This final post in this lengthy series is focused on the last reason why how we were prescribing opioids for chronic non-cancer pain needed to change.  I hope this will help all those with chronic pain and those that have a loved one with chronic pain understand the need to rethink the focus on continuing chronic opioid therapy, especially at high doses. 

I will repeat the summary that I wrote in the initial post previewing this series.   The unintended consequences of chronic use of opioids are the impact on the person’s ability to properly sense their body.  This  has a clear impact on potential for injury or further damage. We need to be able to sense our body and feel pain in order to operate it correctly and not damage it. 

The analogy that I use with patients to drive this point home is this: You have a car that is making a big clunking sound. You are going on a cross- county trip and have your mechanic take a look at it. He indicates that he does not know what is making the noise but advises you to “just turn the radio up really loud so that you can’t hear it,” and then sends you out on your trip. Most of us would agree that is a poor method of dealing with the problem. We do need to understand what is causing our pain and also sense our bodies at some level.  An extension of this is that we need to sense our body in order to not promote injury.

There are two key points here:

  1. CAUSE OF THE PAIN OR THE PAIN GENERATOR:  We need to know what is causing the pain that is in our body to understand what covering that pain up with medication means.  There are some pain conditions where the damage is done and further damage is “unlikely.”  This is fairly rare but they do exist.  So, you need to understand what is causing your back pain (for example).  Is it a sacroiliac joint issue, muscle strain, psoas spasm, facet joint arthritis, a herniated disc, spondolythesis, scoliosis, cancer, etc.  There are many potential causes of back pain and it is not appropriate to say “I don’t care what the cause is, I just want to cover it up.”  We owe it to our patients and to the practice of medicine to actually work up your pain to determine what is the cause of the pain at this point in time.  Remember, the cause now may be very different than the cause of the initial pain.  Our bodies change over time and adapt to the initial or original injury, which means what is causing your pain currently is likely a different animal than it was originally.  It may be similar, but we still need to identify it to understand what the treatments are for that new condition and the potential for damage should we just cover it up.
  2. CONTROL AND SENSATION OF OUR BODY:  Opioids makes us lose the connection to our bodies, both in terms of the physical sensation of the body (e.g., pain, sense of movement, sense of pain) but also in the emotional sensation / experience.  If we do not sense our body in motion or in a stable position, we will not know when we are putting it at risk of injury until it is too late.

In the past we used to provide patients with pain medication to go to their Physical Therapy appointments.  Think about this a moment: we have an injured person who is going to interact with a person that is going to ask them to push their body BUT we are going to deaden their ability to sense their body.  Anybody see a problem here?  Mix in the fact that most of us do not want the Physical Therapist to think we are a “wimp” or “not trying,” so we are already going to over-do just because we are human beings trying to control our presentation to others.  It’s easy to understand that many people would go to one or two Physical Therapy visits and declare “it made me worse.”  This could have been predicted if we were paying attention.  

We fundamentally need to experience our pain when in Physical Therapy in order to report to the therapist what we are experiencing at that moment with that activity, stretch or exercise. Then the therapist needs to be able to understand and explain what is causing that specific sensation.  As a pain specialist, I also understand that the Physical Therapist is a very important member of the treatment team and usually very helpful in defining the CAUSE OF THE PAIN OR THE PAIN GENERATOR.   

An additional issue is opioids’ impact on sensing the fatigue in our body, specifically muscle fatigue.  I live in northern Wisconsin where people burn wood much of the winter.  A person who has a back injury may take their opioid medication to allow him to haul wood into his house.  The opioid helps him go above and beyond what his body can do but he is going to be careful and use good posture and technique.  This sounds great, right?  As he is going along, he realizes it is taking a bit longer because the is moving correctly and slowly.  He has now been up longer than is normal for him, but he still feels “pretty good.”  What he does not realize is that most injuries happen when muscles in the back become fatigued towards the end of an activity.  He can’t sense that fatigue right now, and keeps pushing through to get the wood inside.  It is now getting colder, so he moves a little faster — and all of a sudden his back “gives out,” and he has severe pain and pain shooting down his legs.  He falls down on the icy path between the wood pile and the house.  Great – now we have a NEW INJURY, potentially a herniated disc because the muscles that support the spine became too fatigued from the activity, but his brain could not sense the fatigue.  

We have to remember our body is a musculoskeletal system, meaning the muscles support the skeleton.  If we put all the pressure on the skeleton (and the discs in this scenario), the skeleton / discs will fail under the load.  The muscle system is very important in supporting the low back.  This is another reason to avoid opioids — because they lead us to create new injuries.

The last point is that opioids also impact our sense of the body as a whole, meaning our balance, muscle control, force control, decision-making and everything in between.  They do not make it better, they impair us.  So, people on opioids are prone not just to overdoing it, but slips, falls, missing a step, falling off a ladder, etc.  

As we move forward discussing the issues of chronic pain, we will delve into a better understanding of what are the best ways to treat pain.  Opioids may play a role but it should be a minor role.  I will talk a great deal about my belief in how well our body can adapt, heal and recover from injuries.  We need to unlock that potential.

Thanks for sticking with me through these initial lengthy posts.  As we move forward, I will be focusing on various issues from explaining causes of pain, explaining potential treatment options and discussing coping with chronic pain.  Some will be medically-related posts and some will be more related to psychological components of pain or health.  I hope that this will allow you and your family members to be in a better position to tackle the pain or health concern with a clear perspective and from a position of knowledge. 

Remember that if you have questions or comments, I will definitely address them in future posts.      If I do not know the answer, I will find someone who does and get a post up on that.  As always, the opinions expressed here are my own and do not necessarily reflect those of Marshfield Clinic Health System.