Recovery Enhanced Medicine Institute
The Chronic Pain Experience
Chronic Pain and The Chronic Pain Experience
Anyone who suffers from chronic pain knows how difficult it is to lead a normal life. Recent medical research has indicated that chronic pain is more than a physical disorder in the back, a hip or a knee. Ongoing pain signals from the site of pain (the pain generator) leads to specific central nervous system changes.
These changes are like “short-circuits” that can worsen the intensity of pain experienced even if the original pain signal decreases. So although the pain begins in a knee, low back, or other site, over time the changes in the central nervous system and brain create additional pain. This pain is added above and beyond the pain from the original pain generator. The combination of the original pain and the additional central nervous system pain is called the Chronic Pain Experience (CPE).
It is important to understand that the CPE is real pain. Modern pain science research has clearly demonstrated the central nervous system changes are significant. These changes take place in the spinal cord and brain. It is important to make clear that the changes in brain and are real. The chronic pain experience is NOT “in your head”, which implies that the pain is fake or exaggerated. Your chronic pain experience should never be questioned. If your perception of your pain rating number is a 10/10, then 10/10 is the real level of your CPE.
The central nervous system change also impact your quality of life and functioning. The pain-induced brain changes can result in psychological, emotional and behavioral changes. These changes may effect your ability to perform your job or complete normal tasks. Your mood, your thinking and personal relationships may suffer because of the mental and emotional changes resulting from the central nervous system changes.
As a unique individual, your central nervous system changes occur on a backdrop of any pre-existing medical or behavioral health conditions you may have had before you developed chronic pain. Research has shown that certain genetic factors and life stresses can dramatically effect one's CPE.
Recent life stresses that can effect your chronic pain include:
• Your level of satisfaction with your employment, vocation or educational pursuits
• Your level of satisfaction with support system, including family, friends and social groups
Genetic and previous life stresses that can effect your chronic pain include:
• family history of a mental health disorder such as depression or anxiety
• family history of a substance use disorder
• personal history of a mental health or substance use disorder (even if many years ago)
• personal history of abuse, neglect, trauma or chaos (called Adverse Childhood Events)
Modern pain science research has indicated that the greater the number and severity of these life stresses one has, the severe the CPE is likely to be. These factors have also been shown to predispose a person to problems with prescribed opioids or addictive substances. Ultimately if not addressed they can contribute to the downward spiral of ‘suffering’ too often seen in the CPE.
Chronic Pain and Traditional Opioids
One of the most widely used methods of chronic pain management is the use opioid medications. Traditional opioids such as hydrocodone, oxycodone, morphine, codeine and other related painkillers are very effective at immediately controlling and eliminating acute pain. However there are risks and pitfalls to using traditional opioid painkillers for long-term management of chronic pain. The most commonly used opioids often lose their initial profound pain relieving properties over time. This can lead to increases in the dose or the addition of other potentially addictive medications such as benzodiazepines (Valium, Ativan or Xanax) or muscle relaxants such as carisoprodal (Soma).
Dose increases in traditional opioids can lead to side effects such as constipation, sedation, decreased sexual functioning, impaired immune system functioning and a decrease in respiratory functioning that can be fatal.
There also may be gradual and sometimes unnoticed side-effects that occur in the central nervous system of persons taking traditional opioids.
Gradual and often missed side effects of traditional opioids used for chronic pain include:
• Decreased cognitive functioning in areas of attention, concentration, planning and impulse control
• Emotional changes including depression, anxiety, anger or mood swings
• A loss of joy from naturally rewarding experiences (anhedonia)
• An increase in the stress response (fight/flight) system
These side effects of traditional opioids are often not recognized in the person taking the opioids because the symptoms of disconnection from life, mood changes, anger, anxiety or a lack of joy may be attributed to the chronic pain itself, or the life changes caused by the pain. Of course it is true that chronic pain can contribute to central nervous system changes causing behavioral, psychological and emotional symptoms mentioned above. However the research is clear that traditional opioids can worsen these pain-induced brain changes and increase the suffering of the chronic pain experience.
Buprenorphine: A New Medication for the Chronic Pain Experience
In the past chronic pain sufferers have had few choices when it comes to potent medication-based pain management. Recently, however, the FDA-approved drug buprenorphine has been used with amazing success in chronic pain. Buprenorphine is a powerful opioid pain relieving medication with special pharmacologic properties that make it safer than the traditional opioids used in pain management.
Buprenorphine has a ceiling effect on respiratory depression which means that used at normal pain management doses it does not have the overdose mortality risk seen with other opioids. It is also has a ceiling effect on the reinforcing properties making it less likely to inadvertently lead to misuse, abuse or an opioid use disorder (previously called opioid addiction).
When buprenorphine was first approved by the FDA for opioid use disorder there was some misinformation about buprenorphine's effect on pain published online and in print. It was said that buprenorphine had a ceiling effect in its pain relieving properties. Actual research on buprenorphine has clearly indicated that there is NO ceiling effect in buprenorphine's pain relieving properties.
Buprenorphine was initially derived from the naturally occurring opium poppy derivative thebaine. It was chemically modified by pharmaceutical researchers over 30 years ago and found to have excellent pain relieving properties with the lower risk profile mentioned above.
Buprenorphine has been successfully used as a powerful post-operative pain reliever for more than 40 years in Europe.
There is still some confusion about buprenorphine in the United States because of its FDA approval in early 2000’s to treat opioid use disorder. Many physicians in the US have never used buprenorphine for pain and are unaware of its robust pain-relieving/analgesic effects.
Buprenorphine's excellent pain relieving properties combined with its reduced risk profile make it a valuable tool in the management of the Chronic Pain Experience.
Buprenorphine comes in two under-the-tongue or sublingual forms: Subutex, which is composed of only buprenorphine, and Suboxone, which is a combination of buprenorphine and naloxone (both FDA approved in US for opioid use disorder [OUD]). There are also forms that can be placed on the inside of the cheek (Belbuca- FDA approved in US for chronic pain) and a patch worn on the arm (Butrans- FDA approved in US for chronic pain).
If buprenorphine is used for OUD the prescriber must have several hours of training in using buprenorphine in OUD. Any licensed prescriber can prescribe buprenorphine for pain without a special license.
The choice of form of buprenorphine depends on a number of factors that you should discuss with your pain management team.
What exactly is Buprenorphine?
Buprenorphine is a potent opioid that has unique "agonist-antagonist" properties when it binds to the opioid receptor in the brain. The "agonist" part of the term describes how at the right dose it activates, or turns on (is an "agonist") the opioid receptor, bringing pain relief and other opioid effects. The "antagonist" part of the term describes how above its appropriate dose range it actually blocks or stops the turning on effect and actually turns off the over-stimulation of the receptor. This overstimulation is what causes respiratory depression and death with other opioids. So it is this unique turn on for powerful pain relief combied with its turn off for potentially deadly overstimulation that gives buprenorphine its unique reduced risk profile compared to other traditional opioids that don’t have this property.
Because buprenorphine is a risk-reduced agonist-antagoist opioid that works powerfully at the opioid receptor to block pain, it can be an attractive option for long-term chronic pain management.
Compared to traditional opioid painkillers, long-term use of buprenorphine has a lower risk of side effects, physical dependency and milder withdrawal symptoms when usage ends. Even with these benefits, there are some risks to using buprenorphine, and because it is an opioid it should only be taken under the supervision of a trained medical professional. Overdosing or taking buprenorphine with alcohol, sedatives or CNS depressants can lead to severe complications that include disability and death.
Using buprenorphine has its advantages when compared to other opioids, but using any medication alone is not an effective treatment for chronic pain. Managing chronic pain should include more than just medication; it should also include non-medication based treatments to address the psychological, emotional and social components of chronic pain. This is the type of comprehensive multi-modal pain management program offered at REMI.
Why change your opioid to buprenorphine?
Many patients are disappointed to see that as time goes on their opioid medicines are less and less effective in treating their pain. This occurs because, over time, the central nervous system adjusts and changes. This results in less pain relief and more side effects as the dose of the opioid is increased chasing an ever-moving target of pain relief. Eventually one can no longer take enough pain medication to control their pain. Since they are no longer getting pain relief, the only reason they continue to take the pain medication is to prevent a perceived worsening of pain or to prevent going into withdrawals from stopping the opioid.
By changing the opioid to buprenorphine the central nervous system changes caused by chronic pain and long-term opioid use are given an opportunity to return to a more normal situation of functioning. This improvement allows for better engagement in a comprehensive multi-modal pain management program.