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Alyne Ellis (Host):  Are you taking opioids to control pain just to get through the day? Welcome to our series CGH About Your Health. I’m Alyne Ellis. I’m here today with Dr. Eric Kuhns, a Family Medicine Doctor at CGH Medical Center Main Clinic. This podcast is called Opioids for Pain Management. Dr. Kuhns, we all know when we feel it, but what is pain?

Eric Kuhns, MD (Guest):  Pain is the body’s way of telling you that there’s some damage or potential damage is happening, and it alerts you to this and makes you pull your hand away from flame or avoid walking on an injured leg. The pain starts in receptor cells found beneath the skin and in other organs throughout the body. And when you are injured or sick for other reasons; these receptors send signals along neuropathways to the spinal cord and then there’s a junction there and these signals then get transmitted up through the spinal cord into the brain. And along the way, sometimes these signals can be suppressed a bit. We’ve all heard of people who didn’t feel much pain when they were in great danger and then felt the pain afterwards. And they have pain along the way. It can also be magnified in response to stress or some disorders such as fibromyalgia tend to magnify the pain along the way.

Typically, once the danger or potential injury is healing or gone; this pain starts to get better. There are certain things sometimes stress, sometimes even medications of certain types can perpetuate that pain a bit and it’s important to work closely with your doctor about managing not only when the pain starts but managing the longer term and working off the pain medications and how to do that safely.

Host:  So, how do opioids work when you are in pain and you take them?

Dr. Kuhns:  Well opioids work primarily in the brain. They work on receptors on the brain cells. When the opioids attach to these receptors, they can block or suppress some of these pain signals which is definitely – they are the most potent way to block more severe pain and they work very well in the short term. Over the long-term, one of the issues with that is your brain tends to compensate by making more pain receptors which makes the opioids tend to work less well over time or require progressively higher doses. And this can be a danger in long-term use.

Separately, opioids can also work some on the pleasure centers of the brain and make you feel good or relaxed. Again, there is also a tolerance that can build up and sometimes if you are on it for long periods of time; coming down off the opioids can have the opposite effect and make you feel unwell and it’s one of the ways that opioids can lead to dependence or even addiction over time.

Host:  So, are there different types of opioids?

Dr. Kuhns:  In general, opioids all work in the same way. They are mostly in potencies, some of them are relatively less potent, some of them are highly potent for the various doses. There are also some that are more shorter acting which they work very quickly but they don’t tend to work for very long at any given time. And then there are some that are formulated to be more extended relief where they do not work so quickly but they work for longer periods of time throughout the day.

Host:  And what are some of the signs that you’re in trouble, that you have done an overdose?

Dr. Kuhns:  An acute overdose can come up in a couple of different ways. One, you could be confused or disoriented. That’s one common way. Another way is it affects your drive to breathe and this can especially be of danger if you have sleep apnea or if you have issues with COPD or other lung issues that you really depend heavily on that drive to breathe and the opioids can suppress that. So, you can end up not breathing well or even stopping breathing. Because unfortunately, although your brain gets used to a lot of the effects of opioids; the decrease and the respiratory suppression not as much.

And acute overdose, over time, again some of the coming down off of the opioids can be very, very difficult in the moment and lead to behaviors that people feel they must have another dose right as the other or as soon as the other one is gone, and it can lead them to changed behaviors and affect their life in ways to work around the opioids. And when that starts to happen, we call that opioid use disorder and we try and work with that very carefully to manage that and overall, work the way back down. But this has to be done very carefully and with close supervision by a physician.

Host:  So, if you have to take these medications for a long period of time; you have covered some of the risks, are there others that we should know about?

Dr. Kuhns:  Yeah, constipation is a very common side effect especially over the longer term and it can be severe. In fact, I’ve had patients that have require surgery because they gotten so blocked up from opioids and constipation and they are unable to move, and they cause damage to the bowels from overdistension and problems with blood flow because of the pressure from that stretching. So, that can be a problem over time. Again, the longer you use them, in general, the less well they work. Your brain builds more receptors, you need bigger doses and it becomes harder and harder to manage the pain.

In long term studies, people who in general who are on opioids at one year out have the same average level of pain as if they had not used opioids at all even for the same chronic pain. But they feel a little better when they are on the opioids in the moment and a little worse between doses. But on average, their pain levels are not better than people with the same deal the amount of chronic pain who were not on opioids at one year out.

Host:  So, how do you use opioids safely?

Dr. Kuhns:  The short answer is very carefully and in close concert with your physician. They are really best to use in severe short acting pain or an end of life situations. There are certain situations that we’re stuck with no other good option except to use them long term, but this has to be done very carefully. Often you have to spend some time working your way down to kind of reset your tolerance and then restarting more aggressive dosing. This requires a fair amount of work in close concert with your physician. Generally this should not just be a maintenance free sort of thing that you are always on the same dose forever. It should require some active supervision and close coordination to make sure it’s being done safely and also make sure as you get older that these side effects are not more dangerous, that your lung function is still okay. You are not developing sleep apnea because all those are dangers that could potentially be life threatening if they are not addressed.

Host:  And what about alternatives? If you are going to get off opioids or you are not going to use them in the first place. What do you recommend?

Dr. Kuhns:  Well there’s a large variety and usually dealing with chronic pain like that is a series of trying to manage this in many small ways. One of the things that’s often overlooked is it’s really incredibly important to stay active and one of the best ways that opioids can be used in the acute rehabilitation phase is to manage the pain well enough that you can be more active and you can work with physical therapy and work in doing core strengthening and exercises that help you be more stable and more functional so that over the long term; you don’t need as much pain medication. And I think that’s often overlooked and it is incredibly important. I have had several patients that have had very severe long-term pain and were very disabled on high doses of opioids and with a very focused and intensive effort to work at getting them stronger and moving again; they have become much more functional and worked their way either entirely off opioids or only using it at limited times when they need to be extra active and it allows them to do that activity.

In the acute phase, there’s also – there’s a lot in the perioperative phase that there’s nerve blocks and other medications even IV Tylenol as silly as that sounds, seems to have a significant effect if it’s used right around the time of surgery in helping postoperative pain and limiting the amount of narcotics that are necessary after surgery. Over the long term, there are other medications that can be helpful. Some of them were originally developed an antiseizure medications, some of them were originally developed as antidepressants but they have pain relieving qualities and often it takes a combination of all of these approaches to get adequate pain relief and people are individuals and again, sometimes that takes some tinkering with your physician to find the optimal regimen for you.

But no matter how disabled you are in the moment; focusing on trying to improve your function is really critical to making this better over the long term and being able to work your way off of some of these medications.

Host:  Is there anything else you would like us to know?

Dr. Kuhns:  Certainly opioids are very big in the news these days. I think there is as with most things, there’s truth on both sides. There is – there are times that opioids have been overused sometimes with good intentions, sometimes not. But there is also sometimes there’s too strong a line drawn by the it’s never appropriate and you have to get off immediately. I don’t think either of those things are true at the level that they’ve been advertised in the media so to speak. But there is some as with most things, certainly a grain of truth to all those things and we need to be very conscious and very active about trying to manage this and being careful with it and investigating every other possible alternative. But there is definitely still a place where opioids still need to be used and on occasion, over the long term that we really strive to find every other alternative in that and if they have to be used long term; limit the doses and vary them as much as possible to try and limit some of the long term side effects.

Host:  Thank you so much Dr. Kuhns for this good sound advice. Dr. Eric Kuhns is a Family Medicine doctor at CGH Medical Center Main Clinic. I’m Alyne Ellis. Thanks for listening to this episode of CGH About Your Health. Head on over to our website at www.cghmc.com to get connected to one of our providers. And if you found this podcast helpful, please share it on your social media channels and be sure to check back soon for our next podcast. Thanks for listening.