Opiate Tolerance – FACT OR FICTION

Opiate Tolerance – FACT OR FICTION

By Steve Ariens, Ph.D.

Steve Ariens

Steve Ariens, PhD

We often hear about chronic pain patients need to increase their dosage because of tolerance to their medication(s).

Many of the people that put out all these “facts” tend to blend various facts about pain medications – opiates in particular – and apply it to all those who use opiates both legally and illegally.

Factually, those people who use opiates illegally – to get high – to silence the demons in their head and/or monkeys on their backs… will rather quickly develop a tolerance to getting “high” off of the same amount of opiates … so they tend to increase the amount of opiates that they take to seek that “high” that they were able to reach when they initially started abusing some substance.

Normally, after a rather short period … one to two years… the substance abuser can no longer get a high from the substance that they have in the past, because of tolerance…but they are forced to continue using the substance because of WITHDRAWAL or what a substance abuser calls “dope sick”.

Now the chronic pain patient, many of whom are under treated in the first place. Their pain is caused by a disease state and all too often disease states tend to deteriorate over time and will cause additional pain.

Additionally, many chronic pain patients start down their pain path while they are in their younger years.. And aging itself will cause more aches and pain on top of the aches and pains they are experiencing from their disease state.

Then there is activity induced pain. Most chronic pain patients only wish to be able to act/function like other people… to be “normal”.  Many circumstances will cause them to not “pace themselves”.. trying to do something, keep up with friends or family at a family gathering, or just try to do personal care issue and tasks around the home.

Some profess that rotating opiates helps prevents a patient’s tolerance, but there is no black/white formula of xx mgs of drug A is equal to xx mgs of drug B. What ends up happening is the patient’s pain management is titrated up on drug B and everyone ends up happy believing that they are addressing “opiate tolerance” for the pt.

A patient’s need for increased dosing, doesn’t need a PhD in Pharmacodynamics, just a little common sense will explain a lot.

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There are 14 comments for this article
  1. MARTHA ARNTSON at 8:41 am

    I will UPDATE MY COMMENT once again since my last post here on August 30, 2016.

    The very next day I saw my Pain Management N.P. (August 31, 2016). We once again discussed WHY I DID NOT WANT THE SPINAL CORD STIMULATOR, and once again I told her all the reasons, where were all fact based on research done by many many Surgeons and Physicians along with the Doctor who was originally doing my Spinal Injections. We also discussed my option to “leave their practice since I was not responding to “any” of their suggested routes of pain management, i.e., physical therapy, more spinal injections, exercise, and of course the “Lyrica/Gabapentin route.

    When I had completed ALL requests from my original Doctor to do; the injections, acupuncture, acupressure, physical therapy (only for my neck), chiropractic, and on and on, didn’t WORK, I was sent to their Pain Management Facility.

    My N.P. then stated to me: “Martha, we are NOT GOING BACK TO THE NARCOTIC ROUTE, ever, and if you were a new patient coming in today I would say the same thing to them, we would NOT start with narcotics, but rather the P.T./injections, etc. Need I say that that THAT IS EXACTLY WHERE I STARTED about 3-1/2 years ago? I started with MRI’s, etc., the entire route of everything the Orthopedic Center had suggested and provided for me to utilize to manage pain OTHER THAN NARCOTICS.

    I wonder, has she ever re-reviewed my case history that brought me there in the 2 years I’ve been seeing her? Has she HEARD me? Her response regarding the Stimulator issue again was “since you aren’t willing”….No, I am not willing to have something like that implanted in my spine forever!

    Which brought me to ask specifically if she thought “I am a drug seeking addict”? She stated “No, I don’t think that”. However, her demeanor and behavior towards me changed back in February and in March she abruptly took me off the narcotic Percocet 10/325 mg. 3 x day. Without warning. Claiming my pill count was “way off” when in fact it was not “way off”. I had been called in for a pill count one week before my scheduled appointment (first time ever), and forgot to bring my “backup pills” I keep hidden for emergencies in case I ever ran out or something. She would not accept my reasons for not having those with me that day even though I offered to go back home and retrieve them. (I had never had a pill count in 4 years so did not realize I hadn’t grabbed my hidden bottle). There was much high level anxiety that appointment as she brought in the “nurse” that did my pill count and urine that day. Actually the confrontation upset me so badly I couldn’t even think straight let alone defend myself against her and the Nurse. I was badly shaken and in tears when I left her office. I cried all the way home wondering how could she be so cold and non-understanding of my situation. She was aware I keep my medicines in a speciality bag that has many layers of protection to keep anyone from getting into the bag. It was expensive and worth it since my son was living here and he was a heroin addict. Thus, the reason for me purchasing the bag. However, I always kept at least 15 pills aside in another lock box which I keep in a separate area hidden just in case the bag itself was stolen or compromised in any way. She would NOT listen to my explanation and said “it was NOT ACCEPTABLE THAT I DIDN’T BRING ALL MY PILLS AS ORDERED AND AS STATED IN THE PILL CONTRACT”.

    So, August 31, 2016 N.P. gave me an ultimatum “spinal cord stimulator or find another doctor”. She handed me a copied paper with some names of other doctors. That was it. Sent me on my way with a prescription for the Butrans Patch.

    I received a photocopied letter on Tuesday (after Labor Day), dated 8/31/2016 from their practice, with areas for checkmarks, mine was checkmarked that “I had sought treatment and received narcotic prescriptions from other facilities”, and, that they would not be prescribing any narcotics to me again. Then came the end, “If you need assistance finding another physician, please contact your insurance provider”. End of story. End of what I thought was a caring P.A. and a good patient/doctor relationship without so much as a private note from her. Not that I expected one, but when I left her office on the 31st that day I told her “I will be in touch before my next appointment whether I will look for another doctor but I will let you know if I decide to remain with you or not”. Just a simple conversation between her and I.

    I realize this is a long complicated post, and I also realize it’s not a solution to any of the problems that anyone else might be going through with their P.M. But, I wanted to post this because I feel I am probably NOT the only person that has recently been abruptly taken off their narcotic medicine or had the dose reduced to much lower. I feel it’s relevant to the discussions on this board.

    Thank you for allowing me to post my thoughts, and now my total infuration of the “system” that has allowed these doctors and nurse practicioners (sp?) to bully patients with such nonsense without PROOF of any wrong doing on the part of the patient. I will state I NEVER SOUGHT ANYTHING FROM ANYONE WHILE UNDER THEIR CARE FOR 4 YEARS and I am fighting back! I want my GOOD NAME cleared in the Prescription Drug Database and the letter of dismissal to be destroyed from my file.

    I have contacted many of my State’s resources as to fight back regarding this issue. I urge anyone who has had the same or similar happen that you do everything you can in your power to not be labeled “drug seeker” for the rest of your life. I also have contacted a lawyer as to restoring my name in my community so if I ever need emergency care of what ever I will not have that RED FLAG label against my name.

  2. Cora st.croix at 1:12 pm

    What are most people taking for pain than you I am from Newfoundland chronic pain Thxs

  3. Michael Boyett at 7:36 pm

    I recently wrote a comment about my new doctor insisting I was not getting pain relief (huh?) and was actually experiencing mini withdrawals that drove me to want opiates. So I was forced to taper down to a level required by the CDC – less than 100 morophine equivalent doses. Of course the CDC says it’s a recommendation, albeit one that if violated they can take a doctor’s license.
    I was able to convince my doctor that at a level approximately half of what I had been taking for 8 years, my pain was unbearable. So she allowed me to continue taking that amount. We’re to “reassess” in 6 months. I expect she will want to lower my dose again.
    My pain is from diabetic neuropathy. I am also taking blood thinners for a heart condition so aside from Tylenol, I only have opiates available as antidepressants and neurontin cause suicidal thoughts. I am afraid for my future. I’ve gone from being a productive employee to one facing disability retirement, a retirement of pain. With the government behind the reductions, there really is no hope for someone like me.
    Mike

  4. scott michaels at 10:33 pm

    now of you can only.explain this to the cdc and dea, we could end all of this nonsense

  5. Betsy Shearer at 3:45 pm

    Thank you for such a good down to earth article addressing chronic pain patients.

  6. Carla Cheshire at 3:34 pm

    I’ve been on the same dosage of Fentanyl patches for 10+ years. I have extra hydrocodone/IBU for breakthrough pain, taken as needed. I have not experienced needing or craving more medication. This was because of failed back surgery leading to neuropathy. I’m having a great deal of problems with my right knee now. 2 meniscus surgeries and now I can’t walk because of pain and swelling in my knee, not sure what’s going on. Back to Doctor tomorrow.

    Please NPR do an article on how people are coping with being taken of their opioid medication with no help, titration or medication. Is this even legal? What happened to “Do no harm?”

  7. Jasmin Days at 2:54 pm

    Hello Dr. Steve Ariens. Thank you so very much for breaking down this craziness.
    My friends and I have discussions about this nonsense. What they are doing is classifying us all as the same, drug addicts. Let them feel just one little milligram of pain that we go through and they probably would be screaming bloody murder.

  8. I. Hollis at 10:29 am

    Great article Steve! There is one thing missing from the discussion, pharmacogenomics. I realize you understand this well, but at this historic time of “guidelines” it bears repeating. Many health practitioners know nothing of this important aspect of providing analgesia, and assume those who have genetic metabolizing issues are coming to the table with an already huge tolerance , when in fact they don’t metabolize a large number of commonly used analgesics they way a standard patient would.
    A certain subset of pain patients have genetic anomalies of Cytochrome P450, specifically CYP2d6 that make current opioid prescribing limits of 90 (Morphine Equivalent) currently suggested as the upper limit of opioid dosage suggested by the CDC guidelines, and used by Medicare/Medicaide, FDA, HHS and the CDC obsolete for these patients. Non effective analgesia is causing therapeutic failure for these patients and may even be causing further medical complications such as centralization of pain (Centralized Pain Syndrome), stress on the cardio-adrenal systems and all of the psycho-social aspects of untreated severe pain. There is extreme bias against these patients and they are often labeled as drug seekers or referred to addiction treatment because it is perceived that they have large tolerance levels, when in fact they need high doses of opioids for analgesia to be effective due to how their body processes many classes of medicines. A quarter of all medications including most opioid medications require the CYP2d6 pathway to metabolized. Most of these medications are designed for people with normal metabolism ie: Extensive Metabolizers. Pain is pain, and one person who has what is considered “normal’ metabolism might achieve analgesia with a very small amount of opioid medication, while an Ultra Rapid Metabolizer may need many more times the suggested 90 MED for proper analgesia. Ultra Rapid Metabolizers and Poor Metabolizers require much higher doses of opioid for them to be effective. For example Ultra Rapid Metabolizer’s enzyme system literally chops up the medication too quickly and excretes it before it is utilized by the body. People with metabolic disorders such as diabetics may also require higher doses of medication due to digestive issues from nerve damage. Some people have untreated pain for so long that their receptors are dysfunctional and they require higher doses of pain medications. It is not unusual for these outlier patients to honestly report “no effect at all” from standardized dosing. For patients with Centralized Pain Syndrome each dose of opioid medication improves their health, and sometimes its the only medication that helps calm the CNS in a meaningful way. Each person is different.
    Patients with genetic anomalies of CYP2d6 and other pathways currently being discovered, make up roughly 1/3 of the of the population and to ignore scientific data that proves a different metabolism is discriminatory.
    One third of pain patients have been left out of the discussion.

  9. Terasa Harris at 9:20 am

    I’ve always told my doctors that IF I took those opioids the way they prescribe, it’s a good chance for tolerance to take over. But, IF I take them according to MY pain…I’m okay. Of course, I was penalized for this truth.

  10. Cliff Macway at 9:20 am

    The CDC & pain management doctor crowd are really something. They tout how smart they all are by taking away all chronic pain patients meds and making the U.S. so healthy and wonderful. Who in their right mind would take away an absolutely critical component of someone’s life without REPLACING IT WITH SOMETHING COMPREBLE ????? This kind of thoughtlessness is absolutely insane!!! And here’s the real kicker, they will always get what they need for a good quality of life for themselves.

  11. Martha Arntson at 7:04 am

    Great post Dr. Ariens! However, a solution to this would be what I am seeking.
    What would be the bottom line with patients who are able to STAY on a specific dose/quantity of an opiate medication, even with increased pain?

    I have been through the switching of medications at least 3 x in the past 4 years. The Physician I see now, (physician’s assistant), absolutely refuses to allow doing that. She states that it is a red flag for her prescribing license to the DEA, etc., as well as it has not been proven that switching of opiate medications will take care of the pain problem.

    I have been taken off all opiate medications (with the exception of the Butrans Patch and Subutex (another form of Buphrenorphine), for pain now. Since the CDC’s “guidelines” that were strictly supposed to be “guidelines” have been taken to the extreme in my P.M. group.

    The Butrans Patch is at best nothing better than a couple of Excedrin tablets, and, not to mention the withdrawl symptoms experienced when titrating off of them. That has not been addressed by my P.A.

    So, the bottom line is this: How do patients let their doctor know in no uncertain terms that they NEED a minimal amount of an opiate to be able to do the things they love to do? As in your post “family activities, walking/exercising, even so much as vacuuming causes too much pain to do as I used to.

    I would appreciate any comments to Dr. Ariens post as well as my comments?

  12. Charles Lucas at 5:18 am

    Fantastic column. I do not understand why my pain management team refuse to acknowledge this basic principle. Their “standing orders” are to prescribe a pain killer and that is what you are stuck with for the duration. No change’s whatsoever.
    I began to believe that maybe I am misinformed or mistaken but this article cleared that up. I thank you for that Steve.

  13. connie at 4:59 am

    I was on exactly the same dosage of opiate medication for8 years. While I had marginally good pain control I had recently begun experiencing daily headaches requiring medication. Excedrin usually helped but made my stomach hurt really bad. Percocet took care of the headache extremely well but of course that was a bad thing. With downward titration o.of my meds per the CDC “guidelines” the daily headaches no longer respond to Excedrin. This is most likely seen by the powers that be as requiring MORE opiates because of long-term use while in fact it’s because my spine has deteriorated over the years. It’s more than sad that the stupidity of those who should know better can’t see reality. You can teach someone who is ignorant because of lack of information but you can’t teach stupid !

  14. Peggy Baxter at 4:15 am

    Finally someone who knows what they are talking about! To many doctors and regular people think that if you are taking pain medication you are an addict! How stupid!