Opioids for relief of chronic pain? Try less risky treatments first

Chronic pain is one of medicine's conundrums. It has a myriad of causes, including injuries that fail to heal properly, nerve damage, and aging joints. And sometimes it seems to arise for no apparent reason. It's notoriously tough to treat.

As a result, people with chronic pain face a host of frustrations and often try many treatments and painkillers before finding relief. A new report from the Consumer Reports Best Buy Drugs project offers fresh guidance on using the strongest of these painkillers—called the opioids—to treat chronic pain.

This 20th Best Buy Drug report compares 12 opioids. We've chosen four generics as Best Buys for people who have chronic pain and whose doctors have concluded that an opioid is necessary. Based on their relative low cost, the evidence for effectiveness, safety, side effects, and dosing convenience and flexibility, the Best Buys are:

• Codeine plus acetaminophen
• Morphine extended release
• Oxycodone extended release
• Oxycodone with acetaminophen

These four medicines have a long track record and provide good value. They range widely in monthly cost, depending on dosing regimen. But most low-dose regimens will run you less than $150 a month or so.

There's no reason to take the brand-name versions of these drugs—Tylenol #3 or #4, MS Contin, OxyContin, or Percocet—or any opioid for that matter.

Evidence links the long-term use of opioids to some unpleasant side effects, such as loss of interest in sex and impaired sexual function; a decline in immune function; and an increase in the body's sensitivity to pain.  Also, the opioids carry the risk of being addictive and are prone to abuse and misuse. In people who genuinely need them to control moderate to severe pain, addiction is rare, however.

Our report finds that many consumers believe their chronic pain warrants the strongest of pain relievers. But the evidence actually shows that everyday pain relievers, when used in moderate to high doses, can be just as effective as the opioids against many forms of chronic pain—like back pain, osteoarthritis, and recurring muscle pain. And they are a lot safer.

If you suffer from chronic pain we also advise you to talk with your doctor about non-drug measures. Several, including cognitive behavioral therapy, exercise, spinal manipulation, and physical rehab programs, have been shown to ease pain and/or improve quality of life.

The bottom line: don't use opioids until you have tried other, less risky, pain relievers first, and failed to get adequate relief. Those include acetaminophen (Panadol, Tylenol, and generic), non-steroidal anti-inflammatory drugs (the so-called NSAIDs), such as ibuprofen (Advil, Motrin, and generic) and naproxen (Aleve, Naprosyn, and generic), or other non-opioid prescription painkillers.

To find out more about the uses and side effects of the drugs in this class, read our FREE Consumer Reports Best Buy Drugs report.

—Steve Findlay, managing editor, Consumer Reports Best Buy Drugs

Comments

[jhen]

The management of patients with chronic pain is a common clinical challenge. Indeed, chronic pain is often inadequately controlled in patients with cancer and in those with non-cancer chronic pain. Because of the complex nature of chronic pain, successful long-term treatment is more difficult than for acute pain. Most often acute pain is nociceptive, whereas chronic pain can be nociceptive (i.e., in response to noxious stimuli), neuropathic (i.e., initiated by a primary lesion or dysfunction in the nervous system) or mixed in origin. Opioids are the current standard of care for the treatment of moderate or severe nociceptive pain.Successful pain treatment and symptom management is an attainable goal for the majority of patients with chronic pain. Further controlled clinical trials are needed to define the role of opioid therapy in chronic non-cancer pain, and to establish criteria for patient selection and specific treatment algorithms.

[JS]

Regarding your comment that taking opoids for chronic pain only results in an increase in the body's sensitivity to pain, ie. "hyperalgesia". So far the only "report" that I have encountered was by a Dr. and a RN, and contains phraseology that I have never encountered in any work on opoids and pain relief, was based on a large, statistically insignificant subject pool of six (6) patients, and seems not to have been duplicated by any other researcher(s) so far. This is to be believed without several "grains" of salt?

[M Doino]

I have had Chronic pain for 15 years, and treated it most recently with opiates. This article is misleading and possibly dangerous. I have permaent damage from NSAIDs. My liver and G.I. tract are ruined. I have no way of knowing the extent of the damage from the Vioxx, which my Dr though was safe as mother's milk. I am really sick and tired of all of the quacks and charlatins an the Pain Management Industry. I have been nearly paralyzed by a steroid injection. My health has been damaged permanently by Physical Therapy. It seems the industry is dominated by "Old Wives Tales" and misinformation. this incompetance has ruined my life making it now impossible for me to work, not because of my pain condition, but because of the incompetant Doctors who have treated it causing me more damage. Another common pain diagnosis, is an imaginary "hysterical" disorder that only women get. This was described in victorian times and even though there is no empirical proof of this disorder, Females with pain from verifyable sources are routinely dignosed with this. The mediacal business in this country is in the Dark Ages, typified by this irresponsible article. The ERs are full of people bleeding out, because they tried to manage Chronic intractable pain with cheap OTC medications. This article was most likely writen by someone with a fiacial stake in the sale of dangerous OTC meds.

M Doino

[blackysc]

I have suffered from chronic back pain for about eight years. I have attempted all of the interventions that were mentioned in the article (and more).

I do still take NSAIDs (recently switched back to ibuprofen from Mobic) and occasionally a muscle relaxant. Those work all right for episodes of acute pain, but the constant day-to-day pain that is caused by the arthritis and disc damage in my back cannot be controlled with them.

My doctor recently prescribed the Fentanyl patch. It works. What can I say? I've never wanted to take a lot of opioids (because of possiblity of side effects and/or addiction), but it WORKS. Nothing else has.

[lucinda floeter]

I have degenerative disc disease, from my c-spint to the ls spine I have very little fluid left in discs and also cracks in disc.the disease peaked in 2004, and I was forced to quit work and the pain management md put me on the opoid, fentynal 50mcg patch to change every three days, and oral oxycontin three tabs a day, well after four years on this, my husband would tell me that I did or said a bad thing to family, I would cry and tell him I didnt and didnt remember the situation he was talking about, my memory as to where I put things was progressively getting worse, I alienated three stepchildren and my husband, finally at my youngest sons, there was an angry episode by me, my son took me aside and said I want my mom back, and told me things I had been saying to his wife, which I couldnt imagine saying, he also said I talked about suicide alot, now that is not me,I came home(oct-2007) and went to a 25mcg patch and cold turkey quit all oral pain medication, after about a month, I feel like I am comming out of a fog, my memory was really worse than thought, and was now comming back, I found I had put things in very unlikely places, like laundry soap under my bed!! that just one thing, I am still finding things, now I can remember where I put things, we were so close to divorce, my husband had started paperwork, now he has been willing to stand by me, as if it took four years for the meds to get me where I was, I didnt know how long it will be until I am myself, so please, try other things before opoids and make sure your significant other or family member monitor you very closely for any unusual behavior, I thout the meds had actually ruined my life, thank god my son stepped up to me, so please please, only use them if really necessary!!!

[Christine]

I am disappointed in your article. I consider most of your information to be well balanced, well researched, informative and timely. You really did not do your homework on this one. For the many people who suffer from chronic pain these kinds of articles continue the stereotype of addiction and make it more difficult for them to receive the pain relief they so desperately need. I am an RN and a chronic pain patient and I suffered for years after a failed back surgery which resulted in arachnoiditis (an inflammation of the arachnoid space and development of scar tissue which wraps around the spinal nerves.) I suffered for twenty years because doctors did not prescribe the proper medication because I had "chronic pain." Adhesive Arachnoiditis is a contraindication for surgery. Additionally I have stenosis, degenerative disc disease and re herniated discs which have caused scoliosis of about 50 degrees from the degeneration of my discs among other things. There was no need for me to suffer needlessly . It was physian fear and prejudice and television programs and articles like yours which perpetuated it. I have actually had doctors walk out of the room and not return rather than discuss treatment with me. Finally, after myriad doctors, pain clinics and destruction of my life and career I found a compassionate and knowledgeable doctor who prescribed Fentanyl patches. While I continue to have pain and disability my life is now at least tolerable. I would hope that as a source who is considered by many as solid that you would investigate this more thoroughly and rewrite your review of opiates for chronic pain.

[Michele]

Something not mentioned in the article or any of the comments is the fact that codeine is not effective for pain relief in some people. This may be a rare incidence but my pharmasist just informed me of this recently. Unfortunately my husband and I were not aware of this until he became dependant on codeine as he began to take larger doses and more frequently in order to try to relieve his chronic pain. On top of his prescribed doses, he began using more and more acetaminophin with codeine and ASA with codeine that are readily available without a prescription and still he had no really effective relief from his pain. As a result he has suffered not only addiction to codeine but extreme stomach pain from the ASA and possible liver damage from the tylenol. Now he faces a long road to recovery from addiction and is still suffering the original chronic pain along with the his new stomach symptoms.

[Cynthia]

Thank you for providing such an important and overlooked view of the use of opioids for chronic noncancer pain. I am a pain psychologist and every year our intensive rehabilitation program helps hundreds of patients to improve their pain, mood, physical functioning and overall quality of life. Patients engage in intensive physical therapy and cognitive behavioral training to better manage their pain while withdrawing from high doses of opioids that have not improved their pain nor functioning after being on increasing doses for several years. Research from the past two decades does little to support the benefits of long term use of opioid to improve pain and/or functioning for most patients. The average clinical trial for opioids for chronic pain is only 5 weeks with max of 16 weeks. Even pharmaceutical supported research in two decades hasn't been able to support the widespread use of opioids for chronic pain for most patients - works for some, but not the majority. Not that the commercials, ads or rate of opioid prescriptions would reflect that reality. Bottom line is that conservative approaches should be used and consistent with the national pain organizations recommendations (American Pain Society, American Academy of Pain Medicine) and newly published opioid prescription recommendations per DEA, functional improvements (physical, social, mood, family) rather than solely pain on 0-10 scale should be the measuring stick to determine if the opioid treatment is working. If one is able to function with the opioids, then no argument. But if one isn't functioning better, then it is not the right treatment and should be discontinued - same as cholesterol medication, antidepressants, etc. If no cure is available (for most chronic pain it is not), then goals and behaviors toward better functioning and quality of life is the research-supported treatment of choice.

[Greg]

I do not suffer from chronic pain. Thank God, but I know doctors who are terrified of losing their licenses if they prescribe too many pain killers. What kind of society do we live in were the DEA and other police forces get involved in medicine. It should be up to the doctors only. The police forces aren't train in the field of medicine.

[Christine W. Kulikowski]

For 30 years I suffered chronic pain which I thought everybody felt. Four years ago I was diagnosed with Ehlers-Danlos Syndrome, a genetic disease that causes collagen to tear easily and keeps it from repairing. After 11 orthopedic surgeries and 15 root canals, I was finally allowed to take prescription opioids: my pain was legitimized by the diagnosis.
I tried the less addictive options first, but I needed something stronger. I found that Talwin (pentozocaine/nalaxone) works very well. It is supposed to be a less addictive drug than codeine or morphine, although it was recently added to the reportable drug list (schedule 2?). It would be informative for Consumer Reports to investigate this drug. It's in between the mild/moderate pain killers and the heavyweights.

[Tammy Bernier]

I have degenerative disc disease and it appears to have worsened over a course of time, and I was hit from behind, to cause whiplash. My doctor states, my neck is trying to be straight and it is not suppose to be. My husband lost his job in February, so I lost my insurance as well. I have always been able to trust my doctor with refills, but at the end of March, after paying insurance of 397.00 a month and visiting the doctor regularly as I have had breast cancer, my doctor would not refill my pain medication until I come in. My doctor was not there, on vacation, so somebody who has no idea about me, refused to refill my medications until I go for an office visit. This was extremely inappropriate in my mind, as it could not have happened at a worse time, no insurance, no money, so in the past month, I have laid flat for 10 days due to my pain, not able to function at all. I have limited activities, or I should say, I limit my activities due to being immobile for 10 days. If this is the governments' way of regulating meds, they should pay me disability and pay my insurance as well. I don't like to think I am disabled, have not tried to collect, but it looks as if that is my next and only option as I cannot sit for long periods or stand, without chronic pain in my upper and lower back. I have pinched nerves as well and my doctor stated that she could see my pain in the MRI. I have been to physical therapy and traction was the only small relief I got out of that, but my insurance would not cover a unit for home use and the relief was only for a limited amount of time, maybe 12 to 24 hours of "some" relief, depending on my medication and stretches, etc. I am 49 years old and WAAAAAAYYYY too young for this type of pain and the treatment I get from the doctor and insurance. Is there any route I can take to help my cause? Please let me know. Thanks so much. Tammy

[Anne]

Liver damage - I understand that the liver can regenerate with cleansing. Please research the info - the testimonials will amaze you. First, cleanse the colon (most prefer from the top down), then kidneys, and then liver. For all of them, they advise a healthy diet, but you can eat normally. For the colon, take Bentonite clay (health food store), probiotics, and psyllium (like Metamucil) - plus a laxative if necessary. With this, do a parasite cleanse which is simply herbs taken orally for 30 days. Kidney cleanses (1 to 10 days) and liver/gall bladder cleanses (1 day) consist of grocery store items added to your diet.

I have no medical background, but like many others with chronic pain, I have been researching my affliction (migraines) for years and tried many alternative therapies. Not only do cleanses clear the body of toxins, unhealthy tissue (even used with cancer treatment) and parasites (which 90% of us have), but, according to anecdotal evidence and some professionals, it relieves the cause of the pain as well as a myriad of other symptoms.

I am only finishing my first colon/parasite cleanse, but already notice increased energy and optimism, a desire for healthy food and exercise, and a small decrease in my need for painkillers.

There are caveats - check with your Dr - and don't try when pregnant or nursing.

[Gary Gibson, MD]

I have always appreciated information from CR. I assume you do a better job of rating consumer products than on a topic as individualized and complex as what is causing someone's pain and how it should be most appropriately treated. You are in way over your head trying to be a medical resource- there are plenty of objective ones online already (WebMD, American Rheumatology Association, AMA, ACP, etc)

[Evelyn Rios]

I have Fibromyalgia, Chronic Fatigue syndrome, degenerative disc/joint disease, 2 herniated discs, missing 1 disc, both of my sacroiliac joints are disintegrated (one was broken loose by an inept physical therapist) and finally a broken tailbone that has never healed but is offcenter. I am in constant chronic excrutiating pain 24/7. I don't think I could live if I didn't have my 2x10mg hydrocodone 3 times a day and muscle relaxer zanaflex (which doesn't help as much as Soma did but doc wouldn't/couldn't prescribe Soma due to it being a highly sought after street drug!). I use 3 - 12 hr Lidoderm patches for the horrific pain in my sacro joint area and base of my spine. I spend 95% of my day prone in bed. If I don't do too much I can get away with one dose of pain meds and my 12 hour Lidoderm patches. I do try to walk 3-5 times a week 30min. When I first became ill with fibro and CFS I didn't know what it meant to really hurt 24/7 just ached here and there but shortly after being dxd I fell and messed up my back. My primary doc said I couldn't have broken anything because I would have gone to the ER in terrible pain so no x-ray just ibuprofen and flexaril. Yeah right! After 6 mos of suffering she finally sent me to ortho who told me the same thing, never doing an x-ray or MRI of my back. He sent me to 6 wks of physical therapy which was hell on earth for me until the phy therapist broke my second Sacro joint loose and forced the worst ruptured disc to break into 3 pieces and I couldn't feel my legs anymore. My ortho did the MRI on Mon. & Tues. he called to say I needed emergency 8-10 hr 3 level spine fusion surgery and removal of worst disc with replacement with a piece of my own hip. I was stupid and said ok. Came to with good news/bad news - he removed the 3 pieces that were causing me to lose feeling in my legs (didn't put anything in the empty disc spot) but he found out I needed a 13 hr - 4 level fusion. The only guy he did was paralyzed in a wheelchair so he refused to do another. Next ortho said surgery would be easy. I was sitting in his office getting the surgery scheduled when a lady came in using a walker and told me she and 20 other patients were in a lawsuit against my surgeon because he was doing surgeries on people he couldn't help and leaving many paralyzed or in worse shape than when they came in. That doc is now a malpractice lawyer believe it or not. I have been treated by many docs like I was crazy, put on anti-depressants before being dxd with Fibro and CFS. Even after hurting myself worse my company Aetna Healthcare refused my disability because their experts said I should be able to sit up and take opiods and still work 8 hr days. Social Security thanks to God approved me in record time of 2 1/2 mos after just reviewing my x-rays and MRI and a letter from my wonderful pain doctor. I have been on the same dosage for 7 years now and my liver is fine. I do take milk thistle and eat lots of liver friendly foods and don't drink or smoke, though. Before being on hydrocodone I found out I cannot take codeine without extreme psychological side effects like one of the above posters said she had. Thanks to God hydrocodone doesn't affect me the same way. By the way OTC pain meds like alleve and motrin caused my dad who was also suffering with Fibromyalgia to have liver failure and bleeding ulcers. His veteran's hospital docs wouldn't/couldn't give him prescription meds for his pain and had him thinking it was all in his head too. Motrin almost killed my mom who had acute mylogenous leukemia when she had a severe allergic reaction and went code blue in the hospital after a nurse failed to see allergic to ibuprofen on her id bracelet. My sis-in-law died from liver failure from drinking alcohol at the same time she was taking tylenol for a toothache. Her doctor told her to take OTC pain meds but failed to warn her about mixing tylenol with alcohol killing your liver. That was before tylenol started putting the alcohol warning on the label. All drugs can be dangerous and just because prescription drugs can be sold on the street shouldn't justify causing people to suffer needlessly to make the DEA happy. It really upsets me when someone thinks I just want to take painkillers for fun or something. People in real pain don't typically get high from the pain meds. I still have approx 50% pain on bad days even with the maximum dosage but I don't want to go to morphine until I can't take it anymore. I wish all docs would think before they say things and not assume that someone is just out to get drugs. I have tried all possible treatments except for acupuncture (I can't stand needles) and any exercise hurts me worse than it helps. Even pool therapy just set off my asthma which made my body hurt worse. It has taken my 5 years to be able to walk 30 min more than once or twice a week. I have seen a total of 6 ortho surgeons and all but the second doc say I have more than a 70% chance to be permanently paralyzed and would probably still have 50% or more of my original pain since they can't fix the sacro joints or crooked broken tailbone. If I have the tailbone removed I risk needing a colostomy bag if any nerves get cut that affect bowel regulation. I am 45 and feel like I am going on 95.

[rich benett]

i need a liberal pain management doctor in minnesota i'm in chronic pain 24\7 for last 11 years 3 back surgeries 2 left shoulder waiting on another these doctors are affraid to perscribe adiquit pain meds.

[Sandylns]

The report on best drugs is quite comprehensive it does however, give some questionable suggestions. I have been on opiates for the past six years. My pain is due to surgical interventions not properly carried out. As a consequence, I am now disabled. Having tried NSAIDS with almost disasterous results and gabapenten/triptan etc without any pain relief. I am fine using Morphine IR and have no side effects or addiction. Using this type of medication wisely will not lead to addiction. The other suggestions such as NSAIDS, need to be taken under strict medical supervision. NSAIDS cause internal bleeding if taken in large doses. Also. Aceteminaphen will cause severe liver damage, again using it in large doses. For me, opiates work with a minimum of side effects