Chronic pain is a health problem that is affecting about 20 percent of the European population (Van Hecke, Torrance & Smith, 2013). Considering the cost of chronic pain, we should take into account the public health care expenditure but also costs caused by loss of productivity (Boonen, 2005). According to the ‘NHG standard: pain’ (De Jong et al., 2018) for the pharmacological treatment of pain, the first step is the use of a non-opioid analgesic, including paracetamol, followed by the use of non-steroidal anti-inflammatory drugs (NSAIDs). If this does not work (sufficiently), step two is the prescription of a weak opioid analgesic such as tramadol. Step three consists of the administration of strong opioid analgesics, including oxycodone and morphine. Opioids consist of a natural or synthetic chemical that interacts with the opioid receptors on the nerve cells in the body and brain, thus reducing feelings of pain (Murphy & Rafie, 2021). In the United States, the pharmacological management of chronic pain was so widely used that it led to an epidemic in opioid use (Upp & Waljee, 2020). Also in the Netherlands, opioid use almost doubled between 2008 and 2017, from 4,109 opioid drug users per 100,000 habitants to 7,489 users per 100,000 habitants (Kalkman,, Kramers, van Dongen, van den Brink & Schellekens, 2019). However, the use of opioids in the management of chronic pain leads to multiple problems.
Effect of opioid use
Opioids provide short-term pain relief (Furlan, Sandoval, Mailis-Gagnon, & Tunks, 2006), but long-term use of opioids will increase pain (Rivat & Ballantyne, 2016). After one month of regular use, opioids change the brain structure (Younger et al., 2011). The use of opioids leads to hyperalgesia (i.e., the condition in which pain sensation is increased) and allodynia (i.e., pain resulting from a stimulus that is normally not painful) (Rivat & Ballantyne, 2016). Long-term use of opioids reduces the functioning of the opioid receptors or even causes these receptors to disappear. This may lead to opioid tolerance (i.e., a higher dose is required to achieve the same analgesic effect) (Roeckel, Le Coz, Gavériaux-Ruff, & Simonin, 2016). In this way, opioids can in fact cause or maintain chronic pain.
Apart from the fact that opioids can actually increase pain, increased use of opioids may also have other negative side effects. Examples of such negative side effects are: constipation, fatigue, poor sleep, nausea, and depression. These side effects have a negative effect on the quality of life (Frank et al., 2017). It is therefore not surprising that multidisciplinary pain rehabilitation programs for the treatment of chronic pain have been shown to be more effective than the use of opioid medication (Frank et al., 2017). However, little is known about the process and results of tapering off use of opioids (Cunningham, Evans, King, Gehin & Loukianova, 2016).
Tapering off opioids
Patients who were tapering off opioids in pain rehabilitation programs experienced significant reductions in pain, depression, anxiety, somatic symptoms, pain catastrophizing, and the impact of pain on daily life was noticeably lower. There was an improvement in the quality of life (Crouch et al., 2020; Cunningham et al., 2016). The process of tapering off opioids took place in a supportive environment in which patients can learn effective coping strategies to use during the tapering process.
A qualitative study focussed on patients’ perceptions of risks, barriers and facilitators of opioid tapering, and potential benefits of opioid tapering. The results showed that patients were afraid of pain increase when tapering opioids (Frank et al., 2016; Henry et al., 2019). Patients were prevented from starting tapering because they were afraid of the withdrawal symptoms and also feared the lack of effective alternatives to cope with their pain. Support both from the social environment and a health caregiver who the patient trusted, was an important reason for the success of the process of tapering off opioids. The patients who participated in this research reported an improvement in quality of life after tapering opioids. To successfully taper opioids, patients have to learn how to deal with the pain,understand pain and central sensitization, and also how to handle it in such a way that it becomes bearable and manageable (Henry et al., 2019). After their case study of opioid tapering, Agarwal and colleagues (2020) concluded that pain education is an important factor in successful opioid tapering. It especially aims on how to understand pain and central sensitization during and after tapering and to change perceptions on pain during the process.
It can be concluded that multidisciplinary pain rehabilitation programs and pain education appear to be an effective treatment method for people with chronic pain and the process of tapering off opioids. This appears to improve quality of life and provide an effective evidence-based treatment for coping with chronic pain on a non-medication-oriented way (Crouch et al. 2020; Cunningham et al., 2016).
Hiske Akkerman MSc.
Psycholoog, fysiotherapeut, Rijksuniversiteit Groningen
Prof. Dr. C. Paul van Wilgen
Psycholoog, fysiotherapeut, epidemioloog, Transcare Groningen (www.transcare.nl) VU Brussel PAIN onderzoeksgroep, Pain in Motion internationale studiegroep.
2022Pain in Motion
References and further reading:
Agarwal, V., Louw, A. & Puentedura, E. J. (2020). Physician-Delivered Pain Neuroscience Education for Opioid Tapering: A Case Report. International Journal of Environmental Research and Public Health, 17(9), 3324.
Boonen, A., Heuvel, R. van den, Tubergen, A. van, Goossens, M., Severens, J. L., Heijde, D. van der & Linden, S. van der (2005). Large differences in cost of illness and wellbeing between patients with fibromyalgia, chronic low back pain, or ankylosing spondylitis. Annals of the rheumatic diseases, 64(3), 396-402.
Crouch, T. B., Wedin, S., Kilpatrick, R. L., Christon, L., Balliet, W., Borckardt, J. & Barth, K. (2020). Pain rehabilitation’s dual power: Treatment for chronic pain and prevention of opioid-related risks. American Psychologist, 75(6), 825.
Cunningham, J. L., Evans, M. M., King, S. M., Gehin, J. M. & Loukianova, L. L.(2016). Opioid tapering in fibromyalgia patients: experience from an interdisciplinary pain rehabilitation program. Pain Medicine, 17(9), 1676-1685.
Frank, J. W., Levy, C., Matlock, D. D., Calcaterra, S. L., Mueller, S. R., Koester, S. & Binswanger, I. A. (2016). Patients’ perspectives on tapering of chronic opioid therapy: a qualitative study. Pain Medicine, 17(10), 1838-1847.
Frank, J. W., Lovejoy, T. I., Becker, W. C., Morasco, B. J., Koenig, C. J., Hoffecker, L. ... & Krebs, E. E. (2017). Patient outcomes in dose reduction or discontinuation of long-term opioid therapy: a systematic review. Annals of internal medicine, 167(3), 181-191.
Furlan, A. D., Sandoval, J. A., Mailis-Gagnon, A., & Tunks, E. (2006). Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. Cmaj, 174(11), 1589-1594.
Hecke, O. van, Torrance, N. & Smith, B. H. (2013). Chronic pain epidemiology and its clinical relevance. British journal of anaesthesia, 111(1), 13-18.
Henry, S. G., Paterniti, D. A., Feng, B., Iosif, A. M., Kravitz, R. L., Weinberg, G. ... & Verba, S. (2019). Patients’ experience with opioid tapering: A conceptual
model with recommendations for clinicians. The Journal of Pain, 20(2), 181-191.
Jong, L. de, Janssen, P. G. H., Keizer, D., Köke, A. J. A., Schiere, S., Bommel, M. van …& Verduijn, M. M. (2018). NHG-Standaard pijn.
Kalkman, G. A., Kramers, C., Dongen, R. T. van, Brink, W. van den & Schellekens, A. (2019). Trends in use and misuse of opioids in the Netherlands: a retrospective, multi-source database study. The Lancet Public Health, 4(10), e498-e505.
Murphy, J. L. & Rafie, S. (2021). Chronic pain and opioids. (pp. 13-23). Washington, DC: American Psychological Association. doi:10.1037/0000209-002
Nijs, J., & Wilgen, C. P. van (2010). Pijneducatie-een praktische handleiding voor (para)medici. Bohn Stafleu van Loghum, Houten.
Rivat, C. & Ballantyne, J. (2016). The dark side of opioids in pain management: basic science explains clinical observation. Pain reports, 1(2).
Roeckel, L. A., Le Coz, G. M., Gavériaux-Ruff, C., & Simonin, F. (2016). Opioid-induced hyperalgesia: cellular and molecular mechanisms. Neuroscience, 338, 160-182.
Upp, L. A. & Waljee, J. F. (2020). The opioid epidemic. Clinics in Plastic Surgery, 47(2), 181–190. https://doi.org/10.1016/j.cps.2019.12.005
Younger, J. W., Chu, L. F., D’Arcy, N. T., Trott, K. E., Jastrzab, L. E. & Mackey, S. C. (2011). Prescription opioid analgesics rapidly change the human brain. PAIN®, 152(8), 1803-1810.