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Opioids: What Are They, Addiction Concerns & Other Alternatives

Melanie Cole (Host): It's estimated that seventy-eight people a day die from overuse of opioids. Use of these drugs have skyrocketed in recent years. My guest today is Dr. Wes Whitten. He's an anesthesiologist and a pain management physician with Nebraska Pain Institute. Dr. Whitten, welcome to the show. Let's first start with a little lesson; what are opioids and what are they mainly used for?

Dr. Wes Whitten, MD (Guest): You bet, thanks so much for having me. So opioids are specialized pain medications. They work on pain receptors that are found primarily throughout the brain and spinal cord. Their purpose is to blunt the brain's perception of pain. So they're very effective tools when they're used for this purpose. So their most effective means are for the pain management around surgery. So it helps with anesthesia and helps the field of surgery to be able to allow us to do all the wonderful things that we're able to do with modern medicine in the surgical arena.

But they have kind of become a problem in the recent history, kind of right around the year 2000, was when there was a big emphasis placed on pain management, specifically around hospital stays and perioperatively, and one of the initiatives was making pain a vital sign. And so with that, there was a big push to increase pain control, and with that came the increased use, and sometimes misuse of opioids.

Melanie: Why are they so addictive?

Dr. Whitten: Opioids are addictive because of the way that they work on the brain. They bind to a few different receptors in the brain, and one of those receptors releases feel good hormones like dopamine, and with that it releases dopamine as well as other endorphins to give your brain a sense of pleasure and satisfaction.

After being on opioids for an extended period of time, the brain becomes used to that extra stimulant and the extra endorphins that are released, and your body gradually stops producing those itself. Therefore when you stop the medications, you get less of the dopamine and those feel good hormones, and your brain and your body go out seeking more of it, and therefore the body knows that they get that feeling from opioids and causes it to seek out more opioids.

Melanie: What a great explanation, Dr. Whitten. Thank you for explaining that because people don't truly understand that. So now tell us about some of the short-term and long-term effects of opiates, and some of the side effects that people experience, and the reason that we're having this segment today.

Dr. Whitten: You bet. So with opioids, when you first start taking them, there are a lot of side effects that are very common. They range from mild to more severe. Sedation is a common thing with opioids, it makes you a little sleepy and also can cause you to be dizzy, can cause nausea and vomiting, as well as constipation. So the more dangerous things that we experience with opioids are things like respiratory depression. What that means is that it tells your body to not breathe as much or as frequently as it should, and that's the main reason why there's a risk of death associated with opioids, is that if you take too many opioids at one time, then it can cause the body to not breathe as much as it should or potentially not at all, which can ultimately lead to death.

After being on opioids for an extended period of time, then the body will develop a physical dependence to them. That means that your body needs the medication in order to maintain its normal state, and if you stop them abruptly then you will likely go through withdrawal. That's why whenever we do stop somebody on opioids, we take them down slowly in order to avoid those withdrawal symptoms which are a sign of physical dependence.

Physical dependence is not the same thing as addiction. Addiction is the psychological component associated with that dependence and with long-term use. So with that, there always is a risk of addiction and also a risk of tolerance, and that's one of the biggest issues that we run into with chronic pain and opioids, is that the body will develop a tolerance to opioids. In other words, medications you start off on initially doesn't work quite the same as it did when you first started it, and therefore your body will require additional medication, and that's what has in a roundabout way led to our opioid epidemic. We previously didn't think that there was an opioid ceiling, that if some is good, then more is better, and over time we've found that that's not the case, and now we're taking steps in order to help rectify that.

Melanie: Wow, it certainly is becoming quite the problem in this country. So let's discuss some non-surgical alternatives to opioids for pain management. You're a pain management physician and an anesthesiologist, so speak about some of the other things that you might try instead, before, or after an opioid situation where someone might be using them, then they get off them, but they still have pain to deal with. So talk about some non-surgical alternatives, Dr. Whitten.

Dr. Whitten: Absolutely. I want to start off by saying that there is a time and a place for everything, and so with that, there are certain conditions that really do need surgery. And so I want everybody to know that there are times when surgery is the best option, and there are times where medications are the best option, and there are times when other interventions are best.

And so it's my experience as a pain management physician, the number of alternatives that we have available now are greater than there have ever been before. That we have newer medications that are safer, that are non-addictive, that are able to help manage pain in lieu of opioids, and we can discuss those a little bit later.

But with that, the mainstay of my treatments involve interventions. And so the interventions that pain management is able to offer are things like nerve blocks where we can inject numbing medicine right at the nerves that are causing the pain, numb them up, and see how that helps their pain. That's one avenue to get pain relief.

If the pain relief doesn't last long enough, there are things like radiofrequency ablation, which is a specialized procedure that's done with a special needle, and we essentially zap the nerve that's bothering you, and that can give you several years’ worth of pain relief. There also are steroid injections that can help with joint pain or with different spine pain, and so those are very simple procedures where we numb up the skin and insert the needle close to the area that's bothering the patient and administer the steroid medication to help decrease the inflammation, and therefore improve their pain.

Historically speaking, taking oral steroids, in other words pills by the mouth that are steroids, have been able to help with the pain. But with that, you require a larger dose of steroids and it also goes throughout your whole body. With these procedures, we're able to deposit a more concentrated smaller dose directly at the area that's bothering the patient, therefore we minimize the side effects associated with it and maximize the pain relief.

Additionally, there are different proliferative type therapy like platelet-rich plasma injections and stem cells, which those have been very effective in treating different pains. Joint pains are an area where there's probably the best evidence, and that's where you hear of a lot of athletes and people in the news that go and get platelet-rich plasma, it's also called PRP, they go and get these injections. It helps them heal faster, and so those are another alternative for a different approach.

Additionally, we have things like spinal cord stimulation where we insert a specialized device that sits right along the back side of the spinal cord. We're able to send electrical signals directly into the spinal cord in order to essentially confuse the pain signal as it's going from the nerve that's bothering you up to the spinal cord and to the brain. We intercept that pain message, scramble it, and the brain doesn't perceive it as pain anymore.

Melanie: Wow, that was awesome, Dr. Whitten. You just explained so many alternatives to opioids. Where do physical therapy, rehabilitation, exercise programs, meditation, even psychotherapy or anti-depressants, where do those fit into this pain management picture?

Dr. Whitten: Absolutely. So I like to offer well-rounded therapies that are tailored directly to the patient's needs and their desires because again, there's a time and a place for everything, and with that I'm a big believer in focusing on what the patient wants as far as their therapy in order to get better.

Diet and exercise are always a part of that therapy in the sense that a good diet will help with your overall health. Also by avoiding sugar. Sugar creates a pro-inflammatory state. With increased inflammation, you get increased pain, and therefore limiting sugar and having a diet can help there. Exercises helps release those feel-good endorphins that we were talking about that opioids do, so you can create your own exogenous options. So in other words, create your own hormones that make you feel good and feel better, so those are always important. Things like physical therapy and chiropractic and occupational therapy are all very good therapies that can help in their own respect in order to be able to improve the patient's overall well-being.

And so those are all very important things that I like to focus on as well. As far as some of the non-opioid medications that we offer, there are things like anti-inflammatories that are very good at helping typically joint pains respond very well to those and are non-addictive. There are other pain medications, and this is an area that I like to focus on whenever I talk with patients about this. I prescribe pain medications. Those pain medications when you go to the pharmacy and pick them up, then it might say that they're a seizure medication or it might say they're an anti-depressant. Those are kind of over-arching categories. Some of these medications are seizure medications, some of them are anti-depressants, but more importantly in my arena, they are pain medications that help with the patient's pain.

What happens with a lot of neuropathic type pain is the nerves themselves are causing the pain, and the medications that we give to fix that slow down the conduction of the electrical signals to the nerves. And by slowing that down, then it slows down the pain signal, and therefore reduces their pain. Well that same medication may also help them with a seizure disorder as it slows those seizure signals that are being sent, and therefore helps for seizures.

So one thing that I've heard a lot of times is people say, "I don't have seizures, I don't need a seizure medicine, I don't want them to cause seizures." Same thing with the anti-depressant. They say, "I'm not depressed. I don't need an anti-depressant." But I think it's really important to focus on the fact that these are pain medications that are good non-addictive medications similar to being able to help treat their pain regardless of the over-arching category that they fall under.

Melanie: Dr. Whitten, it's such a great segment with such great explanations of all the options out there. What's your best advice? Wrap it up for us with a summary of your best advice to people that are either on opioids and looking for alternatives for pain management or just looking for some help for their pain.

Dr. Whitten: You bet. So in general, everybody experiences pain, and typically pain will get better with time and conservative therapy. Typically a back injury will get better in six weeks, and so there are certain things that can help expedite that, and there are certain medications that can make that easier in the short-term. However, if you have severe pain or if you have pain that's lasted longer than three months, you really should seek out your doctor, talk to them about it, and see what it is that they can do to help.

And again, if these pains are severe or long-lasting, then talk to your doctor about getting in to see a pain specialist in order to be able to see what they have to offer. So pain specialists focus on this all day, every day, this is what I treat every patient that walks in the door, and looking at helping their pain, and more importantly improving their function and improving their quality of life. And so with that, getting in to see somebody, and looking for other alternatives, and also educating yourself online. There are a lot of good websites that you're able to find information on pain and pain treatment, and being able to have an intellectual conversation with your provider about different alternatives to be able to treat your pain, improve your life, and be able to get you back doing the things that you want to be doing.

Melanie: Great information. Thank you so much, Dr. Whitten, for joining us today. It's even more urgent that people hear about alternatives to opioids for pain management, and you've explained everything so clearly. Thank you, again. And a special thank you to our podcast partner, Inpatient Physician Associates. If you'd like more information about healthy living, go to www.bryanhealth.org. That's www.bryanhealth.org. This is Bryan Health Podcast, I'm Melanie Cole, thanks so much for tuning in.