While I am not a great fan of taking narcotics on an ongoing basis, there is one situation where I think narcotics may be useful within the DOCC framework. The situation is when patients can’t function at the most basic activity level. In this case, taking narcotics for adequate pain control can help significantly. Though it does not solve the chronic pain problem, it allows patients in the short-term to move around more easily and start the recovery process.
Narcotics all have similar effects and side effects. They just vary in how they are administered and how long they last. In other words, codeine and heroin have the same effects and side effects, but heroin is much more concentrated and is generally taken intravenously. Codeine is not as concentrated and is swallowed in the form of a pill.
There are two basic categories of narcotics: they are either direct derivatives of opium or artificially synthesized.
Examples of direct opium derivatives are:
Examples of semi-synthetics are:
- Oxycodone (Percocet, Percodan, Tylox)
- Hyrocodone (Vicodin, Loracet, Norco)
- Tramadol (Ultram)
It’s important to distinguish whether a narcotic is long acting. (Some in this category are encased in a slow-release outer coating.) The most common one is oxycodone, which when enclosed in a time-release capsule, is Oxycontin. It’s critical not to chew a time-release narcotic, because the amount of drug ingested over a short time can be lethal. Other narcotics are long acting just by the nature of the chemistry of the drug. The classic example is methadone. The effects of the drug last so long that one must be vigilant in not taking too much too quickly.
The Downside of Narcotics
I am careful about long-term narcotics, but not for moral reasons–I spent about five years actively prescribing them. Rather, I’m cautious because there’s a significant downside to the medications. For one, there’s the tolerance factor: the liver becomes more efficient in breaking down the drug and it takes more of the drug to have the same effect. Secondly, many patients just don’t feel that great on narcotics. They complain of fuzzy thinking, which they sometimes don’t even realize until they come off of them. Thirdly, narcotics are addictive. It’s a true (i.e., chemical) addiction, and therefore extremely difficult to break.
The most disturbing aspect of narcotics is that they affect the sensitivity of the nervous system. The term for this process is “up-sensitization” or “opioid-induced hyperalgesia.” In rat studies, it’s been shown that repeated administration of narcotics causes them to be more sensitive to pain stimuli. (4) It’s unclear exactly why this happens. It may stem from the fact that narcotics cause changes in the glial cells in the brain and spinal cord, which insulate the nerve sheaths.
At the start of the DOCC program, I never stop or decrease a patient’s current narcotic intake. Instead, we first deal with sleep and stress — when you’re in chronic pain, your life is difficult enough without the additional strain of coming off pain meds. Once you develop decent stress management skills, then you can start a gradual tapering off of the meds. The tapering off rarely occurs before six months of being engaged in the program, and usually it takes 12-18 months for a given patient to be really ready to stop them. However, eventually stopping narcotics should be a clear goal in your mind.