Why the painkillers don’t work anymore… Opiate Hyperalgesia

“My whole body hurts now, more than my back ever did after surgery…. Why?”

Over the last five years, doctors and scientists have begun to more fully understand the process of pain amplification called Opiate Hyperalgesia. When opiates are taken for any reason, complex and profound changes occur on a cellular level over time. The most basic example for opiate dependent patients is the experience of things hurting in their body that never hurt before. We must ask, how did this happen?

Historically, prior to the 1990’s in the United States, opiate pain pills were more traditionally used for postoperative pain and for patients dying of cancer. Over the last twenty years, the prescription of daily chronic opiate medication for pain has become a more frequent pathway that doctors offer to patients. This behavior has become normalized with pain being considered “the fifth vital sign” and a philosophy of wanting patients to be more free of their pain symptoms.

Unfortunately, medical knowledge about opioids and their effects on the nervous system over months to years, was not as well understood as doctors originally thought. The belief that treating patients experiencing significant pain with opiates would reduce the probability of addiction to pain medicines has not proven to be accurate. Several studies have shown that up to 46% of patients taking opiate pain medicines take them inappropriately at some point in the most recent 12 month period. This evidence suggests we don’t understand fully the effect of these powerful medicines on the brain, or the signaling of the body to the brain. We can conclude that, in spite of lots of pain medicine, something else is going on that makes people take medicines in a way that is dangerous to them, and this can lead to addiction.

All patients who take daily opiate pain medicines become physically dependent upon opiates. This means they will have significant physical and emotional withdrawal symptoms when they reduce or stop taking the pain medicines. The reality of physical dependence is a factor which drives many patients to continue to take opiate pain medicines in spite of reduced effectiveness over time for treatment of pain symptoms. This change in effectiveness is due to tolerance to the opiate medicine. Opiate tolerance creates the biological need to take more of a medicine to have the same pain-relief effect. This process is what drives doctors to prescribe higher doses of opiate pain medicine to their patients. One of the biggest challenges that patients in chronic pain and their treating physicians have faced is the reality that for many patients, the use of opiate pain medicines is a pathway of diminishing returns demonstrated by tolerance and Opiate Hyperalgesia.

Molecular biology has allowed scientists to understand the following changes that take place when opiates of any kind are present in the body of a human being.

1. Opiate receptors in brain neurons and spine neurons are reduced (the body reduces the number).

2. Spine nerves and brain nerves change the way they chemically communicate.

3. The body makes chemicals that change the way opioids bind to receptors.

4. NMDA and Glutamate-linked opioid receptors change signal volume to the brain (increase) providing pain signals from pathways that usually don’t signal pain. This elegant and very clear molecular pathway has answered why many patients taking opiates cease to have pain relief and experience pain in places and in ways they never have before.

This last category significantly changes the way patients experience being in their bodies, and this is now known to be the driving force of pain amplification.

Buprenorphine is FDA indicated for all patients who are opiate dependent. With or without addiction behaviors, all opiate dependent patients can be treated with buprenorphine to free their bodies from opiate dependence with the goal of eliminating their physiological dependence on the opiate medicine.

Many buprenorphine providers, including our team, have observed over a period of weeks to months through buprenorphine detoxification, a dramatic change in the pain amplification that has occurred due chronic opioid use. We have observed profound physical changes in our entire population of opiate dependent patients, regardless of the origin of their opioid dependence. Interestingly, buprenorphine is the only opioid which antagonizes (turns off) the NMDA and the glutamate-linked opiate receptors that amplify pain.

Current biological research and pharmacology research is taking place to further understand and potentially redefine the appropriate use of prescription opioid medications, including buprenorphine. It is important to clarify that buprenorphine is an opiate to be used in treatment for the indication of opioid dependence. All opiates have an analgesic (pain treatment) effect. To this end, buprenorphine is not to be prescribed as a “pain medicine”.

Hazelden is proud to offer integrated, multidisciplinary care with certified physicians, nurses and counselors with backgrounds in Psychiatry, Pain Management and Addiction. Please contact us if you are opiate dependent and would like to discuss buprenorphine detoxification as part of your Pain Recovery program.