Today we’ll look at the medication category of Narcotics, also called Opiate Medication. These are medications designed to treat both acute and chronic pain.
Today is the deadline for submissions to November’s Pain-Blog Carnival, which will run this Friday, November 30. Please submit your post here.
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This article is one in a series on Medications for Pain… What are your choices? How do various medications work? What are the pros and cons? How about side effects? (Discuss these ideas with your doctor. Don’t make any changes to your treatment by yourself.)
Of all medications for pain, narcotics probably get the most press and cause the most controversy. If you judged how important or effective narcotics were based on how much is written about them, you’d assume they were the primary treatment for pain:
Blue = Narcotics Red = Everything else
Instead, your pain medication regimen should look something like this:
If used, narcotics should be 1 medication in an array of helpful treatments.
Narcotics:
Narcotics include opium derivatives (Morphine and Codeine) and synthetic opiates (Methadone, Demerol, Oxycodone).
Effect of Narcotics:
Narcotics work at opioid receptors, where they interfere and stop the transmission of pain messages to the brain. They also alter one’s psychological reaction to pain. Patients sometimes report still being aware of pain, but not having such an aversion to the feeling.
Side Effects:
- sedation
- nausea or vomiting
- constipation
- breathing difficulty at higher dosages
Issues with Narcotics…
1. Effectiveness
Unfortunately, while narcotics are great for acute pain, they often don’t work so well for chronic pain, especially nerve pain. The balance of good effects versus problems may not be so favorable in chronic pain.
2. Tolerance
When narcotics are used, over time your body gets used to their effect. So to get the same effect, often a higher and higher dose is needed. Often as the dosage is increased to continue to get a benefit, the side effects continue to increase. However, don’t mistake tolerance, which is simply a physical process, with addiction.
3. Addiction
True addiction is a disease in which people continue to use a substance (alcohol or drugs), despite bad consequences such as physical illness, relationship problems or inability to function at work. Just because your body is tolerant to a medication, doesn’t mean you’re addicted. Addiction is a behavior; tolerance is a physical process.
However, a small percentage of patients who use narcotics will develop true addiction, with symptoms such as lying about how much medication they’re using, doctor shopping to get more prescriptions, obtaining narcotics illegally, and using the medication to get high rather than to control pain. Only about 5% of patients who are prescribed narcotics for chronic pain develop addiction. The risk is higher in people who’ve been addicted to drugs or alcohol in the past, and for those who have few other coping skills to deal with pain.
4. Side Effects
Side effects of narcotics can be significant. The 2 most bothersome ones are usually sedation and slowness in thinking, and constipation, which can be severe.
5. Do Narcotics Increase Pain?
An under-recognized problem is that for some people, narcotics can set up a process where pain will increase over time, even if they initially decrease pain. Narcotics can cause what’s call hyperalgesia, which is an increase in pain sensations. When this occurs, sometimes doctors think the medication isn’t working and increase the narcotic, when in fact the narcotic itself is increasing pain. A vicious cycle can develop. As with all drugs, for narcotics to continue to be prescribed, it should be clear that they’re decreasing pain.
Conclusion… Pain is bad, and sometimes narcotics are helpful and should be used. We need to be sure that for any patient, the benefits are worth the risks. When narcotics are used, it’s important to see if a person’s functioning is improved, in addition to a decrease in pain.
I’ll be interested in reading your thoughts about narcotics in the comments…
Thanks to Not Walton at Flickr for the first photo.
Next Monday, we’ll look at Upcoming Advances in Pain Medication. Other articles in this series:
27 responses so far ↓
Nickie // Nov 26, 2007 at 8:15 am
I have used opioids as part of my treatment plan. Because of all of the hype surrounding them, I was really quite scared to even try them. I think they can be helpful, but for me, it’s taking a while to figure out the correct dose. We know they help me, we just have to find the correct med and dose.
I’ve also been fortunate to not experience a lot of side effects.
How to Cope with Pain // Nov 26, 2007 at 9:54 am
Thanks, Nickie for your comment. Like Nickie says, for many medications it takes a while to find the right dosage. Keep working on it!
Christy // Nov 26, 2007 at 10:36 pm
Unfortunately, I look a lot more like the first pie chart than the second. Initially, that was not the case, but the only medicine that seems to make any difference is Vicodin (well, the Duragesic patches helped, but I wanted out of that). Part of it may have to do with the fact that I’ve had 9 knee surgeries so it’s a good medicine to have immediately after a surgery, but I’ve been taking it on a daily basis since 2003.
I have no poor side effects and after taking it for so long, I can function like any normal person while on it, but the stigma that comes with it certainly sucks.
How to Cope with Pain // Nov 27, 2007 at 6:35 am
If it works and you have no significant side effects, then it’s good for you. Besides pain relief, it’s important to look at if it helps you function, ,which you say is the case. Good for you!
Many patients comment about the stigma, which is unfortunate that it comes along with a class of medication that sometimes really helps patients.
jeisea // Dec 1, 2007 at 6:58 pm
I really appreciate this article as it clears up a few things for me. I took Tramel (Tramadol maybe in the US). I felt fantastic (young even) for about 6 hours. However I very quickly developed a tollerance and within weeks of first taking it my body withdrew form the drug with resultant shaking, vomiting etc for over 30 hours. In the end I felt worse than before I took the drug. I appreciate learning the difference between tollerance and addiction.
I can not take pain meds now and consider that this is a blessing as I’ve been able to find real pain and symptom relief without the use of medications and the hell that can go with taking them. I encourage others to empower themselves by learning from websites such as yours and make informed decisions about treatment.
How to Cope with Pain // Dec 1, 2007 at 7:52 pm
Yes, big difference between tolerance and addiction.
Glad to hear this website helps a bit! Thanks.
bad druggy // Dec 21, 2007 at 12:34 am
How does Jeisea cope with her pain without medicine. I have osteo arthrties in the neck. I tried the NSAI but help little. Dr gave me an Endyral patch, Morphine, Oxycontin, Methadone, and thougth hey help the pain ,the side effects are making me misarable. I am trying Oxyconting again. Does anybody there know if the side effects get better with time? I got Reglan for nausea and constipation, but what can I do about the itching and headache, and gummy groggy, tired feeling, I can’t even concentrate to read a book.
How to Cope with Pain // Dec 21, 2007 at 5:26 am
You’re right… while opiates can help, they often do have significant side effects. Sometimes these side effects do lessen a bit as your body gets used to the pain.
You might look over other posts about non-medication ways to help with pain. (You can use the search feature above to help with that.)
jeisea // Dec 21, 2007 at 8:46 pm
Hi BD
Hope you don’t mind my answering your question, “How does Jeisea cope with her pain without medicine?”
The truth is I sometimes cope with great difficulty. The reason I can’t take medications is because I get dangerous cardiac reactions to most meds. A Vascular Physician/Cardiologist advised me never to take them, including paracetamol. This is due to dysautonia affecting my blood pressure. I had no choice but to look for alternative ways of coping and now realize that not taking medications has been a blessing.
At first I was devastated and frightened. Faced with sink or swim, I decided to swim. I began by changing my attitude from what can be done to help me to what can I do for myself. Then I hit the internet. I looked up research. When I didn’t understand I sent emails to the researchers, and all those contacted have helped me. I wrote down what helped, eg heat packs, etc. Hooshmand’s website helped me with practical “do-able” stuff like epson salts baths.
I discovered something Dr Lorimer Moseley had written about mirror therapy. It sounded feasible to me so I keep seeking information and research. This was about July last year. I asked my physiotherapist for help. He didn’t know anything about Moseley at the time. Also at this time, I came to the decision that the hands-on physical therapy I was having was making me have more pain. Also at the time I had been given many diagnoses of inflammation problems, eg tendonitis in many areas. I was on a downhill run.
My new physical therapist knew about CRPS/RSD. She taught me to do whole body therapy at home. She taught me how to calm the sympathetic nervous system by activating the parasympathetic system. This reduced pain. She gave me some control. In August last year my old physio saw me in the street very excited about DR Mosely and mirror therapy. He gave me the book “Explain Pain”. I went home and worked out what I thought might work and tried using a mirror to retrain the brain.
This is the single most effective help in pain relief I have found. However I had so much pain and all over my body that I could only do a bit at a time and an area at a time. It’s taken very hard work doing both physical therapy and mirror therapy, and more recently laser acupuncture to get me to the stage today where I am looking forward to a joyful, much less painful, Xmas. Last Xmas was very hard for me. Now I am grateful for no medications. Mirror therapy and acupuncture provided the most pain relief, but exercising yourself every day is a very important part of retraining the brain. Changing the way I feel about my pain and putting a positive spin on whatever life throws at me is how I cope.
I hope all who read this have a blissful, joyful season. Thank you HTCwP for helping us all so very much this year.
Jeisea
How to Cope with Pain // Dec 22, 2007 at 6:58 am
Thanks, Jeisea, for your wonderful answer! I know from Jeisea that it’s a lot of work to be in the driver’s seat of helping yourself with pain treatment. And it’s a process – don’t expect yourself to get there overnight. Thanks for sharing, Jeisea!
bad druggy // Dec 25, 2007 at 5:25 pm
I want to thank How to Cope with Pain and Jeisea for their helpful information on pain. My problem with pain has led to a problem of chronic insomnia. Pain and insomnia have led to chronic depression. When I visit my doctor, he loads me up with medications, but never tries to get to the root of the problem. But I can not tolerate the stuff, especially the opiods. I’ve tried, but all I can do is take it for one or two days, and then I have to stop. Your thoughtful advise, has given me hope, and I have decided to seek other non-chemical methods of therapy to amiloreate my pain. Thanks so much. BD
How to Cope with Pain // Dec 27, 2007 at 3:51 pm
I’m glad you’re seeking non-medication ways to help with pain. And you might try a pain management specialist to see if medical/medication ways might bring you some relief, as well. Often, it’s the combo that works best!
Suzen // Jun 22, 2008 at 8:22 am
I have chronic pain and have tried numerous pain meds. I am on a new one called oxcycoton, not sure of spelling, anyway, I have found it helps greatly with my pain, but I itch something fierce while taking it. The itching deters me from taking it all of the time, so only when the pain is so bad, I could just vomit-that’s when I will take 1 pill. But the darn itching!!! I have Benydral but then I’m having to take 2 kinds of meds. UGH!! Is there anything to stop the itching without having to take yet another drug??? H E L P……………………….
How to Cope with Pain // Jun 22, 2008 at 9:36 am
Suzen, you’re right, taking a 2nd pill to counteract side effects from a 1st pill it not fun, but if it allows you to benefit from Oxycontin, that might be worth it.
You might ask your doctor to try another narcotic – sometimes side effects will be less with another type.
Good luck!
Sara // Aug 28, 2008 at 11:27 pm
A couple of things I wanted to mention:
The actual percentage of people who get addicted to their pain medication is less then 1%. This has been shown in numerous studies. Most of those do have a prior addiction history.
Also, most of the negative side effects of opiates go away with more regular usage- the exception being constipation.
That is true of any medicine, but the side effect list with anti-depressants or muscle relaxers, for example, is much longer then for my opiates. I run a support group, and I hear a lot of “Oh, I’m trying to avoid medication side effects, so I just take a lot of ibuprophen when I have pain”. After doing medication research, I ONLY take ibuprophen for fever, cycle-related pain, or pain I am pretty sure is inflammation based. I couldn’t believe how much risk there was to such a common OTC medicine. Opiates are safer then most of the other medication options for pregnancy and breastfeeding- an issue many chronic pain patients come up against at some point. Most opiates are catagory B or C- most other meds for fibro are C or D catagory.
Also, there is a phenomenon called “psuedo-addiction” where a patient is exhibiting all the signs of an addict but in actuality inadequately treated. It’s hard to get a figure on this, but I bet it accounts for a lot of ER “frequent-fliers” and other behavior that looks like meds-seeking. People who are uninsured/underinsured and don’t have a lot of options as far as switching doctors or seeing specialists probably also fall into this group. It’s a vicious circle; places like low-income or public health clinics DO have a higher level of patients with an addiction problem, so the doctors begin to see an addict behind every corner, so legit patients go without treatment, and then maybe to deal with their untreated pain, turn to things that create addicts….
I’ve tried almost every med out there, and my opiates are a crucial part of my treatment. I’ve found that for me, no one med is “the med”, but a combo is necessary, along with, of course, different lifestyle things I’ve found helpful. But if I had to cut down to one medicine, it would most likely be my pain meds.
I would love to be able to control my pain with non-analegsic methods, especially because of the stigma (not only with taking opiates, but with taking medication in general- people are considered “better” if they can manage things without meds) but also because if you are in an acute crisis and already on pain meds, at least here you are often denied treatment. I was denied pain medication after gallbladder surgery; a woman I know was denied pain medication when she fractured her knee- there’s other stories I could share along these lines. You do become physically tolerant to a medication- almost any medication- that you take for a length of time (For example, I started on 25 mg. of amitryptiline and am at 250 right now) and when an acute crisis/need comes up, things need to be temporarily adjusted.
However, my pain meds were the missing piece of the pie, so to speak, that allowed me to regain a higher functioning level as well as to try more non-medicinal methods such as exercise (I always find it amusing when someone says “Doctor, I can barely walk”, “Oh, well, then why don’t you try a half-hour a day of exercise?” It shows a big lapse in communication). I look forward to a day where I can hopefully cut down on some of my meds; but I’m less concerned with how many pills I take then with the quality of life I have.
How to Cope with Pain // Aug 29, 2008 at 7:43 am
Sara, thanks for your insightful comments. It sounds like you’re a well-educated patient and an advocate for yourself.
I think you’re right on with focusing on function, as that’s 1 of the 2 most important goals, (in addition to pain relief.)
Tracy // Nov 23, 2008 at 5:03 am
I have chronic pain due to spinal fusion That did not turn out well I have neuropathy down my Left leg that goes into the left foot I do not take any pain meds at all because I am a School bus driver,But some days I find it very difficult to function Is there anything that you know of that may help me that is a non narcotic that I could take that would help with the constant pain due to nerve damage done during my surgery. I am concerned with my mental attitude some days, because I can not walk long distances or sit for long periods this makes things worse I would like to learn to cope better with the pain that I have. I would also like to know if there is any exercises I can do. at this time my exercise is limited because it makes the pain worse.
How to Cope with Pain // Nov 23, 2008 at 10:52 am
Tracy, 2 series here at How to Cope with Pain which might be helpful to you are:
1. Medications for Pain
2. Pain Management Classes
These are both good ways to take at look a medication and non-medication ways to decrease and cope with pain.
Suzzane // Dec 28, 2008 at 7:35 am
hello. Jus wanna ask if how can we classify the effects of narcotics in our body. I mean, what are good effects and what are the bad ones?
How to Cope with Pain // Dec 28, 2008 at 9:22 am
Suzzane, we generally think of pain relief as the “good” effect of narcotics, and all other effects as side effects. However, “side effects” can sometimes be put to good use. For example, the sedation that comes with narcotics is good to help people with short-term pain (eg broken bone or surgery) get extra rest and sleep to heal. If you have long-term pain, the effect of sedation isn’t good during the day, but might be helpful at night.
Some other side effects, eg nausea, are never good.
Hope that answers your question.
OA/RA- MAN // Mar 3, 2009 at 5:32 pm
I have OA and RA. I have been taking lortab for about three years, 3 10/500 per day on average. Recently my blood work showed a high increase in liver enzymes. I am think of trying oxycodone, to eliminate the acetamitaphen in my lortab. maybe 2- 20 mg. time release doses per day.
I function fine on my lortab, but the negative side effects to my liver are not worth the damage. Will I be able to function on hydrocodone?
How to Cope with Pain // Mar 3, 2009 at 5:47 pm
OA/RA,
I don’t prescribe narcotics, so can’t tell you exactly what the conversion would be. However, narcotics are similar, but not all the same. So you might do better with a different one, or you might do slightly worse. It may take some dose adjustment to reach one that’s good for you. But I’d agree with you that a trial of something different would be helpful. I’d suggest talking with your doctor about how to make this transition.
There is some evidence, though controversial, that changing narcotics can reverse tolerance which usually develops with narcotics. This means that you might actually need a lower equivalent dose – and therefore fewer side effects.
OA/RA- MAN // Mar 4, 2009 at 2:28 am
Thanks for the response, It’s nice to have a forum to discuss these issues with other people who can relate.
OA/RA- MAN // Mar 15, 2009 at 5:19 am
Well I just wanted to give an update on my medication change over. I went from 3- 10/500 lortab per day, to 4- 10 mg instant relaese oxycodone. The oxycodone work much better at the new dose, and my liver tests have come back with much improved numbers.
I also use 600 grams of VOLTAREN GEL per month as well. The combination of these 2 medications has been just great. I now have a handle on my arthritis for the time being, I would highly advise the use of both of these meds to anyone suffering a similar fate.
Good luck my chronic pain companions!
Melissa // Oct 2, 2009 at 11:32 am
I have to agree that I am falling into the group where the pain medication is increasing my pain and I have major side effects with very low doses, such as itching, nausea, sedation, and constipation. I have decided to forgo all the narcotics unless absolutely neccessary for actue pain. I have less chronic pain when I do not take them. I do go for epidurals which seem to help me but not for very long. My treatment does look like your second chart. I was leary of the narcotics to begin with, and was very concerned when I had tooth pain that the narcotics they had me on was not controlling. My major problem is nerve pain and muscle spasms. Md put me on low dose of 10mg oxycontin 2 times per day. Seemed to work very well except for drowsiness, but when my epidurals wore off I was in the worst pain of my life, so then they prescribe Percocet 5/325 pain and side effects significantly worse if not taken around the clock. I stopped taking in and within 3 days pain gone. I thought I was crazy.
Melissa // Oct 2, 2009 at 11:35 am
Can narcotics also cause depression?
sparky // Oct 2, 2009 at 4:05 pm
Unfortunately, yes. Just like other sedative medication (like benzodiazepines – Valium, Klonopin) or substances (like alcohol), opioids can cause depression.
Of course, you have to tease out if it’s just sedation or actually depression. And if there’s depression, you have to tease out if it’s due to 1) medication, 2) the situation causing stress and depression, and 3) an underlying psychiatric disorder of depression. It can get complicated!
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