The Difference Between Chronic Pain and Opioids
There is a difference between chronic back pain and chronic pain from end of life conditions.
Opiates are a blessing for acute pain, pain after surgeries and for end of life care. Prescribing them long term for orthopedic pain is misguided at best. Often prescriptions are written that last weeks longer than needed after the initial surgery/injury. People don’t notice when these ‘pain pills’ aren’t really helping with the pain anymore. They help you not care as much about pain, but the perception of pain actually gets worse when opiates are taken long term for orthopedic conditions.
Here’s a great example of what can happen after getting off opioids for chronic back pain. I recently had an elderly friend, in his late 80’s, in the hospital for acute renal failure due to kidney stones. He was constantly being asked what his pain level was. On a scale of 1-10, how bad is your pain. I was surprised to hear him say, after the third day of being there, ‘I have no pain’. This was unexpected since he’s been taking Vicodin every 6 hours for back pain and sciatica for the past 15 years, with the underlying diagnosis of degenerative joint and disc disease with spinal stenosis. Maybe it was because he was mostly just lying in bed (though not in his usual sleep position). Or, I’ll just admit, I don’t know why he wasn’t complaining of pain! What I do know is that after about a week of feeling nauseous he began to be able to eat again.
He wasn’t able to get back home for a month. When he got home he’s wondering when he should start taking his Vicodin again. “Wait a minute”. I asked, “Why do you want to do start taking that again?” “Well, I’ve been taking it for years (even waking up at 3am to take a dose) and my doctor must want me to take it”.
It was hard for me to explain to him that he’d been given a pill from a doctor he really liked a lot, that wasn’t good for him. That he didn’t need to take. Instead he started taking Tylenol for his back pain and continued to eat well to put weight back on that he’d lost prior to and during his hospitalization.
He was weakened after his illness. Over the previous year he’d gone from using a cane to using a walker after he had a flare up of back pain. He had stopped driving himself to the store. When he first got home from the nursing facility even walking across the street with the walker to get his mail was too much for him.
I encouraged him that he would get stronger the more he did, but that strength would come gradually. He started doing the “lengthening and strengthening” isometric exercise in sitting I’d showed him before (sitting tall at the edge of a chair and pulling the belly in towards the spine). “Just do what you can and then take a rest.” I saw brightness in his eyes that I hadn’t seen for a while. I like to think that may have come from getting off the Vicodin. He started to focus on what he could do and not focus on his pain.
He surprised me after being home a few weeks that he had tried driving his car for the first time in a year. He went just a little ways, and realized that he felt OK and drove a little further. Then he decided he would drive all the way into town and do a little shopping!
I took him to a doctor’s appointment a couple of weeks later and he didn’t want to bring his walker. He used his cane instead! He had a neighbor deliver his wood for the winter. Last year my wife and I stacked it for him and brought it into his house. One month out of the hospital he slowly stacked it himself, doing what he could and taking rests. By the second week he could stack as much as he stacked the first week in a couple of days.
In physical therapy lingo this is known as “graded exposure”, gradually doing more and more as pain levels tolerate and dictate. We gradually get stronger. Acute episodes of pain weaken us and at first we have to rest and take it easy. Prolonged use of opioid medication for pain can affect our motivation to do more and get our strength back. Getting stronger is key to recovery from any injury.
Good reason not to take opioids for more than a few days after an acute injury and to get off it as soon as possible after surgeries. Not so good to think that opioids “help” with chronic pain. They just don’t! Gradually getting stronger by letting pain guide you but not stop you and is what really helps.