With opioid prescriptions hitting an all-time high of 207 million in 2013, the possibility that we are experiencing an opioid epidemic in the U.S. is very real. While many people taking opioids under a doctor’s supervision do so carefully and responsibly, an estimated 20 to 60 million of those prescriptions may be for people who have become dependent on the drug without receiving much benefit in the way of pain relief. The dangers of opioid use for long-term or chronic pain have been covered extensively in the media but with one exception: long-term use of opioids is now linked to an increased risk of depression and anxiety, largely due to the way in which opioids interact with and change the brain.
Opioids act primarily on the opioid receptors in the brain, spinal cord, and gastrointestinal tract. They interfere with the brain’s transmission of pain signals and also alter a person’s perception of pain. Opioids do not actually stop pain from occurring. They change the way a person experiences pain in their body. For those experiencing extreme acute pain, opioids can offer profound relief immediately, which can help the body heal.
For chronic pain, the results of opioid use may be quite different.
One of the primary difficulties with opioids in the brain is that the brain actually adapts to the levels of opioids in the body, over time requiring more to achieve the same pain-neutralizing effect.
There are several risk factors for dependence, including initial mood and previous dependence on other drugs, and long-term use does not necessarily lead to dependence. Many chronic pain sufferers say that opioids have given them their lives back after years of suffering from chronic pain. Kaylee is one such patient. Rather than causing dependence, Kaylee says that opioids have helped her become less shackled by chronic pain, in a sense giving her more independence:
“I am a patient who has benefited very much from long term opioid therapy. I have been taking opioid pain medication for[nine] years to manage pain from several herniated discs which, unfortunately, press on my sciatic nerve causing unbearable burning and stinging pain in both of my legs. This is in addition to the initial pain in my back from the discs. Thanks to my prescriptions for opioid pain medication I am able to hold a job, keep house, make dinner and spend time with my son.”
While Kaylee found significant relief and freedom, there is a growing evidence of a new potential issue linked to opioid use: depression and anxiety disorders.
The connection is not straightforward in the sense that researchers are not sure whether opioids put the patient at increased risk for anxiety or depression or if mood disorders make a patient more susceptible to opioid dependence.
The issue is further complicated when it comes to how opioids are obtained. Johns Hopkins University looked at non-medical use of opioids and how they contributed to mood disorders (and vice versa). Silvia Martins, MD, PhD, lead author of the study and an associate scientist with the Bloomberg School’s Department of Mental Health pointed out that the door swings both ways when it comes to opioid dependence and mood disorders, saying:
“Lifetime non-medical prescription opioid use was associated with the incidence of any mood disorder, major depressive disorder, bipolar disorder and all anxiety disorders…However, there is also evidence that the association works the other way too. Increased risk of incident opioid disorder due to non-medical use occurred among study participants with baseline mood disorders, major depressive disorder, dysthymia and panic disorder, reinforcing our finding that participants with mood disorders might use opioids non-medically to alleviate their mood symptoms.”
The study looked specifically at non-medical use, defining it as use without a prescription and not necessarily for chronic pain.
Chronic pain patients might take issue with the comparison of non-prescription use to carefully monitored, prescribed use, understandably, but other studies have shown a connection between even prescribed use and mood disorders, specifically depression.
New analysis from Saint Lewis University found that while opioids offered a boost in mood in short-term use, long-term use of opioids for chronic pain was associated with new-onset depression in patients whose use exceeded 30 days.
Jeffrey Scherrer, Ph.D., associate professor for family and community medicine at Saint Louis University and lead author of the study, believes that there is a biological response to long-term opioid use that may include changes in neuroanatomy and low testosterone (among other changes).
The study analyzed the medical records of nearly 108,000 patients across three healthcare systems. These patients were between the ages of 18 and 80 and presented with no previous diagnosis of depression. Between nine and 12% of patients taking long-term opioids in the three healthcare systems developed new-onset depression, a link that was independent of the previously established links between chronic pain and depression.
Dr. Scherrer points out that physicians should be aware of this risk and monitor their patients not just for dependence, noting:
“Opioid-related new onset of depression is associated with longer duration of use but not dose. Patients and practitioners should be aware that opioid analgesic use of longer than 30 days imposes risk of new-onset depression.”
At Holistic Pain, we believe that there is a need for caution in opioid prescribing.
For any type of long-term opioid therapy, a compliance checklist, such as the one utilized by Pain Doctor, is an important way to monitor and regulate opioid use. Pain Doctor’s 12-step opioid checklist includes the following criteria:
- Assessment of pain (0-10 scale)
- Clear documentation of rationale for opioid use (i.e., chronic lower back pain, degenerative disc disease)
- Clear documentation of beneficial clinical response to opioid use (i.e., decrease pain or increase function)
- Establish goals of opioid treatment and review of goals (i.e., patient has an increased ability to function)
- Current and updated medication list
- Documentation of substance abuse and social history
- Physical examination of painful area
- Documentation of risks and benefits (i.e., risks explained to patient)
- Appropriate referral for additional evaluation and treatment (i.e., psychiatric referral for depression)
- Updated Pharmacy Board review
- Current and consistent UDS within last 30 days
- Sign an Opioid Agreement within last six months
For some, opioid therapy can be a way to regain control of their lives. For others, the risks might outweigh the rewards. If you or a loved one takes opioids for chronic pain, talk to your doctor about the risks of depression.