Jess (not her real name) presents to the GP requesting Endone for her chronic knee pain. She has been using 2-3 a day for the past 4 months following twisting her knee while walking. She is a new patient, having recently moved into the suburb.
It has been seen in the general media and the medical media of late, the increasing concerns surrounding the long-term use of opiates. Opiates are a class of medications that are used to alleviate pain and they do this by blocking the pain receptors μ (mu), δ (delta), and κ (kappa). There are many drugs in this class including codeine, morphine, fentanyl, heroin, methadone, buprenorphine, tramadol and tapentadol. All drugs have side effects, and long-term opioid therapy may cause adverse effects on the respiratory, gastrointestinal, musculoskeletal, cardiovascular, immune, endocrine and central nervous systems. Studies show there is an increased risk of falls in the elderly and increased rates of death. There is no evidence that using opiates in the long term assists the person in any way, indeed there is very good evidence that the long-term use of the opiates makes things worse.
Pain can essentially be broken into two types, nociceptive pain (the pain of a broken bone or muscle strain) and neuropathic pain (nerve pain, pins and needles, burning). These both need to be treated in separate ways. Usually, nociceptive pain settles as the biological cause resolves, the sprain heals or the fractures mend. Neuropathic pain can last longer, nerves being compressed (bulging discs, carpal tunnel syndrome) or not working properly (peripheral neuropathy of diabetes). For some people however, the pain can change from a peripheral cause (sprained ankle) to a perception of pain, this is termed central sensitization. This is when the body perceives pain when there is no reason for the pain to perceived. Opiates are known to increase the likelihood of this happening. When this happens, it can be very hard to reduce the level of pain being perceived. Finally, about 20% of people who commence opiates become addicted.
So, what to do? This is a complex and emotionally challenging area. Jess just wants some pain relief, her doctor needs to discuss the pathology of her knee injury and the likelihood that the initial injury has resolved. They need to discuss the sensitive issue of possible addiction, identify if other comorbidities are involved such as depression or anxiety and assist Jess in gaining insight into her condition, via education and develop a plan that will help her reduce her use of opiate medication. This may mean further investigation, physical therapies, weight loss and possible surgery. It may also mean psychology and medication for depression.
Obviously, this is a lot to complete in one appointment, so several appointments should be planned. Often there is no quick fix for chronic pain, and it can take some time and a lot of physical and emotional energy on both the patient and doctors’ part to come to resolution.
Where to find more information.