The majority of people will deal with chronic or nagging pain at some point in their life, and new estimates suggest that 1 in 10 adults will be diagnosed with chronic pain every year. Even though these numbers are really high, as a society, we’re not doing a very good job of solving the problem of chronic pain.
Even when chronic pain is managed and controlled, it can lead to other issues. When you’re constantly dealing with physical pain, it can be mentally and emotionally exhausting, and the same can be said in the inverse. If you aren’t in the right mindset, it can be difficult to stay active and really work towards preventing chronic pain.
Recently, a new study decided to take a closer look at the connection between chronic pain and mental health – more specifically, depression and chronic pain. For their study, researchers out of the University of Edinburgh in the United Kingdom examined physical and mental health assessments of more than 100,000 individuals.
Depression and Pain
After looking at the findings, researchers uncovered:
People who have partners with depression were more likely to experience chronic pain.
A person whose spouse was depressed had an 18.7 percent increased risk of suffering from chronic pain.
Also of note, having a parent with chronic pain increased a person’s likelihood of developing chronic pain by 38.4 percent.
“We hope our research will encourage people to think about the relationship between chronic pain and depression and whether physical and mental illnesses are as separate as some believe,” researchers wrote.
At the end of the day, this research shines a little more light on another potential avenue for chronic pain management. Sometimes we need to go beyond the root source of the pain and look at environmental and other contributing factors. If we can improve our mental health and the mental mindset of those around us, we might be able to reduce the number of people who have to battle chronic pain on a daily basis.
This week there was another article on the pain management problems at the Veteran’s Association. As with all practices, the VA has had a long history of pushing opioids/narcotics as a main treatment strategy. Then suddenly a year ago, the VA decided these were not great management options and everyone had to be weaned to low dose or off these medications.
Options of management were not really given to anyone; it was just going to be the policy. This week, it was announced that one of their lead physicians has been awarded a grant to study options in weaning. Two options seem to be available, either with help of physical therapy and psychology, or possibly a slow wean by the pharmacist or with your physician.
Weaning Off Opioids
Pain is extremely complex. When a cause of the pain can be identified and treated, it is the best of all cases. Unfortunately, about a third of the population in general does suffer from chronic pain, and in many cases there is no reversible cause. Options to manage pain then become the course. Sometimes it is simple to manage and very successful. However there are oftentimes multiple generators of pain signals and it becomes difficult to develop a successful management routine. Treating pain does take a degree of compassion and it also often requires multiple strategies. Just saying no to drugs, especially to opioids, is a bit short sighted.
Addiction and abuse of opioid medications is extremely well documented. Overdose deaths are becoming rampant. Those who have pain are not resistant to having problems with opioid addiction. Furthermore, combining some medications, like those for anxiety or sleep with opioids significantly increases the risk of overdoses. Patients who have had problems with addiction to drugs, smoking or alcohol also have higher risks for addiction.
There are many ways to treat painful conditions. One of the most important aspects of treatment of pain is working with a skilled, experienced, board certified expert in pain management. These are medical experts who hopefully have extensive ability to identify the causes of pain and develop multiple treatments to help manage the combination of problems causing the pain. They can help coordinate a variety of disciplines covering psychological needs, physical therapy, interventions and all the way through a variety of medications. As noted, there is not a single magic cure, especially not medication alone.
Unfortunately, the VA has seen a problem with opioid abuse and decided that this should be the focus of pain management. The goal appears to be to kill the devil, and get rid of this class of medications for most patients. Pain is much more complex than treatment with a single medication. Some people are dependent upon this as part of their overall management. At this time, there are not a lot of effective medications to treat pain. Research is making strides at better understanding the mechanisms involved in pain and the cells in the body that perpetuate the problems. Still we are definitely lacking solutions.
Instead of making opioids the enemy, maybe there is a better strategy. At this time we need to work on better treatments for pain instead of just eliminating medication options. Using pain management experts who can employ multiple strategies to properly diagnose and treat pain problems is what is needed. The recognition is needed that decisions on treatment options of pain should be made by pain experts, not by addiction experts administering a budget policy. Pain is truly complex and not simple to fully diagnose, manage, or treat.
The death of Prince has been a turning point of how serious the opioid addiction epidemic has become. Almost every medical pain specialist has been aware of the problems with opioids, pain and addiction, but now others are taking note. There are many concerns with prescribing opioids, from whether they actually help control pain, are there better treatments, and how many additional problems they are causing. We know one of the big problems caused by opioids that has become horribly worse is opioid addiction. Many people with and without pain are addicted to opioids. A new way to help treat addiction is in development – vaccines.
The information for this blog comes mainly from an article by Susan Giados published in the July 9,2016 issue of Science News Magazine. For those who are interested in a variety of scientific topics, this is a twice a month magazine, usually about 30 pages long packed with short fascinating articles. Well worth looking into.
The Heroin Scene
Heroin and opioid medications are accounting for about 30,000 overdose deaths a year. Here’s how it came to be popular in the US.
1960’s – Heroin first came on the drug scene in big numbers in the early 1960’s. It was a strong drug that produced an intense high. Most users came to the drug while searching for more intense highs, but the drug was not particularly pure or cheap.
1970’s – Major education and opium eradication efforts into the 1970’s suppressed its use.
1980’s and 1990’s – The late 1980’s introduced long acting opioids like OxyContin onto the market, and big pharma pushed these drugs as safe and as the answer to any all pain was simply to take a pill.
2000’s – By the early 2000’s opioids were the first and most common way to treat pain, and every doctor was prescribing them. The rate of addiction rose drastically, and as the awareness has grown, the access to prescriptions has slowly become harder. Opioid addicts now were everywhere.
Now comes into play some very interesting economics. Addiction itself has driven a market to supply people with opioid medication. It spawned an under culture of “pill mills” where almost anyone could go and get a supply of opioid pills. Many people would “doctor shop” for pills, use some and sell the rest for money. Drug cartels started to get into the mix manufacturing and selling them, further fueling addicts. The government then started clamping down on the supply since about 2010. The drug cartels have long had the ability to make heroin, and now they knew they could make large, pure amounts cheaply. For addicts, those who got hooked on pain pills for any number of reasons now saw heroin as a cheaper and often easier to obtain option than prescription medications. Now heroin has become a major problem as more addicts are turning to that to treat their cravings and pain.
Addiction to opioids has become a huge problem. There now are three medications that are used in the treatment of addiction; methadone, buprenorphine, and naltrexone. Methadone and buprenorphine are used to reduce cravings, and must be continued indefinitely. Naltrexone is used to block receptors and is used almost exclusively to reverse opioid overdoses. Unfortunately of those who seek treatment for addiction, only 25% end up receiving medications to help prevent relapsing back into addiction. Vaccines were first attempted in the 1970’s, but the science and cost of development were barriers, and the methadone was cheap and easy to use.
Addition and Vaccines
Now a little additional primer on addiction. Opioid drugs alter the brain pleasure circuitry and cause changes in the structure and function of the brain. Opioids act on the nucleus accumbens in the brain, and they increase the amount of dopamine in the brain. Opioids also act on the mu receptors throughout the nervous system, stimulating dopamine. These are the same chemicals that stimulate the pleasure centers in the brain and reinforce enjoyable activities like eating, sex or listening to good music. Dopamine, in other words, is what is stimulated by compounds like opioids and by stimulating pleasure. Over time, drugs of abuse can change the circuitry in the brain, decreasing the sensitivity of the reward centers and disrupt the centers involved in self control. Addicts tend to lose the ability to enjoy the normal every day activities, and then they need higher and higher doses of drugs to stimulate euphoric/happy feelings. The need to feel pleasure drives the brain, impairs decision making and self-control, and then the only drive is to take drugs just to stay on an even level.
The goal of a vaccine is to train the body’s own immune system to identify the specific offending drug molecules and rid the body of them at even high doses. One of the vaccines being developed is aimed at heroin and its breakdown product morphine. To be effective, heroin in the body breaks down quickly to morphine, and both these compounds need to be targeted to be helpful. The other problem is when going after a drug, there are millions of molecules in the body suddenly, unlike an infection with a few replicating viruses. So to develop a robust vaccine to stimulate the body’s immune systems and chemicals to rid it of certain compounds like opioids is a bit difficult.
So far scientists have been successful in developing a vaccine specific for heroin and the breakdown to morphine that works in rats. The vaccine trains the immune system to neutralize the compounds and even fatal doses of drugs can be handled. The intake of heroin or morphine no longer produces a high, and drug seeking is not pleasurable. A series of three shots was able to produce months of ability to block drug seeking and pleasure by specific opioids. A second vaccine similar to the one for heroin is being developed for fentanyl. After a number of months, the brain starts to reset to more normal patterns of stimuli producing pleasure versus the strong pull to using narcotics. Blocking the drug seeking and pleasure of opioids does also affect all the pain relieving abilities, and the vaccines essentially cause the body to destroy these compounds making them ineffective for any purpose.
Using vaccines is another tool to control addictive behavior in the future once they are perfected for human use. They will be only for specific compounds, like heroin, morphine and fentanyl and not every single narcotic in general. They will be targeted at the most abused compounds and in that way allow a person still to be able to use certain other opioids if necessary for pain control.
Addiction does occur in the pain patient population. The percent of addicted patients in studies is highly variable, on the low side it may be 2-5 percent, although a common number is up to 17% or higher. Addiction is occurring when the need to take a drug is overriding, judgement is impaired and normal activities are suppressed over the needs for getting and taking the medication. Further, the amount of drug needed is escalating fairly rapidly. When addiction becomes an issue, then being weaned from the whole category of drug is needed and appropriate psychological help for addiction and full treatment is necessary.
This past Monday, Minnesota expanded its medical cannabis program to include individuals who are suffering from severe, chronic and intractable pain. Opening the doors to these patients could bring relief to thousands of people whose pain has not been quelled by traditional treatment techniques.
Before the program opened up to intractable pain, the Office of Medical Cannabis announced that they had 1,827 active patients receiving medical marijuana. Although the numbers haven’t been released yet, likely because it will take some time to sift through all the applications and medical material, state planners project that the number of participants may jump to 5,000 or more.
Proponents hope that the influx of patients will ensure those in pain will get the treatment they need, while current members hope their presence will help lower what some feel are extremely high prices.
Watching Closely
While it’s certainly exciting that people with chronic conditions will have another potential treatment avenue, many doctors are hesitant to fully embrace medicinal marijuana for chronic pain. Many champion marijuana as safer than opioids, which cause more than 300 overdose deaths in Minnesota each year, but we really don’t understand all the compounds in marijuana. It may not lead to overdose deaths, but until we know more about all the compounds in cannabis, we’re not going to be able to treat any patients with pain with any degree of certainty.
Minnesota is one of 25 states that have legalized medicinal marijuana, and the vast majority of those states list chronic pain as a qualifying condition. Studies have also shown that overdoses have fallen in those states with medicinal marijuana, and doctors in those states are writing fewer prescriptions for potentially dangerous opioids.
Hopefully those who truly need relief will be approved and find help through the state’s medical marijuana program. I hope the state reinvests some of the profits into future studies to ensure we are doing everything in our power to keep our patients safe, and so we can better understand how cannabis and pain are related.
For more information about the program, including a list of eligible conditions or how to apply, click here.
A nationwide survey of alcohol and substance abuse uncovered that chronic pain oftentimes plays a big role in why individuals begin to abuse opioids. The study revealed that individuals with chronic pain are 41 percent more likely to develop prescription opioid use disorders or to become addicted to opioids, according to the new report.
For their study, researchers looked at reported opioid use disorders and demographic factors, including age, gender, family history and other behavioral factors in more than 34,000 adults. The data was collected in two segments over a three-year period.
“These findings indicate that adults who report moderate or more severe pain are at increased risk of becoming addicted to prescription opioids,” explained Mark Olfson, Professor, Columbia University Medical Center in the US. “In evaluating patients with pain, physicians should also be attentive to addiction risk factors such as age, sex and personal or family history of drug abuse.”
Who’s At Risk?
After examining the results, researchers uncovered:
While men or younger adults remain the ones at higher risk for these disorders, women and older adults who became addicted to opioids are observably the ones who also reported chronic pain.
Participants who reported chronic pain with prescription opioid use disorders were also those concurrently suffering from mood and anxiety disorders.
Researchers concluded by saying that the results show physicians need to be more aware of the opioids they’re prescribing and to whom they are prescribing them to. They believe enhanced monitoring of some patients at greater risk for abuse can help prevent people from abusing opioids.
Prescription pain pills can certainly help provide relief for patients with chronic pain, but they should never be viewed as a solution. Exercises, physical therapy and even some surgeries can help provide temporary and permanent relief. Instead of managing pain, we need to keep treating it and solving the problems.
The majority of people will deal with chronic or nagging pain at some point in their life, and new estimates suggest that 1 in 10 adults will be diagnosed with chronic pain every year. Even though these numbers are really high, as a society, we’re not doing a very good job of solving the problem of chronic pain.
