Opioids - A War Within a War - Part Three

Opioid Facts

In this third post of the “Opioids - A War within a War” series, we’ll take a look at some of the facts about opioids to help those who are opioid-naïve better understand the basics.

Types of Opioids:

Examples of Frequently Prescribed Opioids:

• Dilaudid (Hydromorphone)

• Fentanyl (Duragesic)

• Hydrocodone (Vicodin)

• Morphine (Kadian, Avinza)

• Oxycodone (OxyContin: extended-release version)

• Oxymorphone (Opana)

• Tramadol (Ultram)

These opioid drugs, a.k.a., narcotics, are Schedule III Controlled Substances as designated by Congress in the Controlled Substances Act of 2014. This status means they exhibit a high potential for abuse. As a result, they are closely regulated, requiring a prescription from a licensed medical professional before your pharmacy will fill them.

Opioid Delivery Methods

Getting opioids, which you need into your body so they can go to work to relieve your pain, can take many routes. Today doctors have many more medication delivery options than in days past when a pill or a shot were the only options. The following drug delivery methods allow doctors to determine how quickly or slowly your medication enters your bloodstream to provide the needed efficacy, speed, and duration of the pain relief they offer.

• Oral Fast-Acting / Immediate-Release Pills: This method of opioid delivery works quickly, but they generally have a relatively short duration of a few hours. (Oxycodone and hydrocodone are good examples of this type.)

• Oral Slow-Acting / Extended-Release Pills: Opioids in this class of extended-release medications make use of timed-release technologies to deliver pain relief over a longer period, generally in the range of twelve hours or so. Oxycodone ER (Xtampa) is one example of this delivery method that I’ve tried. Unfortunately, most ER opioid versions have failed to deliver adequate pain control for me when used alone. Before I had my “pain pump” implanted, my pain management doctor combined an extended-release formulation, used only at night (to help me sleep through the night), with an immediate-release drug taken during the day has provided me with much better around-the-clock pain relief.

• Transdermal (Skin Patches): This method delivers medication through the skin from an adhesive patch and is a good choice for treating around-the-clock pain needs. (Fentanyl/Duragesic patches are a typical example of a transdermal delivery device.)

• Intralingual (Oral Patches): This delivery method uses a small patch that adheres to the inside of your cheek to provide an extended-release of an opioid over time, lasting up to twelve hours or longer. (Belbuca is just one example of an intralingual or sublingual device.)

• Intravenous (IV): Generally, typically available only in a hospital or doctor’s office, IVs get opioids into the bloodstream the fastest of any of the above delivery methods. This method is for severe pain where time is of the essence. (A morphine drip is one typical example for IV delivery of powerful pain medications, which I used many times following my three spinal fusion surgeries.)

• Intrathecal: This term is better known by its more common name, the “pain pump.” (A misnomer if there ever was one! After all, who wants to pump more pain into their bodies? Shouldn’t it be called a “no-pain pump?” Oh well, I digress.) This delivery method works by implanting a round pumping device into your abdomen or back. The pump then dispenses a timed-release dose of opioids directly into the intrathecal space or the space surrounding your spinal cord. There are many advantages to delivering pain medications this way. The main advantage is that it can provide the same or even more significant relief than oral opioids even when delivering a far smaller amount of medicine—some 300 percent less than is typically required by other delivery options! This method may also eliminate many problems caused by delivering pain medications through the digestive tract, such as stomach problems and constipation.

Opioid Efficacy, Titration, and Tolerance

• “Efficacy” is a common medical term that describes the effectiveness of a drug. It is an essential characteristic of any medication, and it determines how well a medication, treatment, or therapy works or doesn’t work for its intended purpose. The higher the efficacy, the more pain relief an opioid will offer. The key for pain sufferers is to find the proper opioid to provide the most significant degree of pain control with the fewest side effects and negative downsides. If you are opioid “naive”—that is, you’ve never taken them before or in a long time—the efficacy for most opioids should be quite high, but you also may be subject to their increased side effects. Next, we’ll examine “titration.”