The Use and Misuse of Opiates in Pain Management

Addiction: Conditioning the brain for reward

            It is estimated that there are 1.7 million heroin and 3 to 4 million prescription opiate addicts in America. Recent data informs us that in this current era of opiate abuse more people are dying from prescription drug overdoses including opiates than are dying from highway accidents.  To better understand what we in the treatment and recovery field are facing, it is useful to consider the science of pain and reward.

            Endorphins are the natural opioids that give us a feeling of contented well-being in the world.  Natural brain reward chemicals, Endorphins and Dopamine are released when we eat, exercise or have sex.  Our brains are used to releasing small amounts of endorphins and dopamine in response to these survival related activities.  When people are exposed to exogenous, or outside-of- the-body opioids, the brain responds by releasing very large or unnatural levels of dopamine. This tidal wave of dopamine is rewarding and reinforces the behaviors that cause it release. In addition to creating a down-regulation of opioid and dopamine receptors, the brain imprints this profound experience of reward.  

         Evidence within the pain management field reveals the brain and nervous system start down regulating opioid receptors immediately after exposure to opioids. This down-regulation leads to tolerance to opioid therapy for pain treatment. Tolerance leads to the need to take more medication to achieve the same level of pain relief, and leads to deeper levels of physical dependency on the opioid pain medication.

      We now know that opioids also amplify pain in many patients, independent of whether they suffer from addiction.  A type of nerve cell called a microglial cell activates in response to opioid medication and changes the way in which the brain receives pain information. Chronic exposure to opioids leads to microglial cell activation and pain amplification. It is proposed that the experience of pain amplification or “hyperalgesia” may lead patients into the spiral of opioid misuse and abuse in an attempt to achieve the prior states of analgesia associated with early use of these powerful medicines.  Further evidence suggests microglial cell activation within the brain may lead to permanent destruction of reward neurons and/or pain signal pathways between neurons from exposure to high-doses of heroin or opioids. This permanent amplification of pain is known as hyperpathia.

     I have observed clinically that many patients suffering from chronic pain become deeply tolerant and physically dependent on opioids, and begin to misuse and abuse their medication as a direct result of these unanticipated side effects of the opioid medication. Many of these patients demonstrate abuse and/or addictive behaviors, and are at great risk of death due to their attempt to achieve analgesia and/or avoidance of withdrawal. These attempts have become the main driver for the risky accelerated use of prescription opioid medications. 

            In the United States there are upwards of 14 million patients receiving daily prescription opiate therapy for pain. It is estimated that four out of ten patients regularly misuse or abuse their medication. For people who have been abusing opiates who are successful in completing a detoxification to an opioid-free state, it takes upwards of two years for the brain to restore itself from the chemical and brain cell imbalances (allostasis) caused by opioid abuse. Some addicts may require periods of medication assistance with buprenorphine or methadone to reduce cravings and withdrawal symptoms to a point where behavior change from the compulsive use of opioids or other drugs is achieved. There is an abundance of medical evidence that supports the clinical utility of providing buprenorphine or methadone to patients. While this issue remains deeply controversial within the context of abstinence-based recovery, the evidence is clear that the use of Medication Assisted Treatment saves lives, reduces relapse and drug use, and reduces associated medical and criminal justice costs.

            Of equal importance, the development of deep attachment to the feeling created from opioids becomes the most potent driver of relapse behavior. This reality is complicated by the associated deep levels of physical dependency which yield protracted periods of post-acute withdrawal and prolonged substance-induced mood disorders. These conditions are primary drivers for relapse behavior.

            Opioid relapse after a successful period of detoxification is exceptionally dangerous as the patient’s tolerance to opioids is dramatically reduced. Use of a small fraction of the previous amount of opioid can lead to death due to unintentional overdose.

Why is relapse with  opioids so common?

     It is important to remember that the burden of addiction is an evolutionary process turned upside down.  When the brain experiences large releases of dopamine, this creates a profound and deeply existential and reinforcing experience. With opioids in particular, it is difficult for an addicted person not to return to those experiences.  If we consider the perspective that the disease of addiction is ultimately grounded in an individual’s spiritual or philosophical condition, this juxtaposition between deep biological reward states and an individual’s existential reality exists. A duality surrounding attachment to control and the ‘artificial’ state of intoxication could not be more profound than in the brain of the opioid addicted person.

     Some patients report the slightest hint of emotional or physical distress leads to a deep triggering to return to the warm comfort of the opioid high.  The challenge for many opioid addicted individuals is to truly embrace the concept of ‘never-again.’

            I present to my patients the concept of recovery from addiction as a pathway to “brain ownership.”  By this I mean, we educate on the nature of the chemical brain lesion and conditioning that has occurred through repetitive substance use behavior, and then provide immersion in 12-Step oriented treatment and fellowship along with medication-assisted recovery support.  Medication will not do the work over the long-term. It is a useful tool, but is not and cannot be the ultimate solution. The support of recovery fellowship, relentless internal integrity and accountability, and a program of abstinence-based recovery represent the most powerful and free solution to the problem of addiction.

A message of Hope

            I think that the most important message to any person addicted to opiates is the following: you must admit your powerlessness over the drug.  I have seen people try to rationalize their way into their recovery.  Every time I have seen that happen people seem to find a new bottom.  I have always thought that it is critical for recovering people to ask themselves if they are ready to get the divorce from their drugs.  If a person can release that suffering, the pain of addiction becomes an option that they have chosen. Then when they accept their powerlessness and have suffered enough, they are ready for a spiritual awakening

            In my practice it is deeply gratifying to see patients who have to deal with pain and accept that they can’t get high anymore because it is not going to be safe and their pain will continue to get worse if they keep increasing their dose of opiates. Recovery treatment must focus on something more than the provision of medication. Treatment providers must offer a safe context for pain recovery as well as sobriety which includes working the 12 steps, accepting limitations, working with a sponsor and defining whatever their limitations may be, making a phone call, working with a group of experts like physical therapists, physicians, pain psychologists.

            If we as health providers can create a stable platform using varying modalities enhanced with medications, I believe that we can help patients achieve the spiritual transformation that becomes the central core of their successful treatment and recovery programs. Sustained recovery with satisfactory management of chronic pain is an achievable goal in those who suffer from both addiction and pain disorders.

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