Opioids and the Treatment of Chronic Pain

Transcript Highlights
Dr. Lynn Webster
September 24, 2015

Welcome! Thank you for joining us today for “Opioids and the Treatment of Chronic Pain.” This Facebook chat will be hosted by Dr. Lynn Webster and will cover topics such as:

– What are opioids? How do they treat pain?

– Are opioids for everyone? If not, who is a better candidate?

– What are the risks/benefits of opioids? How can you take them safely with other medications?

– And much more!

Dr. Webster has dedicated more than three decades to becoming an expert in the field of pain management. He is a leading voice in trying to help physicians safely treat pain patients while actively working within the industry to develop safer and more effective therapies for chronic pain and addiction.

He is board certified in anesthesiology and pain medicine, and is also certified in addiction medicine. Dr. Webster lectures extensively on the subject of preventing opioid abuse and criminal diversion in chronic pain patients and has authored more than 300 scientific abstracts, manuscripts, journal articles and a book entitled Avoiding Opioid Abuse While Managing Pain: A Guide for Practitioners, many of which are the basis for training physicians who are studying pain.

Dr. Webster has played an instrumental role in his industry as a strong advocate for safe and effective pain resolution methods. The Opioid Risk Tool (ORT), which he developed, is currently used and is the standard in multiple countries and thousands of clinics worldwide. He spends most of his time now developing safer and more effective therapies for chronic pain and campaigning for safer use of medications.

Dr. Webster received his doctorate of medicine from the University of Nebraska and later completed his residency at the University of Utah Medical Center’s Department of Anesthesiology.

Hi everyone! Dr. Webster here!

I’m very pleased to be a guest and look forward to educating, learning and sharing during the next hour. Just so everyone knows, I cannot give medical advice on here. Laws, ethics and common sense prohibit it.

Michele: Is there a way to tell if opioids are no longer helping and a new med needs to be tried versus opioid hyperagelsia without withdrawing from opioids all together?

Dr. Webster: Opioid hyperalgesia is a controversial topic. Some scientists do not feel it is a real entity while others are convinced it exists. There is no foolproof way to know without withdrawing opioids but if your dose was increased and you experienced more pain, then most physicians feel that is an indication of hyperalgesia. It certainly would tell you that you should not increase your dose and may benefit from less or no opioids. Rotating to a different opioid at a lower dose may restore analgesia and be safer.

Pam: Dr. Webster, would you share your thoughts on fibromyalgia and opioid pain meds versus or in combination with other treatments?

Dr. Webster: Opioids are not recommended for fibromyalgia, but I found small doses would help some people. For many, they could cause more harm than benefit. If you try an opioid be prepared to discontinue if they don’t provide substantial benefit. They may help for a while then lose their effectiveness so be prepared to stop if that happens and look for alternatives.

Laurie: I have fibro and systemic lupus and they help tremendously! I do hope they don’t lose effect!‬

Velma: I have had bad back pain since before failed spine fusion surgery in 2007. I am a young 88 and would be okay except for pain and what the meds have and are doing to me. I have had pt, cortisone injections, etc. Is there something I am missing that could help? I am considering but resisting surgery again. Have you heard of prolotherapy?

Dr. Webster: Yes I am aware of prolotherapy. It is helpful for some conditions but is best for small joints. If you choose to consider this be sure to go to someone with experience.

Chrystal: What would you say the conversion of 12 milligrams a day of morphine in a pain pump equals in oral morphine?

Dr. Webster: We cannot determine the equivalence. Generally speaking the oral dose is 10 to 100 times that of intraspinal opioids but it is very individual and depends on many factors. You really can’t rely on any conversion ratio.

PainPathways Magazine: We would love more opioid safety questions. In the meantime, here is an overview article to bookmark and read on opioid safety.

Van: I have tried a lot of different meds and pain meds. All have been a struggle from day to day, past seven years. Are opioids the right drug for treating chronic pain?

Dr. Webster: This is very hotly debated today. There are some excellent physicians and scientists that do not believe opioids should be used for chronic non-cancer pain. However I have treated and had patients who found opioids to be very helpful for decades. There is no one answer for everyone. Opioids can be helpful to some people for some types of pain but may be harmful or not effective for others. This problem is that there aren’t any really good drugs for ALL pain disorders. Some people will respond to anticonvulsants while others may benefit for certain types of antidepressants but most pain types are best treated with an interdisciplinary approach using nonpharmacologic and pharmacologic combinations. If drugs are used it is generally best to use a multimodal approach. This means using small amounts of different drugs with different mechanisms of action because in most instances pain involves multiple receptors and mechanism of pain generation.

CoLee: Hello, I would like to know why family physicians are shying away from prescribing pain medication and sending patients to pain management doctors. These doctors do nothing but give us the medication/shots and then they cost more than going to our family physicians. $600 for myself in this case?

Dr. Webster: There are many reasons. The biggest, I believe, is that chronic pain is far too complicated and family physicians—really all docs—know they don’t have effective tools to treat it. Because there are so few tools and opioids are high risk, docs are afraid to diagnose and treat pain conditions. It’s the sad truth of chronic pain treatment in America today. The best thing for patients to do is not give up on their family physicians and keep them honest about their responsibility to you and your family.

PainPathways: Everyone, Dr. Webster has a great blog with many wonderful articles, including The Search for a Unique Solution to Chronic Pain.

Jason: Medication within the context of the biopsychosocial framework; strategies for determining which of the biological, psychological or sociological factors are more important drivers in the experience of pain for a particular individual?

Dr. Webster: It depends on the individual, the type of pain, social environment, etc. There are many factors. I believe attitude and resilience are important in dealing with pain but if the pain source is focal and can be interrupted easily with a biological approach then I would go for it. For example, an epidural steroid injection can be very effective for spinal stenosis but someone with spinal cord inflammation or arachnoiditis is going to require several different approaches including spirituality for those who are spiritual people.

Laurie: Can you explain why opioids would cause more harm than good? It helps me a lot.

Dr. Webster: Opioids carry more risks than benefits because they can lead to dependence and overdoses. But for a certain subset of the population, opioids can work safely and effectively. I believe that, in the long-term, we need to replace opioids as a treatment method. But, in the meantime, we cannot restrict access to them because they can and do help people like you.

Lydja: Do you agree with using cannabis in tincture or oil form to help control pain?

Dr. Webster: I  am conflicted on this. You can read some of my thoughts on my website LynnWebsterMD.com. I think we need to study marijuana because I believe some of the chemicals in marijuana can help some people with certain pain problems. But Marijuana is not a drug. It is a plant with hundreds of active chemicals. We don’t know which chemicals are therapeutic and which ones may be harmful. Our ability to research it is limited due to the DEA scheduling of it. According to the DEA it has no medicinal purpose so there are major barriers that this poses to researching it. Having said that it is safer than opioids or alcohol. And because there are many reports that it has helped many people I would like to see it available at least to be studied and under controlled conditions be available to treat pain.

Vicki: What are the risks of addiction for the average person who uses opioids for pain management? Is there a way for people with histories of addiction to use opioids safely?

Dr. Webster: This is a controversial area. Some people believe that the risk of opioid addiction is very high with chronic exposure to opioids. I do not. I believe that about 15-20% of the population is vulnerable to some type of addiction (alcohol, cocaine, heroin). However I believe opioid addiction is more likely under 5% in the population prescribed for pain but this is a real number if 30 million people or more are exposed to opioids. Genetics plays a big role in determining who would develop an addiction. Environment also plays a role. Addiction is a devastating disease and many people die from it so it needs to be taken seriously. But so is pain so we need a balanced approach to using opioids but eventually we need to replace the current type of opioids with drugs that are not addictive and more effective.

PainPathways Magazine: We haven’t gotten any questions on this yet…but it is a big deal with folks who take pain medications. Read about Opioid Induced Constipation.

PainPathways Magazine: If you have cancer and are considering or are using opioids, here is some good information on Cancer, Opioids & the Future of Pain Management:

PainPathways Magazine: Checkout the results of our OIC Survey.

Jennifer: How do you feel about pain medications in the treatment of interstitial cystitis?

Dr. Webster: Interstitial cystitis is like CRPS of the bladder. There are no really good medications but anticonvulsants can be helpful and sometimes opioids are helpful for some people. It is a trial and error with most medications.

Marie: Can you explain how opioids help for RSD pain?

Dr. Webster: Opioids are not very effective for RSD (CRPS). If they help, it is by blunting the intensity of pain. Opioids work at receptors by blocking some pain generation and transmission but RSD is now thought to be an inflammation of the spinal cord and brain so opioids are not very effective. They essentially sedate and don’t really block pain as they are supposed to.

CoLee: I would also like to know about withdrawal from pain medications. What is the best way to deal with that, as well as how do you handle it when you switch medications? For example switching from Tramadol to something else.

Dr. Webster: Withdrawing from medications can be difficult and dangerous so only do it with a knowledgeable physician oversight. Rotating from one opioid to another is also tricky. Generally withdrawing from medication has to be done slowly and depends on the drug. It may take weeks to months to totally withdraw from a medication safely and without being sick.

PainPathways Magazine: Everyone, our time is unfortunately up.  We appreciate all of your thoughtful questions and our expert’s time.

PainPathays Magazine: Hi everyone! This is Amy North, editor of PainPathways Magazine. On behalf of the magazine, we’d like to thank our expert and all those who participated in tonight’s chat! We are excited to be offering this great forum for information and inspiration.

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All information provided is for educational purposes only. Neither PainPathways Magazine nor their Facebook Chat hosts are responsible for a medical diagnosis. Individuals should seek a physician for evaluation and personalized treatment plan.