This is a touchy subject, I know.
Many chronic pain sufferers have been treated like someone with a drug problem and had their pain dismissed and left untreated. It is adding insult to injury. The purpose of this article is not to shame anyone but rather to educate. I completely understand what it’s like to hate having to choose between pain and the awful side effects of medication. So this article will discuss the history, mechanisms, research, and risks of using opioids for pain management, 100% judgment free!
History of Opioids
Opioids were originally produced from the poppy plant but are now also made synthetically. They came on the scene in the United States in a big way during the Civil War when morphine was used to treat wounded soldiers.¹ While it was a miracle pain reliever for injuries, many veterans developed an addiction.² Almost 40 years later, the Bayer company released commercial production of heroin, the "wonder drug" for pain, which was even used as a cough suppressant.²
By the 1920s, it was obvious these drugs were highly addictive; drugs like heroin became illegal, but that didn't stop it from spreading. In the 1970s, despite clinicians' reluctance to use these addictive substances, Percocet and Vicodin hit the market.²
In 1980, a letter was printed in the New England Journal of Medicine by Jane Porter & Dr. Hershel Jick that stated in their analysis of almost 12,000 patients treated with narcotics for chronic pain, addiction was rare when there was no prior history of it.² Pain Management became a focus, and opioids were the answer.
In the mid-'90s, oxycontin came on the market, and the number of painkiller scripts went from 2 to 3 million to 10 to 13 million.² The narrative around opioid use became its safety and efficiency at giving pain sufferers their life back, and for the next 15 years, more and more people became hooked.
By 2016, the CDC director Dr. Tom Frieden admitted there wasn't enough data on the long-term use of prescription opioids, but he stated, "We know of no other medication routinely used for a nonfatal condition that kills patients so frequently.² He cited studies showing an increase in pain with opioid use, dependency rates, and the number of deaths.
Types of Opioids
In addition to the drugs listed above, here are some other common prescription opioids:
Opioids work by activating an area of nerve cells, opioid receptors, that block the pain signals in the brain and body. They can also create feelings of euphoria. Your body naturally produces opioids, but they do not have the same effect on the receptors.
A recent study found that endogenous (naturally occurring) opioids activated the whole cell more slowly. In contrast, pharmaceutical opioids such as morphine only activate only the surface (shown on the left) and at a more rapid rate, which may explain some of the undesired side effects.
Research on Opioid Use for Fibromyalgia Pain
By the time I received my fibro diagnosis, I had been prescribed Percocet for over two years. Unfortunately, that continued until I decided I would rather live with the pain than the side effects from narcotics. At the time, my doctor, along with most of the medical community, knew very little about the efficacy of opioids for fibro pain, but luckily research has given everyone some guidance.
An interesting study waaaay back in 2007 (old for research) published in the Journal of Neuroscience examined the opiate receptors in fibromyalgia patients and found a reduced availability and function when compared against a healthy control group, which also correlated with increased pain ratings.⁴ Furthermore, they found those with fibro had elevated rates of natural opioids, despite the pain.⁴
Both the lack of receptor function and already increased levels of natural opioids that were ineffective predict, as the authors stated, a lack of effectiveness for prescription opioids.⁴ It's basically like giving something that we can't absorb, of which we already have a surplus anyway, further stressing out an already stressed-out system. It doesn't sound like a good plan. Although a small study of only 34 participants, it has been cited over 580 times, making it a significant finding for underresearched fibromyalgia.
In 2011, an article was published in The International Journal of Rheumatic Diseases in response to the prevalent use of opioids for fibromyalgia pain despite the lack of research on its success and the well-known risks.⁵ Again, they echoed the inability to target the underlying dysfunctions involved in the central sensitization responsible for the pain.⁵
From 2013 onward, large population-based studies took a closer look at the prevalence of opioid use and its long-term benefits. As the study in 2007 predicted, it was found that anywhere from a third to two-thirds of the patients researched were prescribed opioids.⁶ ⁷ ⁹ Moreover, these patients had poorer outcomes in pain levels, quality of life, depression, and insomnia when compared to fibromyalgia patients, not on narcotics.⁶ ⁷ ⁹A literature review published in the Mayo Clinic that examined all clinical trials, observational studies, and articles published by experts in the field found no evidence for opioid use for fibromyalgia, yet it was still being prescribed. Opioids are great if you have a substantial short-term injury but are ineffective in treating fibromyalgia pain. Not only do they not help, but they also have so many risks.
Risks & Side Effects
The biggest risk with taking opioids is, of course, addiction. It saddens me to say that many of you may have experienced the devasting effects of opioid addiction in your family and friend circles. I know most of us are well aware of how the gross malpractice and greed of many in the healthcare industry cost many people their lives.
I was lucky enough not to get addicted to pain pills, but that wasn't because I was strong. Addiction isn't about strength, character, socioeconomic background, or any other misconception people make. It's really about genetics and brain chemicals! As I mentioned in the last paragraph, opioids really aren't suitable for long-term use because of their impact on the system.
In the research studies cited above, there were correlations between opioid users and unemployment, unstable mental illness, substance abuse, and higher rates of suicide attempts.⁶ ⁹ While it's impossible to prove causation, and it's possible the severity of fibro may have been worse at the onset of symptoms, it's important to note that obviously, the opioids aren't helping the situation. Taking them long-term for chronic nonmalignant pain is still misunderstood, but there is ample evidence mounting for effects on mood, cognitive function, aggravation of pain, and hormones.⁹ None of which a Spoonie needs!
In general, opioids can cause drowsiness, confusion, nausea, euphoria, slowed breathing, and constipation.¹⁰ Opioids can also slow your metabolism, making it difficult for the body to break down other drugs. Even prescription opioids can lead to addiction, creating lasting changes in the brain. Addiction can lead to mild to severe withdrawal symptoms, including muscle and bone pain, sleep problems, diarrhea and vomiting, cold flashes, uncontrollable leg movements, and severe cravings when stopping the medication.¹⁰
Opioid Use Disorder
I couldn't write this article without talking about OUD (Opioid Use Disorder). As we've established, opioids aren't great for Spoonie's pain, but that doesn't mean that every doctor out there is educated. If you have been taking opiates for an extended period, have to increase the dosage, and feel like it still isn't working, but you can't stop taking it, you may have a chemical imbalance in your brain, which is not your fault and can be treated.
Unfortunately, opioid-induced hyperalgesia (increase in pain sensitivity) can keep people hooked. From 1998-2014 hospitalization rates for OUD for fibro warriors increased twelve-fold. Medication to help treat the addiction is the best course of action and can help you safely and permanently stop using opioids with minimal discomfort. If you are struggling, Bicycle Health can get you all the support you need, including meds and support. Do not let shame stop you from getting help.
But What About Tramadol?
Tramadol, a synthetic opioid, has been called a "weak" opiate, and there has been at least some evidence that it has helped in certain circumstances. However, opioids, weak or not, are not approved by the FDA to treat fibromyalgia.¹¹ In 2003, a double-blind, randomized, placebo-controlled study (the king of research study design!) on the effect of tramadol and acetaminophen (Tylenol) in combination in fibromyalgia patients. The results showed the treatment to be safe, with few adverse effects and a moderate improvement.¹³
Tramadol's efficacy and the difference from other opioids may be because it acts as an SSRI (serotonin-norepinephrine reuptake inhibitors), an antidepressant, which has already been proven effective for fibromyalgia.¹¹ However, a systematic review of randomized controlled trials of Tramadol published in 2019 found that out of four trials done, it was only found effective for improving quality of life when combined with the analgesic (Tylenol) and that there wasn't enough evidence to determine it should be used for pain and symptom management or not.¹² One review published in the Expert Review of Neurotherapeutics recommends it be considered for more treatment-resistant cases.¹¹
So even though this article is included under treatments, research doesn't really support the use of opioids for fibromyalgia because they're ineffective, have many side effects, and are highly addictive. Tramadol may be helpful, but research still hasn't garnered enough data to recommend widespread use. Most of us Spoonies are likely not on opioids, but some of us are. If you are struggling with opioids, don't wait to reach out for help; reach out to your provider, and advocate for yourself. There are better options available. If you think you might have OUD, don't be ashamed, it's like getting help for any other medical condition. All types of people have problems with opioids.
Georgetown Behavioral Health Institute. (August 14, 2018) The Origin and Causes of the Opioid Epidemic. https://www.georgetownbehavioral.com/blog/origin-and-causes-of-opioid-epidemic
Moghe, S. (October 14, 2016) Opioid History: From ‘wonder drug’ to abuse epidemic. CNN Health. https://www.cnn.com/2016/05/12/health/opioid-addiction-history/index.html
National Institutes of Health. (May 22, 2018) How opioid drugs activate receptors. https://www.nih.gov/news-events/nih-research-matters/how-opioid-drugs-activate-receptors
Harris, R. E., Clauw, D. J., Scott, D. J., McLean, S. A., Gracely, R. H., & Zubieta, J. K. (2007). Decreased central μ-opioid receptor availability in fibromyalgia. Journal of Neuroscience, 27(37), 10000-10006. https://www.jneurosci.org/content/27/37/10000.short
Ngian, G. S., Guymer, E. K., & Littlejohn, G. O. (2011). The use of opioids in fibromyalgia. International journal of rheumatic diseases, 14(1), 6-11. https://doi.org/10.1111/j.1756-185X.2010.01567.x
Fitzcharles, M. A., Faregh, N., Ste-Marie, P. A., & Shir, Y. (2013). Opioid use in fibromyalgia is associated with negative health related measures in a prospective cohort study. Pain research and treatment, 2013. https://downloads.hindawi.com/archive/2013/898493.pdf
Peng, X., Robinson, R. L., Mease, P., Kroenke, K., Williams, D. A., Chen, Y., ... & Hann, D. (2015). Long-term evaluation of opioid treatment in fibromyalgia. The Clinical journal of pain, 31(1), 7-13. https://journals.lww.com/clinicalpain/Abstract/2015/01000/Long_term_Evaluation_of_Opioid_Treatment_in.2.aspx
Goldenberg, D. L., Clauw, D. J., Palmer, R. E., & Clair, A. G. (2016, May). Opioid use in fibromyalgia: a cautionary tale. In Mayo Clinic Proceedings (Vol. 91, No. 5, pp. 640-648). Elsevier.
Fitzcharles, M. A., Ste-Marie, P. A., Gamsa, A., Ware, M. A., & Shir, Y. (2011). Opioid use, misuse, and abuse in patients labeled as fibromyalgia. The American journal of medicine, 124(10), 955-960. https://www.researchgate.net/profile/Ann-Gamsa/publication/51684399_Opioid_Use_Misuse_and_Abuse_in_Patients_Labeled_as_Fibromyalgia/links/5f8611c892851c14bcc69329/Opioid-Use-Misuse-and-Abuse-in-Patients-Labeled-as-Fibromyalgia.pdf
National Institue on Drug Abuse (June, 2021). Prescription Opioids DrugFacts. National Institutes of Health. https://nida.nih.gov/publications/drugfacts/prescription-opioids
MacLean, A. J., & Schwartz, T. L. (2015). Tramadol for the treatment of fibromyalgia. Expert Review of Neurotherapeutics, 15(5), 469-475. https://www.tandfonline.com/doi/abs/10.1586/14737175.2015.1034693
da Rocha, A. P., Mizzaci, C. C., Nunes Pinto, A. C. P., da Silva Vieira, A. G., Civile, V., & Trevisani, V. F. M. (2020). Tramadol for management of fibromyalgia pain and symptoms: Systematic review. International journal of clinical practice, 74(3), e13455. https://onlinelibrary.wiley.com/doi/abs/10.1111/ijcp.13455
Bennett, R. M., Kamin, M., Karim, R., & Rosenthal, N. (2003). Tramadol and acetaminophen combination tablets in the treatment of fibromyalgia pain: a double-blind, randomized, placebo-controlled study. The American journal of medicine, 114(7), 537-545. https://www.sciencedirect.com/science/article/abs/pii/S0002934303001165