When I started researching the problem of chronic pain and coexisting addictive disorders, including prescription drug abuse or prescription drug addiction, in the mid 1980s I found an incredible amount of publications and research on addiction treatment, and a lot of information on chronic pain management, but not ANY information—publications or research—pertaining to treating someone with both conditions.
Fortunately, that is not the case today. In fact there is so much information it takes a significant amount of time to go through it and seek out the quality sources. My goal here is to update this page monthly to provide a synopsis of news stories and research or publications that are related to chronic pain and prescription drug addiction treatment. I will also be posting interesting news and research updates more frequently on my blog page
The Role Genetics Plays in the Management of Chronic Pain
I've just come across new research about the role of genetics in patients using opiates that I thought important to share. On the Stanford Medical School Website I found a recent posting titled Opiates' side effects rooted in patients' genetics, study shows, written by Tracie White with an exerpt below.
Genetics play a significant role in determining which patients will suffer the most from the disturbing side effects of opiates, commonly prescribed painkillers for severe to moderate pain, according to a new Stanford University School of Medicine study, which pinpoints nausea, slowed breathing and potential for addiction as heritable traits.
What this research highlights is the importance that a patient’s history plays in development of potential risk factors from the long-term use of opiates. Unfortunately, most primary care physicians (PCP), and even pain management specialists, do not conduct an individual or family history of alcohol or other drug problems in patients needing opiates. Keeping the above research findings in mind, I believe this lack of screening is contributing to the growing incidents of prescription drug abuse and even addiction to pain medications.
“One of the most hated side effects of these opiates, nausea, is strongly inherited,” said Martin Angst, MD, professor of anesthesia and one of two principal investigators for the new study, which explores individual variations in the response to opiate use. The study was published June 20 in Anesthesiology. Genetics also play a likely role in determining which patients will suffer from itchiness and sedation associated with the use of these powerful medications, which include morphine, methadone and oxycodone.
“The study is a significant step forward in efforts to understand the basis of individual variability in response to opioids and to eventually personalize opioid treatment plans for patients,” said Angst, director of the Stanford Human Pain Research Laboratory.” Our findings strongly encourage the use of downstream molecular genetics to identify patients who are more likely or less likely to benefit from these drugs — to help make decisions on how aggressive you want to be with treatment, how carefully you monitor patients and whether certain patients are suitable candidates for prolonged treatment.”
Unfortunately, the response to these problems was the creation of what I call the “War on Pain Management,” being waged by the DEA with their crack-down on opiates prescriptions. Pain management providers can become targets and need to look closely at the long-term use of opiates within their patient population.
Many people taking opiates as part of their chronic pain management may find they are experiencing serious problems with long-term use. Some may even develop an addictive disorder due to prolonged exposure to these powerful medications. Others can build up a tolerance and find they need ever increasing doses. Others develop a condition known as hyperalgesia.
For those who may be unfamiliar with this phenomenon, I’m including a definition of opiate-induced hyperalgesia from Wikipedia.
Opioid-induced hyperalgesia or opioid-induced abnormal pain sensitivity is a phenomenon associated with the long term use of opioids such as morphine, hydrocodone, oxycodone, and methadone. Over time, individuals taking opioids can develop an increasing sensitivity to noxious stimuli, even evolving a painful response to previously non-noxious stimuli (allodynia). Some studies on animals have also demonstrated this effect occurring after only a single high dose of opioids.
I’ve been receiving many referrals from pain clinics to evaluate and make recommendations for patients on long-term use of opiates. This benefits the patients by reducing or eliminating potential risk factors and the development of more effective pain management plans, as well as helping the pain clinic avoid becoming future targets for the DEA.
Although tolerance and opioid-induced hyperalgesia both result in a similar need for dose escalation, they are nevertheless caused by two distinct mechanisms. The similar net effect makes the two phenomena difficult to distinguish in a clinical setting. Under chronic opioid treatment, a particular individual's requirement for dose escalation may be due to tolerance (desensitization of antinociceptive mechanisms), opioid-induced hyperalgesia (sensitization of pronociceptive mechanisms), or a combination of both. Identifying the development of hyperalgesia is of great clinical importance since patients receiving opioids to relieve pain may paradoxically experience more pain as a result of treatment. Whereas increasing the dose of opioid can be an effective way to overcome tolerance, doing so to compensate for opioid-induced hyperalgesia may worsen the patient's condition by increasing sensitivity to pain while escalating physical dependence.
If an individual is taking opioids for a chronic non-cancer pain condition, and cannot achieve effective pain relief despite increases in dose, they may be experiencing opioid-induced hyperalgesia. In this case, they may benefit from complete withdrawal from opioid therapy. Many individuals report reduced pain levels when opioids are withdrawn.
Here is a link to additional reading suggestions and more information about pain management.
News & Research Archive — Here is a history of past Research for 2012, 2011