Hyperalgesia and Opioid Risks

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Opioid pain medications are among the most powerful type of prescription pain relieving medications available. They are made by ingredients that are derived from the opium of poppy plants, hence the descriptor “opioid.” Common examples of opioid pain medications include fentanyl (Actiq, Fentora, Duragesic), hydrocodone (Vicodin), morphine (Avinza, Kadian, Roxanol), and oxycodone (Oxycontin, Percolone). They can be greatly beneficial to individuals dealing with chronic pain due to their ability to effectively and consistently manage moderate to severe pain.

However, opioid pain medications can cause considerable side effects, including constipation, dizziness, lightheadedness, drowsiness, nausea, vomiting, dry mouth, and difficulty urinating. In addition, serious and permanent liver damage can also result. Serious allergic reactions are also possible, and are characterized by difficulty breathing, hives, and swelling in the face, lips, or throat. Individuals who consume too large of a dose run the risk of overdose, symptoms of which include a clammy sensation of the skin, confusion, impaired memory, severe restlessness, severe weakness, drowsiness, dizziness, decreased respiration rate, and seizures. The effects of opioids can be intensified by concurrent use of alcohol, tranquilizers, sleeping medications, certain antidepressant medications, and antihistamines. In addition to the outward physical side effects, opiates are highly addictive. Therefore, they are generally prescribed with caution, particularly to individuals who have a prior history of illicit drug use or to those who have a history of prescription drug abuse.

Many individuals who take opioid pain medications will discover that over time, they require larger doses of the same medication in order to gain relief from their pain. This can result from either an increase in the severity of their pain, or from the development of tolerance to the opioid drug itself. Tolerance occurs when the body becomes used to the opioid drug, therefore it requires a larger dose to effectively relieve the pain. In such cases, small increases in the dose (or changing to a different medication) will generally relieve the pain. However, over time, as doses are increased, the drug continues to become less effective. It is important to note, however, that increasing dosage to relieve increasing pain OR to overcome drug tolerance is not a sign that a person is addicted to the drug itself.

In the past, opioid pain medications were generally prescribed for short-term pain relief following surgery, to treat cancer-related pain, and for palliative care at the end of life. As such, many physicians have been historically reluctant to prescribe opioid pain medications for other purposes, such as chronic pain, out of concern for the increased risk of misuse as well as the high potential for drug dependency. However, in 2009, a national panel of pain management experts from the American Pain Society and the American Academy of Pain Medicine published the first evidence-based guidelines designed to assist clinicians in prescribing opioids to patients with non-cancer-related pain. Following a comprehensive review of more than 8,000 published studies and abstracts, the panel determined that opioids are safe and effective for use in treating chronic pain in non-cancer patients who are well-monitored. The guidelines do, however, stress the importance of careful patient monitoring during treatment to screen for effectiveness, and to employ the use of periodic drug screens for those patients who have an increased risk for medication abuse.

Opioid Pain Medications and Fibromyalgia

At present, opioids are not recommended by any currently accepted fibromyalgia management guidelines (Carville et al., 2008; Hauser et al., 2010; Fitzcharles et al., 2011; Ngian et al., 2011). Nevertheless, a number of studies have documented considerable use of opioid use among fibromyalgia patients. Fitzcharles et al. found that 65% of 302 fibromyalgia patients evaluated in their fibromyalgia referral clinic were taking opioids, and 60% were taking strong opioids (Fitzcharles et al., 2011). Berger et al. (2010) analyzed patterns of healthcare utilization among 1,803 fibromyalgia patients and found that nearly half used opioid medications.

The widespread use of opioid fibromyalgia pain medications by many fibromyalgia patients illustrates a continued lack of understanding among many physicians as to the nature of fibromyalgia itself. Considerable research has emerged in recent years showing that fibromyalgia likely results from the body’s inability to properly process pain signals making Fibromyalgia a central nervous system focused condition. This is in contrast to earlier and now-outdated views of fibromyalgia, which classified it as an acute pain condition of musculoskeletal origin. While acute pain conditions generally respond effectively to non-steroidal anti-inflammatory medications (NSAIDs) and opioid pain medications, centralized pain conditions respond better to medications that act to regulate the transmission of nerve signals in the body, such as antidepressant medications. A large body of research demonstrating the effective use of antidepressants to treat various fibromyalgia-related symptoms supports this.

Furthermore, opioid medications are often requested by fibromyalgia patients who are frustrated at the perceived lack of effective treatment options available. Unaware of the changing understanding of the true nature of fibromyalgia, and also frustrated by the lack of available options to help their patients, many physicians agree to prescribe opioids in an honest attempt to help their patients’ pain. It is, however, also prudent to understand that many physicians may also appropriately prescribe opioids for acute pain conditions that coincidentally occur alongside fibromyalgia.

Hyperalgesia Risks

Other emerging research related to the side effects and overall impact of long-term opioid use also provides evidence against their use in fibromyalgia patients and other individuals with chronic pain syndromes. Hyperalgesia refers to increased pain sensitivity that the patient experiences as increasing pain despite the use of increasing doses of opioids. Research suggests that long-term use and high doses of opioids may contribute to the development of Hyperalgesia. In other words, long-term use of opioid pain medications has the potential to actually cause pain or worsen pre-existing pain. Therefore, individuals who are taking opioids for fibromyalgia may inadvertently be worsening their pain, or contributing to it, rather than alleviating it.

The risks presented by Hyperalgesia to Fibromyalgia patients who seek to relieve their long term Fibromyalgia pain through the use of opioid pain medications is great. This phenomena is not commonly understood among the general public and most individuals experiencing severe pain have a strong tendency to care about nothing but relieving their pain immediately. But while resorting to opioid pain medications can provide effective short term relief,  patients frequently tend to build a reliance upon the medication. This reliance and trust in its effectiveness often leads to long term usage. While the patient may not in fact be addicted to the drug or technically be abusing the drug, the long term usage carries a very high risk. In the event their protracted usage of opioid pain solutions results in Hyperalgesia the patient will have in effect caused their own increased pain while at the same time eliminating one of the most effective short term means of pain relief.

While there are clear benefits to the short term usage of opioid pain medications as an option for the short term treatment of a particularly difficult Fibromyalgia flare up, research evidence does support the conclusion that overall the usage of opioid pain medications for the long term treatment of Fibromyalgia should be discouraged.

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Benyamin R, Trescot AM, Datta S, Beenaventura R, Adlaka R, Sehgal N, Glaser SE, Vallejo R. Opioid complications and side effects. Pain Physician. 2008;11:S105-S120.

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