GRACE :: Treatments & Symptom Management

Opioids 101, And Opioid Myths

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Opioids are a class of pain medications that are frequently used for cancer-related pain, and for good reason. They target the opioid receptors, which are found throughout our body and effect pain transmission in the nervous system, from our peripheral nerves all the way to the brain. Of note, our bodies make natural opioids—you may have heard of endorphins or enkephalins, which act on these opioid receptors as well. Opioids can help with all three main types of cancer-related pain that I mentioned in my last post: somatic (body-related), visceral (organ-related), and neuropathic (nerve-related). Opioids are usually used by physicians if medications such as tylenol or NSAIDs (like ibuprofen) aren’t working.

Examples of opioids include morphine, hydrocodone, oxycodone, dilaudid (hydromorphone), or fentanyl. There are several others, but those are the most common. They come in many different forms (pill, liquids, intravenous or subcutaneous, transdermal) so that there are quite a few options that can be tailored based on patients’ individual characteristics.

Opioids are recommended by the World Health Organization as the next step in pain management if pain is not controlled by non-opioid medications. A general approach is to first start with short-acting opioids (immediate-release forms) and see how much a patient needs in a 24 hour period to relieve their pain. If there is regular and frequent usage (more than 2 or 3 doses in 24 hours), then a long-acting or sustained release opioid can be used for more consistent and convenient control of pain, instead of ups and down from short-acting medications. This long-acting dose is based on how much short-acting medication a patient uses. Alongside opioids, non-opioid medications can still be used, and multi-modal therapy is a good strategy for complicated pain.

Side Effects

Opioids do come with a side effect profile just like any other medication. Here are some of the more common ones:

Constipation is probably the most common side effect and unfortunately, it does not go away after a body gets accustomed to opioids because of the opioid receptors in the gut. Generally, patients who are on scheduled opioids or who take them on a daily basis should be on a bowel regimen. See my previous post on cancer-related constipation for management recommendations.

Nausea and vomiting can occur when first starting opioids or with major dose changes, but this usually does not persist beyond the first several days. Opioids cause nausea via the chemoreceptor trigger zone in the brain similar to how chemotherapy can do this (see my prior post on nausea for more information) as well as the vestibular center (our balance center in the brain) and receptors in the gut. Medications such as compazine and haldol are particularly effective for opioid-related nausea. If the nausea continues despite these medications, it is worth looking into other causes for the nausea.

Sedation is another side effect that can happen when an opioid is first started. It usually dissipates after the first several doses. Respiratory depression, or respiratory slowing, can accompany sedation but again, usually the body very quickly becomes accustomed to the opioid and this side effect is not persistent. Caution should be taken for patients who have problems with ventilating (taking breaths) or who have little breathing reserve, as well as for patients who are on other sedating medications. Start low, go slow.

Pruritus, or itching, can also occur when first starting opioids due to histamine release and occasionally persists. Anti-histamines can be used for opioid-related pruritus

Myths and Misunderstandings

Opioids are a misunderstood class of drugs due to a variety of reasons, including portrayals in the media as well as their “off-label” use on the streets. For physicians, opioid prescribing is regulated and monitored, and this can sometimes be a barrier as well to appropriate use. People refer to opioids as “narcotics,” meaning “drugs that blunt the senses”— and even this common term has negative connotations. You don’t hear about the police unit called the “opioid” squad—it’s called the narcotics squad. There are a lot of myths out there, and I wanted to address some of the major ones in this post.

Myth #1: If I take opioids for my cancer-related pain, I will become addicted.

This is a very common misunderstanding of the physiologic changes that happens when a patient is taking an opioid for cancer-related pain. This has to do with the difference between “addiction” and “physical dependence.” Addiction is defined as a disease characterized by behaviors focused on abnormal use of the drug (compulsive and not solely for pain) and continued use despite physical or psychosocial harm. Addiction is psychological dependence. Addiction rarely occurs with the use of opioids for cancer-related pain, despite what you may see in the media. Physical dependence does occur—it means that an abrupt stop or reduction of the medication results in withdrawal. Physical dependence occurs with a variety of medications—consider high blood pressure medications, as they often cause physical dependence and have major withdrawal symptoms if stopped abruptly such as low blood pressure and fast heart rates. I’ve seen posts on the GRACE site about steroid withdrawal symptoms as well.

Sometimes patients tell me that they interpret needing higher doses of opioid medications as a reflection that their body is becoming more dependent on the opioid. However, in general, increasing requirements for opioid pain medication usually indicate a change in the disease process or the underlying cause of the pain. It may sometimes be a reflection of increased activity exacerbating the pain or other causes that can be worsening the pain.

Myth #2: If I take opioids for my cancer-related pain now, they won’t work for me should my pain get worse.

This is not true—opioids are considered medications that don’t have a therapeutic “ceiling” or maximum dose. Escalating doses can sometimes be limited by side effects, but opioids come in multiple different forms and modes of administration. If one opioid stops working as well, physicians can rotate the pain regimen to a different opioid.

Myth #3: If I take opioids and get relief for my pain, then I may be masking symptoms of my cancer and miss something.

I have not seen this occur when patients have been undergoing treatment for their cancer-related pain. In general, if patients are in communication with their physicians about new pain symptoms or changes in their pain, that will preclude “missing something.”

There are other myths out there, and I think opioid myths and misperceptions by both patients and clinicians have been barriers to optimal pain management. I will be addressing more complicated pain syndromes, specifically neuropathic pain, as well as other strategies for pain management in upcoming posts.


10 Responses to Opioids 101, And Opioid Myths

  • catharine says:

    Dr. Harman -

    Thanks so much for this post — especially information on the myths and misunderstandings. I’ve succumbed to Myth #3 on occasion and have wondered whether to cut back on my pain meds (morphine and NSAIDs) to see if I’m “missing something.” I won’t take that route now.

    I was fortunate enough to get a consultation with an excellent pain management specialist through my HMO (via a wonderful, helpful relative who knew of his expertise). This physician took the time to explain all options, side effects, etc. and we decided on a pain management regimen that has really helped. My regular oncologist probably wouldn’t have time for such a detailed discussion, so I know how lucky I am. I hope that others experiencing cancer-related pain take advantage of this type of expertise where available. Additionally, your posts provide a lot of good info in this area.

    Fear/anticipation of pain are some of the most disturbing (and possibly unnecessary) things about having cancer.

    - Catharine

  • myrtle says:

    Hi Dr Harman,

    Thanks so much for this series about pain. I was trying to decide which category my pain was in but am not sure. At diagnosis, I had a very deep throbbing pain in the right side of my chest that reverberated with every heartbeat (apparently from a 3.0 cm tumor in the upper right lobe). They kept upping my dose of Ocycodone until it was 120 mg BID with Percocet every four hours and even though I was snowed, I still hurt all the time. Thankfully, when the radiation and chemo kicked in at about three months, the pain subsided and has not returned but I have real fear of returning to the state of pain that I experienced and I wonder if there are options for pain when it does not seem to respond to the standard treatment or is there just some pain that cannot be controlled?

    Thanks so much,
    Myrtle

  • Dr Harman says:

    Dear Myrtle and Catharine,

    Thank you both for your comments. Catharine, I’m glad that you had a good experience getting some additional assistance with your pain management. Pain specialists are a great resource for patients with cancer.

    Myrtle, what a difficult experience you have had–it sounds like your pain may have had multiple components so that is probably why it is hard to pick a category for it. The fact that it was not responding very well to opioids may suggest that there was a nerve component. There are definitely options when standard treatments aren’t working, particularly when pain is complex, as your pain has been. Sometimes that is a time when a pain specialist can be consulted to assist. There are non-opioid options to treat pain that can be given with opioids; sometimes this can help decrease the opioid doses. Our armamentarium is expanding in terms of medications and treatment modalities that are improving pain management.

    -Dr. Harman

  • myrtle says:

    Thanks for your answer Dr Harmon. I am sorry for posting my question twice. I am not sure what happened as it did not seem to post the first time. Anyway I will certainly ask for a pain specialist if I ever find myself in that situation again and it is comforting to hear that there may be other avenues to address the probelm.

    Myrtle

  • Dr West says:

    For Myrtle and others — if your comment doesn’t appear immediately, it’s likely the spam filter has sucked it up. Don’t take it personally, since it can be very sensitive, but the alternative is to have a high likelihood of being over-run by spambot comments we don’t want.

    I’m starting to get alerts about comments for me to check in the filter, so I’m hopeful that the delay will be short between the comment being submitted and it appearing. However, it’s perfectly fine to try again — I just don’t know what the filter would get triggered by, except for several hyperlinks.

    -Dr. West

  • texatl says:

    Dr. Harmon,

    Again thank you for this series of articles. I too have been operating under false assumptions. My question to you, or Dr. West, is about duration and liver damage.

    I had my full Thoracotomy over a year ago and I am still on a regime of Lyrica and Norco (10/325). While most of the pain has ceased (95%), there is numbness and shooting burning pain still around my incision site and left. I recently saw my Pain Specialist and he said that sometimes, the pain never goes completely away.

    The Norco reduces the number of occurrences of the sharp pain and I wonder if I am doing damage to my liver after 15 months of taking it. I take 1-2 pills a day and 1 75-mg of Lyrica.

  • Dr Harman says:

    Dear Texatl,

    Thank you for your comments and feedback. Unfortunately, indeed for some patients, post-thoracotomy pain does not ever completely resolve. Your question re: liver damage is a good one. It is always something to be careful about in taking combination medications (vicodin, norco, percocet, etc) because the tylenol is usually the limiting factor in terms of how many tablets you can take in a day, due to liver toxicity. For patients with normal liver function, it is recommended that the daily dose of tylenol should not exceed 4000mg per day. If you are taking 1-2 tablets of Norco, that is at most 650mg in one day. As long as your liver function is normal, that does not come close to the recommended daily limit. I will also say, though, that patients who have some compromise to their liver function (due to their cancer or other diseases) need to be more careful and should not use more than 2000mg in a day.

    It is great that you have a pain specialist–a great resource. He can also be a guide if your tylenol doses increase as to how to modify your medication regimen.

    –Dr. Harman

  • dfourer says:

    I got good pain relief from Vicodin (Hydrocodone 5mg) in years past. Now that dose has no effect. The next time a painful condition developed (a Pancost tumor), I switched to morphine. The dose rapidly went up. I was hospitalized with severe pain and put on dilaudid followed by time release morphine 180mg per day. After a few good nights sleep, I developed breathing difficulty, which grew steadily worse over two weeks. I was in a terrible panicked state and no one told me it could be caused by morphine. The pain mysteriously left me. I cut back on the morphine one afternoon and discovered I was not going to die after all–I could breath. Soon I was taking no pain meds at all and feeling OK. Physical withdrawal, and then relative wellness for several months. What does it all mean?

    The pain gradually returned, as my left arm muscles atrophied. The oncologists are working on treating the cancer, but I need a good pain specialist. I fear the pain.

  • catdander says:

    Hi dfourer,
    My husband has a pancoast tumor, right now with little pain. He’s taken time released morphine, ms contin 240/day for 2 or 3 months and now back to just one or 2 oxycodone 5s a day.
    What helped put his arm pain at bay was lyrica. As you know the tumor can affect nerves around the shoulder and lyrica is what licked that pain.
    As a matter of fact he hasn’t taken lyrica for a couple of months and I’m going to fill it today to see if it will take care of the bit of pain he’s having.

  • Dr West says:

    While many oncologists are pretty good at handling typical cancer-related pain, neuropathic pain like that from direct compression of nerves or nerve damage can be particularly challenging and are often managed best with drugs like Neurontin (gabapentin) and Lyrica (pregabalin). It’s I also think that these may be the cases best served by being managed by a pain specialist and agree that a consultation and potentially longitudinal follow-up with one is desirable if one is available.

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