Should I be working if I still have chronic pain?

Opioids are a controversial topic in pain medicine, however on the whole the field is moving away from using opioids for chronic pain. The reason for that is that risk/benefit analysis on societal level does not favor this approach. That does not mean that it should never be used, however the situations where it is appropriate are becoming more and more rare outside of palliative care.

When opioids, such as Oxycontin and MS Contin, were introduced in the 1990’s there was a genuine hope that these medications would make chronic pain a thing of the past. These medications would control severe chronic pain in the same way one controls high blood pressure and patients would be able to return to their jobs and normal activities. Unfortunately, while these medications were highly effective in the first few months of use, overtime they became less and less effective which required elevation of doses over time. Worse, a significant percent of patient lost self-control and started abusing these medications. Let me make it clear, these were not the people who faked illness in order to abuse opioids. These were people who had genuine severe pain, but were also prone to addiction.

So there ended up being three groups of patients:

1. Patients who had severe pain and were taking their medications as prescribed and deriving some benefit from them.
2. Patients who had severe pain and were initially taking their medication as prescribed but then became addicted and started using them for euphoric effect.
3. Drug addicts who faked illness in order to obtain high quality opioids free of charge.

The problem was that there was no way for doctors to identify which group the patient they were seeing belonged to. Also, in addition to addiction there were many other side effects that were discovered over time including falls in the elderly, constipation, reduction of testosterone with associated erectile dysfunction, drowsiness, suppression of breathing drive and death. Long term studies showed that instead of improving function and helping patients return to work, these medications actually reduced function over time.

In my own practice I do not start any new patients on Opioids, however I still have some “legacy patients” whom I have known for years who did well with their opioid medications. Although I encourage these patients to reduce the doses because of risks outlined above, I do not force the issue as they are very unlikely to start misusing the medications after all these years.

So to sum up, whether to take opioids is a decision you should make together with your family doctor. As many family doctors do not prescribe opioids at all, it is important to talk to yours to understand if that is even an option for you. I would, however, advise exhausting other treatment options including physical modalities, non-opioid medications and injections prior to considering starting on Opioids given their history.