When Opioid Pain Relievers Stop Working


What do 100 million Americans have in common? Pain. Chronic pain. Pain so persistent and so severe that it interferes with daily function. If you aren’t one of those people, it’s likely you know someone or maybe even several people who fall into that category.

Many people experiencing chronic pain are taking narcotic medications in a class called opioids. The most common use of opioids for chronic pain involves taking one drug that is long-acting with a sustained-release over time. The goal is to control baseline pain.

A short-acting opioid can be prescribed for those days and times when there is breakthrough pain (pain that can be felt or perceived even with opioids). When the combination of the long- and short-acting opioids don’t work anymore, then it may be time to try a different medication within the opioid family of drugs.

Switching opioids sounds easy enough. After all, the person is already taking opioids for pain control. What’s so difficult about taking a different one? The biggest concern is for drug-drug interactions. Safety is a key issue.

Physicians want their patients to experience good pain control with the fewest side effects possible. We may all be the same species (i.e., humans), but every person is slightly different in how the body reacts to medications. We can’t predict how they will respond to individual drugs, drug combinations, and/or opioid switching.

Sometimes the underlying disease or condition that is causing the pain affects medications at a biochemical level. Those reactions aren’t always predictable either. To take it even a little further, consider this: drugs are metabolized (broken down) by the liver and then sent through the blood stream throughout the body.

The drug doesn’t just affect one system. It impacts all the systems. Then the kidneys have to filter out all the chemicals and get rid of any by-products that aren’t used. Many patients who are taking opioids are also taking other medications and supplements (vitamins, calcium, antioxidants, etc).

Studies show that the average person taking opioids also swallows 10 or more other pills each day. All of these substances have to be broken down and processed within the body. The potential for adverse effects increases with each medication or supplement taken.

Where are we going with this line of thinking? Experts suggest that physicians pay attention to the ways in which opioids are metabolized and work. If it becomes necessary to switch opioids, then try and find an opioid that works in a slightly different way.

For example, if one medication is broken down by the cytochrome P450 (CYP) system of the liver, then prescribe an opioid that does not require involvement of that system. This approach could potentially lower the number of drug-drug interactions (DDI) that occur with opioid combinations, especially when there are other medications being taken as well.

One alternate opioid now available on the market is called EXALGO. EXALGO is a form of hydromorphone (other examples of hydromorphone include Palladone and Dilaudid). This type of extended-release opioid is not broken down by CYP enzymes. It can be considered when baseline pain is not being managed well with other opioids that are dependent on breakdown by cytochrome enzymes.

As with any new medication, there are precautions (warnings about what to watch out for) and contraindications (reasons not to take them). The EXALGO drug cannot be prescribed for patients who have any gastrointestinal or respiratory problems. It is intended for use with patients who have significant, chronic pain (not mild cases).

One final note about opioids. It is possible to develop a condition called opioid toxicity. Breathing becomes impaired. Blood pressure drops and the patient becomes very lethargic.

Reporting any new symptoms when taking these medications can help prevent this problem from developing. Even minor problems such as upset stomach, nausea, headaches, constipation, vomiting, and dizziness should be reported immediately to the prescribing physician or dentist.