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Help or for Addicts and Chronic Pain Patients Concerned about Addiction

News about Pain and Addiction

There is more newly published  pain and addiction research on pain than could possibly be summarized on any website. Readers may find the news and comments below of interest:

Daily Morphine Use Changes Brain Gray Matter: Over the past decade, opioid medications such as morphine and oxycodone have increasingbly been prescribed to treat chronic. In some patients, use of these medications alters the “reward centers” in the brain leading to addiction.  A new study published in the August 2011 edition of the journal PAIN reports that opioids change the thickness the brain’s gray matter. Researchers at Stanford University, California, conducted a longitudinal, MRI (magnetic resonance imaging) study examining 10 individuals with back pain (experimental group) who were administered long-acting oral morphine daily for 1 month. Brain imaging was conducted immediately before and after the morphine administration period, and a third time at an average follow-up of 4.7 months. Similar imaging was conducted on a separate group of 9 subjects with back pain who did not receive opioids (control group).  The authors report that 13 brain regions in morphine-administered subjects showed significant changes in brain volume, and the degree of change in several regions correlated with morphine dosage.

Younger JW, Chu LF, D’Arcy NT, et al. Prescription opioid analgesics rapidly change the human brain. PAIN. 2011(Aug);152(8):1803-1810.

Dr. Colameco’s comments: While it is unclear as to whether the reported changes in brain structure are detrimental, this study raises concerns that the long term use of opioids may have deleterious effects.  Opioids are known to reduce sex hormone production and lead to decrease pain thresholds (hyperalgesia) in many individuals consuming these medications on a daily basis. Population-based studies have failed to demonstrate improved function in those consuming opioids for painful conditions compared to control groups. The role of opioids in treating chronic pain remains controversial.  Individuals with mental health disorders or a history of addiction are usually poor candidates for opioid treatment of chronic painful conditions.

How Effective is Lyrica (TM) for Fibromyalgia? Fibromyalgia is a pain disorder characterized by increased sleep disturbance and increased sensitivity to pain. According to the American College of Rheumatology, fibromyalgia affects 3 to 6 million people in the United States.  For many years, physicians debated whether or not the condition was “real” or “psychosomatic”, but it is now generally accepted that fibromyalgia is a disorder of nervous system pain processing.  As with any painful condition, emotions play a role in pain awareness. In the past, some physicians have treated fibromyalgia with opioid analgesics— a practice that has fallen out of favor because of the risk of opioid dependence.

In recent years, the FDA has approved medications specifically for fibromyalgia treatment the antidepressant Milnacipran (Savella) and the antiepileptic medication pregabalin (Lyrica). Another antiepileptic medication, gabapentin (Neurontin) is used “off label” to treat fibromyalgia.  Writing in the Journal of Pain, researchers from the Oregon Health & Science University reported conducting an extensive literature search for studies of any antiepileptic drug compared with placebo or another antiepileptic agent in a randomized controlled trial or observational study.

The researchers concluded that short-term studies reported that both pregabalin and gabapentin had modest effects on reducing pain scores (about 30%) compared to placebo. It is generally accepted that anxiety increases pain awareness, and both of these medications have been reported to reduce anxiety, a possible contributing factor to their effectiveness. Withdrawal from the research studies due to adverse events was significantly greater with pregabalin than with placebo. Compared with placebo, both drugs had greater rates dizziness, headache, sleepiness, and edema (leg swelling). Also, weight gain was a common side effect of pregabalin.

The authors believe that results of their review indicate that pregabalin and gabapentin can be used for the treatment of fibromyalgia with moderate benefits in the short-term but long term evidence is lacking. 

Many fibromyalgia sufferers are turning to alternative or complementary therapies such as yoga, massage, acupuncture, and vitamin supplements.  Given the modest effects of prescribed medication and associated side-effects, it reasonable for patients to continue to use nonmedical treatments even in the absence of proven benefit.

Alcoholism Treatment Linked to a Specific Gene: It is has been known for many years that children of alcoholic parents are much more likely to be develop drinking problems than the general populations and that males appear more at risk than females.  Both the National Institute on Alcohol Abuse and Alcoholism’s (NIAAA) and National Institute on Drug Abuse (NIDA) have studied the relationship between genetics and alcoholism. Based on studies of families, NIAAA’s Collaborative Study on the Genetics of Alcoholism have provided compelling evidence supporting the important role of genetics in alcoholism while NIDA researchers at the have identified clusters of genetic variations in 51 chromosomal regions that might a role in alcohol addiction through complex mechanisms such as control of protein synthesis, regulation of development, and cell-to-cell interactions.

Genetic research is beginning to move from the theoretical to practical, especially in the development medical treatments of alcoholism. It appears that some medications are effective, but only when consumed by individuals with specific genes.

One of the first such studies entitled Pharmacogenetic Approach at the Serotonin Transporter Gene as a Method of Reducing the Severity of Alcohol Drinking was reported in the American Journal of Psychiatry (2011). The anti-nausea drug onadansetron (Zofran ®)  drug is a highly specific and selective antagonist of the neurotransmitte serotonin (5-HT3 )  and researches postulated that this medication might reduce cravings in individuals who had a specific gene affecting serotonin ( 5-HTT LL geno-type). This was a double blind control study of 283 alcoholics with two specific gene variations. Study subjects received anti-nausea onadansetron or a placeb.  Individuals with the 5-HTT LL geno-type who received ondansetron had a lower mean number of drinks per drinking day and a higher percentage of days abstinent (11.27%) than those who received placebo. Genetic research reinforces the notion that those with a strong family history of alcohol abuse or dependence should abstain from drinking, especially during teen and young adult years when the brain neural networks are still actively developing.  Research also hold the hope that alcoholics can be screened with a blood test to determine whether a specific medication might be of benefit in treatment. 

Chronic Back Pain May Impair Memory and Concentration:  Chronic pain has long been considered a disorder of the central nervous system.  Neural networks involving pain, emotions, memory and cognitive function overlap, so it is not surprising that a disorder in one area of the brain may affect other areas.  In a recent study, 64 patients with low back pain were compared to 20 age, gender and education-matched volunteers.  Patients underwent neurological, neuro-orthopedic, clinical-pathopsychological, and neuropsychological investigations. Complaints of difficulty with mental concentration were present in 17.3% of patients and problems with remembering information in 20.2%. Patients with chronic pain showed mild neurodynamic impairments. As compared with healthy subjects, they had significantly worse performance in tests assessing memory (delayed reproduction in the 12-word test), attention, mental flexibility, and visuomotor coordination. (Melkumova KA, Podchufarova EV, Yakhno NN. Characteristics of Cognitive Functions in Patients with Chronic Spinal Pain. Neurosci Behav Physiol. 2011;41(1):42-46)

Anxiety, emotional stress and catastrophic thinking about pain may play a role in cognitive and memory deficits. Chronic pain cannot be cured by simple means (e.g. a medication); because it is a complex, biopsychosocial disorder, pain treatment must be comprehensive.

Tai Chi Effective in Reducing Osteoarthritis Pain but not Strength: In a large, community-based, randomized controlled trial, researchers from the University of North Carolina at Chapel Hill School of Medicine evaluated the effectiveness of the Arthritis Foundation’s 6-week, twice-weekly tai chi course. The tai chi group had modest improvements in pain, energy levels, and more of a feeling that they were in control over their lives. There was no evidence that strength was improved when measured by activities such as getting up from a chair, walking speed, or standing on one leg. However, the ability of participants to keep balance while reaching did improve. (Callahan LF, Shreffler JH, Hackney BS, et al. Evaluation of Tai Chi Course. Effectiveness for People with Arthritis. Arthritis & Rheumatism. 2010(Oct);62(10 Suppl):S288). The results of this study are summarized in a YouTube video.
FDA Approves Vivitrol (TM) for Opioid Dependence:  Based on research studies conducted by the pharmaceutical company Alkermes, the FDA approved a once monthly the a once-monthly intramuscular injection if naltrexone for opioid dependence. The drug had been approved to treat alcohol dependence since 2006, where the proposed mechanism of action is somewhat different. Vivitrol works to combat heroin or prescription opioid dependence by blocking receptors.  It does control cravings in the same way as Suboxone (TM) or methadone does, rather it blocks opioids from attaching to the receptors. Opioids, whether illicit or prescribed to treat pain, are ineffective.  Studies compared the safety and efficacy of extended-release naltrexone with that of placebo for 6 months in patients who had completed detoxification, Patients receiving extended-release naltrexone were more likely to stay in treatment and to avoid the use of illicit drugs than were those receiving placebo. Of the treated patients, 36% were able to stay in treatment for 6 months without using drugs compared with 23% in the placebo group. (October 2010)

It is unclear as to type of addict that might be better served by Vivitrol than by other treatments.  One concern is the fact that opioids needed to control pain in hospital settings are blocked.  Another concern is that individuals "coming off" Vivitrol are at increased risk from accidental overdose given the fact that opioid receptor has been blocked and could be more sensitive to the amount of drug an addiction might consume.

Chronic Back Pain May Impair Memory and Concentration:  Chronic pain has long been considered a disorder of the central nervous system.  Neural networks involving pain, emotions, memory and cognitive function overlap, so it is not surprising that a disorder in one area of the brain may affect other areas.  In a recent study, 64 patients with low back pain were compared to 20 age, gender and education-matched volunteers.  Patients underwent neurological, neuro-orthopedic, clinical-pathopsychological, and neuropsychological investigations. Complaints of difficulty with mental concentration were present in 17.3% of patients and problems with remembering information in 20.2%. Patients with chronic pain showed mild neurodynamic impairments. As compared with healthy subjects, they had significantly worse performance in tests assessing memory (delayed reproduction in the 12-word test), attention, mental flexibility, and visuomotor coordination. (Melkumova KA, Podchufarova EV, Yakhno NN. Characteristics of Cognitive Functions in Patients with Chronic Spinal Pain. Neurosci Behav Physiol. 2011;41(1):42-46)

Anxiety, emotional stress and catastrophic thinking about pain may play a role in cognitive and memory deficits. Chronic pain cannot be cured by simple means (e.g. a medication); because it is a complex, biopsychosocial disorder, pain treatment must be comprehensive.

FDA Approves Cymbalta (TM) for Chronic Back Pain: The FDA has approved approved Cymbalta, duloxetine hydrochloride, an antidepressant, to treat chronic back pain and osteoarthritis pain. The link between mood and chronic pain is strong, and, increasingly,  pharmaceutical manufactures are seeking approval for medications that boost neurotransmitters involved in both pain and addiction. The FDA granted the new indication based on results of four double-blind, placebo-controlled, randomized clinical trails in which patients randomized to duloxetine reported a greater reduction compared with the placebo group. In addition to its use for treatment of depression, duloxetine is approved for treatment of diabetic peripheral neuropathy, generalized anxiety disorder, and fibromyalgia.  A similar medication, Savella (TM) is approved for the treatment of fibromyalgia.