Risks of long-term opioid treatment
In the first installment, A balancing act – opioid use throughout history, we reviewed some historical highlights to help us understand how we arrived at the present situation. Now we'll cover many of the potential side effects and risks of long-term opioid treatment.
Opioids are not recommended as first-line migraine therapy. They are usually prescribed for those who cannot tolerate or do not respond to other therapies. A study was published in the January 2012 issue of Headache in which researchers analyzed data from AAMP regarding opioid use1.
Here is a summary of what they discovered:
- 70% of those studied had not ever used of opioids
- 13% previously used opioids
- 2% currently used opioids and were not dependent
- 6% currently used opioid and were probably dependent
- Those who used opioids were more likely to be
- be single
- have higher BMI
- have lower income
- Headache disability among opioid users
None of these findings established a causal link1. In fact, it is just as likely that the higher rate of negative outcomes was a result of the disease itself. Those patients more likely to use opioids may simply be more disabled by Migraine.
Not everyone will experience every side effect and some people will experience side effects not documented. Some side effects get better with time and some don’t. Sometimes these side effects do not go away once the opioid is discontinued1.
- Sleep disturbance
- Respiratory depression
- Cough suppression
- Papillary constriction
- Truncal rigidity
- Nausea & vomiting
- Temperature dysregulation
- Lowered seizure threshold
- Renal function depression
- Immune system suppression
- Endocrine system suppression
After two weeks of continuous use
- Tolerance occurs
- Potency is reduced
- Cross tolerance occurs
- Constipation & GI slowing does not improve with continued use
- Respiratory depression may worsen
- Patients may escalate use, leading to psychological dependence
- Withdrawal symptoms begin 6-12 hours after cessation and last for 2-3 days but, cravings can continue indefinitely.
- Altered thermoregulation
- Pupil dilation
- Generalized pain
It is also important to note that the new DSM-V has replaced both Opioid Dependence and Opioid Addiction with a new diagnosis, Opioid Use Disorder1. In order to meet the diagnostic criteria, patients must exhibit “problematic pattern of opioids use leading to the clinically significant impairment or distress, as manifested by at least 2 of the following, occurring within a 12 month period:”
- Opioids taken in larger amounts of over a longer period of time than was intended
- Persistent desire or unsuccessful efforts to control or cut down opioid use
- A great deal of time is spent using, obtaining, or recovering from effects
- Failure to fulfill major role obligations at work, school, or home
- Continued use despite problems because of opioids
- Important activities are given up
- Recurrent use in situations that are physically hazardous
- Continued use despite knowing of physical or psychological problem because of opioids
- Tolerance (unless used under "appropriate medical supervision")
- Withdrawal (unless used under "appropriate medical supervision")
Please note that just because a patient is under a doctor’s care does not mean that addiction cannot occur. According to the new criteria, only tolerance and withdrawal are exempt from inclusion if under medical supervision. If a patient is taking opioids and then putting themselves in situations that are physically dangerous (such as driving or operating heavy machinery) AND that same patient continues to take higher and higher doses over time to achieve the same effect, he or she may still be considered for drug addiction treatment. It’s a hazy area that is largely a judgment call. No two patients are alike. The important thing is for both patient and doctor to communicate openly and honestly so that medical decisions are made in the best interest of patient well-being.
Can you tell when a migraine attack is coming?