Long-term Effects of Opioid Pain Relievers

As someone who suffers from chronic pain, I was wondering what are the long term effects of my pain medication? At this point in time Lyrica is not available to me and SSRIs, like Cymbalta, have horrible side-effects with me. So, my doctor in all his wisdom prescribes me Vicodin to control my pain. So, what are the long-term effects of it’s usage?

During my research I found very little on the long term effects. Most of what I found dealt with addiction to opioids and opioid-mix drugs. Currently, very few people become addicted to drugs like Vicodin and Percocet, though they do become physically dependent– which is not the same as addicted (explained further below). Some of what I found also dealt with the effects of overdose on opiods mixed with acetaminophen, such as liver and kidney damage that could ultimately lead to death (which is the case with any drug that contains acetaminophen).

Here are some of the facts regarding addiction and physical dependency to opioid/opioid-mix drugs from WebMD:

Addiction Myths¹ :
Addiction: Hospice patients worry about becoming addicted to opioids. With hospice, however, it is rarely an issue. People with chronic pain also worry about addiction, but it turns out that for most adults, if they do not already have a substance (alcohol or drug) abuse problem, addiction is not much of an issue even when opioids are used on a long-term basis.

• A study was done in which 12,000 nonaddicted people who needed opioids were followed up to see if they had become addicted. Four out of 12,000 showed addictive behavior (less than one tenth of 1%).
• Generally, the only people who develop addictive behavior after being given opioids had an addiction problem before the opioids were given for pain. Most people take opioids until the pain goes away. Then they stop taking them because they do not want to feel dizzy or drowsy. Once the pain goes away, the toxic side effects of dizziness and drowsiness come back.
• Anyone who takes any medication just to “get high” is already showing addictive behavior and needs to stop taking addictive substances, including opioids, other addictive drugs, and alcohol, immediately.
• Some people with actual painful illnesses are addicted to mind-altering substances. They get prescriptions because of their actual illnesses. Here’s how the patient or the family can tell the difference between someone who needs opioids for pain and someone who is abusing opioids. Normally, the dose of opioids is arrived at by the patient telling the doctor how they are doing with the pain and by participating in their activities of daily living. A chronic pain patient who is not addicted to medication will tell the doctor the truth about his or her ability to function and do what needs to be done in daily life.
• Addicts will lie about performing activities of daily living. The addict will claim that the pain is so severe that they need a higher dose until they get to a dose that causes them to be asleep most of the time. Then, they will tell the doctor that they are doing fine and are able to do all the activities that they need to do.
• Selling the medicine to others is a federal crime that could get the seller a very long jail sentence and could lead to government seizure of your car or your house.
• Family members must let the doctor know what is actually happening in this sort of situation. When an addicted person actually has a painful syndrome, the doctor, with the help of the family, may have to decide what the dose of medication should be, without reference to the dose the pain patient thinks would be best. Sometimes, in severely addicted people, the opioids should not be used at all. Some addicted people can be treated with opioids if necessary as long as they cooperate carefully with the treatment plan.

The physical dependency of my Vicodin is well documented, but I’m glad to know that the kind of addiction exhibited in such shows as “House” is so rare. Still, I worry about the damage my body will have due to long-term use. The WebMD article tells me that opiod/acetaminophen and opioid/NSAID (ibuprophen, naproxen) aren’t recommended for long-term use by chronic pain sufferers simply because over time they can damage the liver, kidneys and stomach (NSAIDs). However, an article from the Mayo Clinic states²:

No evidence indicates that long-term use of single-agent opioid analgesic preparations results in end-organ failure, as may be seen with other analgesics (eg, NSAIDs), or with certain combination opioid analgesics

And the WebMD states:

Strong opioid medications are slightly different in this regard, and this is fortunate for people who suffer from severe pain. With strong opioids, the dose depends on the amount of pain. These medications should not mixed with acetaminophen or other non-opioid drugs when used to treat chronic pain. People with intense pain can take very high doses of opioids without getting side effects. Some people with intense pain get such high doses that the same dose would be fatal if taken by someone who was not suffering from pain. In the pain patient, that same high dose can control the pain and still allow the person to be wide awake enough to do his or her activities of daily living.

• Long-acting opioid: The best way to treat chronic, severe pain is by keeping it under control all the time. Your doctor can do this by using a long-acting opioid to keep the pain under control and a short-acting opioid to deal with those few times during the day when the pain breaks through. So, if you are on morphine, you would get a slow-release tablet that would keep your pain under control most of the time, and a short-acting tablet or liquid for those times when your pain breaks through.
• Bad opioids: Some opioids are not recommended for chronic pain.
  • Demerol (meperidine), which is used often for acute pain after surgery, is a poor drug for chronic pain. It is not absorbed well when taken by mouth, and it causes dysphoria (feeling truly lousy) and seizures if used for more than a few days.
  • Talwin (pentazocine) is also bad for chronic pain. It has a ceiling effect. There is a maximum dose after which raising the dose gives no further pain relief. It also causes withdrawal symptoms when given to someone who is also taking another opioid.
  • The opioid/acetaminophen or opioid/NSAID combination drugs are fine for short-term use, but acetaminophen is poisonous to the kidneys and liver when used for a long time or in high doses. Many NSAIDs are toxic to the kidneys and stomach when taken for a long time or in high doses.

Doctor’s Argoff and Silverstein, writing the article located on the Mayo Clinic Proceedings, clearly states that “single agent” opioids show no long-term effect leading to organ failure, but combined with acetaminophen or NSAIDs can have dire results as shown by WebMD. So, am I to take from this that I should find another way to manage my chronic pain? I’m thinking that over the long haul I will be forced to go back to Amitriptyline and possibly try Lyrica– after I talk to my doc about this new drug.

Yesterday, while I was doing my research for this post, the FDA was busy approving a new, long-acting opioid for moderate to severe chronic pain.

The US Food and Drug Administration (FDA) has approved morphine sulfate/naltrexone hydrochloride (Embeda), an extended-release oral opioid analgesic for the management of moderate to severe pain when a continuous, around-the-clock opioid analgesic is needed for an extended period of time. This Schedule II agent is the first FDA-approved long-acting opioid that is designed to reduce drug liking and euphoria when tampered with by crushing or chewing.

Does this drug count as a “single agent opioid” and will it be safer to use than Vicodin (mixed with acetamenophin) or Percocet (mixed with NSAIDs)? Can this be something that will have fewer adverse long-term effects for chronic pain sufferers? As I’m not a doctor, I can’t really answer those questions– but they will be posed by me to my own doctor. It’s something I’m genuinely interested in. I have chronic noncancer pain and want relief from that without having to wonder if I know anyone close who would be willing to donate part of their liver later on in my life³. This is something that I’ve been thinking about for quite some time and I believe it’s time to review my options and sit down with my doctors again.

A note on physical dependency:
Physical dependency is different than addiction in that addiction causes people to seek the drugs anyway that they can get them, including lying to their doctors about their pain and daily activities. Physical dependency cause the withdrawal symptoms when people stop taking the drugs as well as heightened tolerance over time. That means that people suffering from chronic pain are likely to take more of the medication to get relief– which is what can lead to the most damage. This is why it’s so important to talk to your doctor honestly about the need to increase your dose of medications if and/or when that happens.

One more note: One of the side-effects of Vicodin is intense itching all over. I’ve recently discovered this in my research (having developed this recently and wondering what is going on). It’s normal and you should make sure to tell your doctor if you experience. I was under the impression that this was an effect of long-term use of the medication, but I’m wrong. It’s normal and can occur in people that have just started taking it.

1. WebMD: Chronic Pain Guide: http://www.webmd.com/pain-management/guide/narcotic-pain-medications [↩]
2. Contemporary Clinical Opioid Use: Opportunities and Challenges * W. L. Lanier and E. D. Kharasch
   Mayo Clin Proc. July 1, 2009 84(7):572-575 [↩]
3. That statement is only half tongue-in-cheek, by the way. [↩]