Join Dr. Grigory Karmy M.D., a distinguished chronic pain management physician with over 20 years of experience, on a captivating journey through the world of pain relief in his podcast series. Delving into the latest regenerative medical treatments like PRP, stem cell injections, and prolozone therapy, alongside educational discussions on pain transmission and the latest medical innovations, Dr. Karmy shares invaluable insights and real-life stories, empowering listeners to find relief and regain control over their chronic pain.
This episode explores the current approach to opioids in Ontario from the perspective of a clinician with over 20 years of experience in chronic pain management. The segment takes a close look at how the approach to opioids has evolved over the past two decades.
Despite their longstanding presence in pain management, opioids remain shrouded in confusion and misconceptions. Through expert analysis and up-to-date research, we unravel the latest information surrounding this crucial class of drugs, shedding light on their current role in medical practice.
Tune in to learn about the complexities of opioid therapy and the current landscape of chronic pain management in 2024 and beyond.
If you have any questions for Dr Karmy, feel free to email us at karmychronicpain@gmail.com.
The biggest problems with opioid is the one that everybody knows about, and that's addiction. but that's not the only one.
Raveena:
Welcome to Chronic Pain Chronicles with Dr. Karmy, where we delve deep into the complexities surrounding opioid use, addiction, and recovery. I'm Raveena, your host and advocate for understanding the multifaceted aspects of this pressing issue. Today, we confront a critical aspect of the opioid crisis. It's entanglement with chronic pain management. 20 percent of the general population has or will develop chronic pain, which is why it is such an important issue to tackle. As we explore the evolution of opioids in the pharmaceutical industry, we're joined by Dr. Gregory Carmi, an expert in pain management with over 20 years of medical experience.
Dr Karmy:
Hello, this is Dr. Karmy, and today I just wanted to discuss my thoughts on opioid medications. I think there is some misinformation or misunderstanding about opioids, so I just wanted to clarify a few issues. First of all, there is this impression that opioids are these extremely powerful medications for chronic pain. Although this can be the case. It's not as straightforward as it sounds. First of all, opioids don't work equally for every type of pain. That is true for opioids. That is true in general for most approaches in pain management. They tend to work better for some people than others. They tend to work better for some conditions than others. In the case of opioids, tend to work better for joint pain, for bone pain, sometimes for pain due to inflammation, tooth infection, that sort of stuff. What the opioids do not do as well is control pain due to nerve damage. nerve compression, muscle pain, or fibromyalgia. In addition to that, in cases where opioids do help, Or often they don't help for very long, because of a condition, or property of opioids called tolerance. Now there's a number of medications that can have tolerance, but the amount of tolerance that opioids have is greater than for most other medications. Essentially what tolerance means is that if you start taking opioid at a given dose, and I'm talking mostly here about opioids like oxycontin, oxyneo, Fentanyl or Duragesic patches, I'm not discussing to the same extent opioids like Percocet, or Tylenol number three. And the reason I'm making the distinction is that, when we're talking about OxyContin and Duragesic, the doses tend to be much higher. the medication is typically in your body for. 24 hours a day, you can certainly get to the same doses with Percocet or Tylenol 3, but if somebody is taking one tablet of Tylenol 3 every couple of days or two or three Percocets a week. Often, the risks, the amount of tolerance tends to be lower. So let me go back to tolerance. Tolerance, essentially, what it means is if you start somebody on, let's say, 15 milligrams of long acting morphine twice a day, initially, often what they find is that their pain levels drop by, let's say, 70%. Okay. But then, after a period of time, which can range from a few weeks to a couple of months to in some cases as long as a year, what happens is that the amount of improvement in pain becomes smaller. So if it's 70 percent drop in pain initially, maybe after a few months or a year, this drop ends up being closer to 10 to 20%. Now you can make this medication a little bit more effective by trying to raise the dose. Transcripts to make up for the fact that effectiveness is dropping. But again, because opioids are associated with a lot of tolerance, if let's say you double the dose, the pain levels might drop down to, let's say, 50%. But then again, over time, they tend to drift back up again to maybe 10 to 20 percent reduction in severity of the pain. If you think about chronic pain in general, and that's by definition a pain that lasts for over three months, but typically it's there for years and years. If there's one quality you want to make sure is not chronic. In that medication, it's tolerance. So I do have patients that come to me and they will sometimes comment on the fact that they're taking morphine, the most powerful pain medication out there, and their pain is still not controlled, and they're convinced that nothing is gonna help them. Because if the strongest medication doesn't work, what could possibly work, and they're also convinced that's a sign that something really awful is going on, that's causing the pain, like cancer, for example, for most patients, especially if they've been on long acting opioids for over a year, these are not particularly powerful medications. I think they grabbed disproportionate amount of headlines when they came out in the 90s and 2000s. but I think a big reason for that is at that point we just didn't have too many options for treating patients with chronic pain and now we have many more options available. And the results in patients with chronic pain are much better than they used to be. So let's talk a little bit about pros and cons of opioids. The biggest problems. with Opioid is the one that everybody knows about and that's addiction, but that's not the only one. patients on high doses of Opioids develop low testosterone levels. Testosterone for those who don't know is a male hormone. If the levels are low, it can often cause lack of energy. Cause people to have difficulty with erections, then obviously it can cause constipation. The thing about tablets in general is that they don't just go where you want it to go, which in this case is spinal cord and brain, or at least parts of the brain that control pain, perception, The medications, of course, go everywhere throughout your whole body, and opioid receptors are not just present in pain centers, it's present throughout your body. And the opioid receptors in the gut slow down gut motility. And, most patients on opioids develop constipation. It can be treated, either with general medications for constipation or there's even specific medications that just block the opioid receptor in the gut without blocking opioid receptor in the rest of the body, a more specific treatment. but it is a fairly common side effect. Other side effects? it does affect your brain in terms of ability to focus and concentrate. It can increase chances for falls in the elderly. There was a period of time when there was a discussion, are opioids the safest treatment for the elderly because of side effects from anti inflammatory medications, which is another treatment options for arthritis. And, although opioids don't have the same side effects that anti inflammatories do, they have other side effects. And I think the jury is still out about safety of opioids in the seniors. So let's go back to addiction for a minute. That is the most important side effect of opioids, and I think that's the one that really The use of this medication, first of all, majority of patients who take opioids do not get addicted to opioids, the risk of addiction is about 20%. So in other words, 80 percent of people do just fine and about 20 percent of people get addicted. Okay. Bye. The problem, there's two problems here. One problem is that if you do get addicted to opioids, chances of being successfully treated for that addiction is very low. there was a study where they looked at patients who became addicted to opioids and, they put them in treatment programs, typically treatment programs involve, some sort of counseling sessions. Sometimes they will involve separating a person from the environment where they Addicted because of peer pressure, because of, maybe making it more difficult to access opioids, and often a lot of these programs will often have replacement therapy. In other words, they substitute, more dangerous opioid with, a less dangerous one like methadone or Suboxone. In any case, at one year. Only 10 percent of patients were able to successfully treat their addiction. So once you become addicted, generally speaking, curing that addiction is very, hard. There's also another issue, and that is why is there. Is there a way to perhaps not give opioids to patients who are going to become addicted? Is there a way to predict who is going to get addicted and who isn't ahead of time? And only treat the patients who are not going to get addicted. After all, 80 percent do not get addicted. We actually do have some tools to help us separate people who are likely to get addicted from the ones who are not. not likely to get addicted. The problem is they're not terribly reliable. They're mostly questionnaires that ask you a set of five, six questions. One of them is called opioid risk tool. That's probably the most commonly used one. The problem is that people lie, especially if the questions being asked. It can be embarrassing, have you ever been addicted, or have you ever been sexually abused as a child. And the other thing is even if they answer truthfully. there's still a risk of becoming addicted even if you end up in a low risk category. So, what are my final thoughts on opioids? I think that opioids are still used as a tool in pain management in Ontario. I think that Effectiveness of opioids is exaggerated. It may work for certain things in certain people, but for majority of people, the benefit, especially after the first year of use, is relatively small. It will not Let patients who were unable to work because of their pain go back to work, as a general rule. On the flip side, if you belong to that 20 percent who get addicted. To opioids, the harm is incalculably big. You could lose your job, you could lose your family, addicts who overdose on opioids can die. if you look at opioids from the perspective of risk versus benefit. With small benefits and very large risks, and also fairly large percentage of population potentially becoming addicted, it is not a great medication. Having said that. There are some patients who have been on opioids for many years and have done well with their opioid medications, and if these patients try to stop opioids or reduce their opioids and have been unable to do so because either the opioids help them a lot or the withdrawal experience is just too unpleasant. There's nothing wrong with continuing, especially if their doses are within the range that is currently recommended by College of Physicians and Surgeons of Ontario.
Raveena:
Thank you for listening to the first episode of Chronic Pain Chronicles with Dr. Karmy, a podcast which explores chronic pain from a physician's point of view. In future episodes, we will explore some of the most effective and commonly used approaches to managing chronic pain, including ketamine and lidocaine infusions, nerve blocks, and regenerative medicine approaches. We will also try to explore the causes of chronic pain and understand where the field is going in the future. I am Raveena Aujla. Till next time. When it comes to your health, always consult with your own physician or healthcare provider for personalized advice and guidance. The information provided in this podcast is for educational and informational purposes only and should not be considered medical advice or a substitute for professional medical care.
