The aim of the wise is not to secure pleasure, but to avoid pain.
By the time Greek philosopher Aristotle (384 B.C. – 322 B.C.) made this observation, physicians were already using opioids to treat pain. Hippocrates, an ancient Greek physician known as the “father of medicine”, had noted that opium “was an incredibly useful drug in treating pain, internal diseases and epidemics,” according to a report by the United Nations Office on Drugs and Crime website.
For millennia, opioids have been used for the treatment of pain, especially acute pain following injury or surgery. The unintended consequence of this widespread use has been an “epidemic” of opioid abuse and overdose. The Center for Disease Control estimates that more than 100 people die from opioid-related abuse every day in the United States. This has led many physicians, surgeons, and pain management specialists to re-think the risks versus rewards of opioid prescriptions. Some have even questioned whether these drugs meet the pain reduction objective.
Recent Research Questions the Efficacy of Opioid Treatment
After surgery, opioids — such as morphine — are routinely used to manage pain. However, according to a new study carried out at the University of Colorado Boulder, these drugs could actually raise the likelihood of experiencing chronic pain.
The results of this study, published in April 2018 in the journal Anesthesia and Analgesia, noted that “Compared with rats given saline, those that received the morphine endured postoperative pain for over three additional weeks. Also, the longer the morphine was provided, the longer the rats’ pain lasted. The study also revealed that tapering of the morphine dosage makes no difference. This tells us that this is not a phenomenon related to opioid withdrawal.”
In the brain, there are specialized cells called glial cells that protect and support nerve cells. As part of their role as “protector,” they direct the brain’s immune response, including inflammation.
The trauma of surgery activates glial cells’ receptor (TLR4) and they help to orchestrate the inflammatory response. This “first hit” of surgery primes them for action when the second hit occurs. The second hit is morphine, which also stimulates TLR4. With this second hit, the primed glial cells respond faster, stronger and longer than before, creating a much more enduring state of inflammation and sometimes local tissue damage.
This research is informed with an understanding of pain and how it affects tissue, nerves and the brain. As Dr. Kevin Ju, a spine surgeon at Texas Back Institute notes there are different kinds of pain – chronic and acute – and they must be treated differently.
Chronic Versus Acute Pain
“Typically, we associate pain with an injury,” Dr. Ju said. “As the injured tissue heals over time, the pain goes away. This is a typical characteristic of acute pain.
“Chronic back pain is different. It persists for more than three months and may vary in intensity. It may be caused by an ongoing mechanism such as arthritis, persistent nerve root compression, nerve root injury or other ongoing processes. In some cases, the exact cause of the pain cannot be identified and can be associated with changes that have taken place within the nervous system itself. Chronic pain lingers even after the body is healed. ”
While the two types of pain are both unpleasant, they are distinct phenomena and require different types of treatment.
“In the beginning, the two types of pain are similar,” Dr. Ju said. “At onset, acute pain feels no different from chronic pain. The primary difference – and this is important – is that acute pain serves as a biological function. It is a warning that you have injured your body and it is telling you that you need to take it easy and let your body heal.
“For patients with acute pain, we try to ascertain the cause for this pain. For example, was the injury a disc herniation? A fracture? When we determine this cause, we target treatment to address this. This can be in the form of injections, physical therapy and, as a last resort, we can do surgery to repair the injury. Once this injury has healed, the patient’s pain will be relieved, and they can get on with their lives.
“With chronic pain, even after an injury has healed, the patient is still in pain. His or her nerves are hypersensitive, and the way the brain processes pain is different. This type of pain can often be debilitating, and it requires a multi-disciplinary approach to treat it. This can include medications, physical therapy, biofeedback, and behavioral therapy.
“With chronic pain, we must ensure that there is no on-going injury or damage. If there isn’t any tissue damage, it is a matter of the way the nerves and the brain are processing this pain. At this point we call on our other TBI colleagues to be involved – our psychologists and other conservative care physicians – and we try and we treat the ‘whole’ patient.”
Should Opioids be Used for the Treatment of Pain?
Since ancient times, opioids have been used for treating acute and chronic pain. Is this still good medicine?
“In general, one should always try to avoid using opioids for treating pain, especially chronic pain,” Dr. Ju said. “However, there are rare occasions where judicious use of opioids is appropriate. Opioids relieve pain by directly and powerfully binding to receptors in the nervous system to decrease feelings of pain. They can also create feelings of relaxation and contentment, in spite of the pain.
“I typically recommend that patients start with non-opioid medications to try and manage their pain before resorting to narcotics. These can include Tylenol, Nonsteroidal Anti-inflammatory Drugs (NSAIDs) (e.g. ibuprofen, naproxen), gabapentin, and/or tramadol.
“As with any medication, there are potential side effects and certain medications may not be appropriate for all patients. However, these medications typically have a safer side effect profile than opioids, which can lead to constipation, sedation, respiratory depression and are much more addictive than the non-opioid alternatives.”
To hear the complete interview with Dr. Kevin Ju, click on SpineTalk.