Psychoactive Properties of Opioids and the Experience of Pain – Journal of Pain and Symptom Management – February 2016
Here is a letter to the editor of a pain journal from Stephen R. Connor, PhD of the Worldwide Hospice Palliative Care Alliance.
He points out what so many of us have noticed: if you take opioids when you’re in pain, you do not get “high” (see also Opioids, Endorphins, and Euphoria)
A frequently held view in palliative care is that when patients in pain use opioids, they do not experience the psychoactive or euphoric effects of opioids.
Furthermore, that those not in pain who use opioids do experience these euphoric effects that may lead to opioid-use disorder.
Other than common clinical experience, there is scant evidence to support this view, and the contention awaits validation through empirical study.
The following ﬁrst-person example of this effect is shared to call for research on this important but neglected topic and to help demythologize and improve access to opioids for those in pain.
While working in hospice at a hospital in Northern California many years ago, I awoke at 2 AM at home in excruciating pain. My wife drove me to the emergency room at my hospital where I was greeted by staff to whom I offered the self-diagnosis of a likely kidney stone attack. The staff supportively said that they needed me to produce a urine sample to conﬁrm my condition. Blood in my urine sample gave them the assurance that I was in severe pain and I was given 15 mg of intramuscular morphine.
The injection did not remove my pain but allowed me some ability to separate myself from the excruciating experience of the pain. There was no euphoria or any sense of pleasure.
I waited until, some hours later, I was sent for an intravenous pyelogram (IVP) procedure to image the stone. Before administration of the IVP dye, I was given another injection of morphine. As the IVP contrast dye was injected, the stone moved from my kidney to my bladder.
As the stone moved to my bladder, the intense pressure pain I was experiencing dissolved. As the pain diminished, I began to feel the psychoactive effects of the morphine. Suddenly I felt high on the morphine.
A warm sensation ﬁlled my body and I relaxed on the gurney. A sense of euphoria and deep contentment swept over me. I was put in a hallway to await results. At about 6 AM, the director of nursing on my hospice ward came to check on me (conﬁdentiality for staff is not so much). Later, she said I looked very happy. I have not had any desire to repeat the experience.
The psychoactive properties of opioids are quite variable, and there is much variation in what is reinforcing from person to person.
Severe pain will trump most of these psychoactive effects, but what one experiences when taking an opioid is affected by many complex factors including
- the type of pain,
- its intensity,
- short- or long-term use,
- which opioid is used,
- genetic variations,
- the dose taken,
- patient characteristics,
- and so forth.
It is surprising that more research on the difference between patients using opioids when in pain and not in pain does not exist, but given the complexities, it is understandable. Nevertheless, we really need this evidence.
Each year, an estimated 40 million people are in need of palliative care, 78% of whom live in low-and middle-income countries.1
At present, over 80% of the world’s population lacks adequate access to oral morphine.
Opioids are feared and avoided.
Physicians are still taught that they are dangerous and will invariably lead to addiction, even when used for legitimate medical purposes.
In most countries, the police monitor the medical use of opioids and prescribers fear going to jail even if they simply make documentation errors. The paperwork burdens are extensive.
Opiophobia is alive and well throughout the world.
There is a prevailing belief that a patient, even in severe pain, when prescribed an opioid will experience psychoactive effects that will likely transform the patient into an ‘‘addict.’’
In palliative care, we rarely see opioid use disorder in our patients. Time for our patients is usually short, and most die while still receiving opioids.
As I work internationally developing palliative care in many countries, I regularly confront opiophobia and counter this with our usual arguments, including the previously mentioned one, to advance the case for access to oral morphine, which is rarely available.
Evidence for these arguments is lacking and would be very helpful to counter myths about opioids.
What is needed is more rigorous research that effectively demonstrates what we see every day clinically: that our patients in moderate-to-severe pain, when started on an opioid, only experience relief of their pain.
Stephen R. Connor, PhD
Worldwide Hospice Palliative Care Alliance Fairfax Station, Virginia, USA
Connor S, Sepulveda C, eds. Global atlas of palliative care at the end-of-life. London UK, Geneva, Switzerland: World-wide Hospice Palliative Care Alliance and World Health Or-ganization, 2014. Available at: http://www.who.int/cancer/publications/palliative-care-atlas/en/. Accessed November 1, 2015.
World Health Organization. Ensuring balance in national policies on controlled substances: Guidance for availability and accessibility of controlled medicines. Geneva, Switzerland: World Health Organization, 2011. Available at: http://www.who.int/medicines/areas/quality_safety/guide_nocp_sanend/en/. Accessed November 1, 2015.