found that chronic pain costs the Australian economy $34 billion per annum. The largest share of costs is borne by the sufferers themselves (55 per cent).
While chronic pain is today recognised and treated as a disease entity in itself, delivery of care is inefficient and haphazard. There is, however, some cause for optimism. In 2010 Australia was the first country in the world to develop a national approach to improving the lives of people living with chronic pain. Through the National Pain Strategy, a coordinated approach to policy reform is being developed. Several countries are following in Australia's footsteps.
Opioids and pain management
The National Prescribing Service (NPS) recommends that opioids should only be prescribed as part of a broader pain management plan and introduced on a trial basis. Patients should be carefully selected, clearly understand the goals of opioid therapy, be instructed about proper use and be closely monitored.
This is a crucial message. The past 25 years has seen a marked rise worldwide in the use of prescription opioids to treat moderate to severe chronic pain, but evidence suggests that only one in three sufferers benefits. Opioids can be very effective in treating cancer pain and some other types of chronic pain, but for some people and some conditions they are either ineffective or may actually aggravate pain. Adverse side effects from combining different drugs, and individual reactions, such as skin intolerance to morphine patches, can further limit the effectiveness of opioids and other pain relief medicines.
Some patients report being prescribed high doses of opioids from the outset, which over time have no effect in controlling the pain, as well as impairing their ability to function normally.
'We've learned only recently that opioids taken long term at high dosage are implicated in serious physiological damage,' says Dr Penny Briscoe, Head of the Pain Management Unit at Royal Adelaide Hospital. 'They act to suppress hormones such as testosterone and impact upon the hypothalamic pituitary function. Testosterone gives us drive and energy, so without it we become lethargic and unmotivated.
'Long-term side effects can include compromised immune systems, fluid retention, osteoporosis, and infection risk. As you might expect, patients who have managed to reduce or come off high dose opioids report feeling much better.'
Drug dependency and chronic pain
A serious issue for people in opioid substitution therapy, and others known to be past or present illicit drug users, is the consequences when genuine pain is mistaken for drug-seeking behaviour.
The Australian Injecting & Illicit Drug Users League (AIVL) reports that 'people who use/have used illicit drugs routinely find it impossible to get appropriate pain relief irrespective of the symptoms', including treatment for anxiety and other comorbid mental health problems.
Substance use can mask pain from illness or injury. 'When drugs are reduced or withdrawn the pain from injuries surfaces,' says Nicole Wiggins, manager of the ACT peer-based drug user group CAHMA. 'We know of people with serious injuries who have been denied pain relief for months. We need an appeals process or ability to refer clients to an independent medical team. But only a system-wide culture change will remove the attitudes behind these practices.'