Many people can’t understand how someone becomes physically dependent or develops an addiction to an opioid pain medication, such as Vicodin, Dilaudid, OxyContin, Duragesic and Norco, prescribed by their doctor. Understanding the following key concepts can help:
- The brain controls everything we think, feel, say and do through neural networks and brain maps.
- Pain is in the brain.
- Pain meds don’t just block opioid receptors – they also trigger massive releases of dopamine neurotransmitters.
- A person can be physically dependent and not addicted to a pain med, yet the withdrawal symptoms can be the same.
Neural Networks, Brain Maps and Pain
Neural networks are the way brain cells (neurons) talk to one another. They, in turn, exchange information with other neurons (cells) throughout the body via the nervous system.
This “talking” is done through an electro-chemical signaling process. This is easier to understand if you think of neural networks as strands of holiday lights. Anything that happens along a strand of holiday lights – a loose bulb, frayed wire, power surge – changes how that strand works. This in turn changes how all other strands connected to it work.
Basics of a Neural Network
The following is a simplified description of what goes into making a neural network. If any one of these “things” is changed or different, it changes the way neural networks perform, which can then cause a person to think, feel and behave differently. This is where the strand of holiday lights example comes in…
- Cue or Trigger – a sound, sight, touch, smell, memory, emotion…something that triggers the electrical portion of the electro-chemical signaling to start.
- Brain cells (aka neurons) – the “brains” of the neural network; messages are passed from one to another.
- Axons and Dendrites – outgoing and incoming branchlike extensions – take messages to and from cells.
- Neurotransmitters – the chemical part of the electro-chemical signaling process located at the end of outgoing branchlike extensions. These change the electrical signal into a chemical signal that can float across the synapse.
- Synapse – the gap between outgoing and incoming branchlike extensions at the ends of brain cells.
- Receptors – located at the end of incoming branchlike extensions. They accept the neurotransmitter – like a “key in a door lock” – and change it back into an electrical signal to carry on the message to the receiving cell.
Pain and opioid pain medications work on all of these “things” on a wide-ranging, SIGNIFICANT number of neural networks.
Brain Maps for the Things We Do
Through a series of connections, neural networks form systems between the brain and other organs to control our body’s major functions. These include the fight-or-flight stress response system, for example, as well as the circulatory and digestive systems.
Neural networks also work together to form “brain maps” for the things we do regularly. Brain maps take very little, if any, thought. They just happen. And thank goodness they do. If we did not have these brain maps, we would still be trying to get out of bed because the millions of neuron connections needed to do that simple function would take forever to hook together. So, over the course of our lives, we create brain maps for riding a bike, typing, brushing our teeth, reading, climbing, swimming, driving a car, operating equipment, playing an instrument, texting—just think about it! Basically, then, brain maps are our habits, coping skills, life skills and typical behaviors.
When we map opioid pain meds as the answer to relieving our pain, however, the pain meds CAN become the brain’s “coping skill” long after the injury site is healed.
Sharing all of the above and this next section is intended to help a person understand what they can do to change, re-wire (re-map) their brain.
How the Brain Maps Chronic Pain
When you injure yourself, pain receptors in the peripheral nervous system send pain signals to the spinal cord. At the spinal cord, bundles of sensory neurons in the dorsal horn act as a hub and send reflex messages to the injury site (take your hand off the burner, for example) and pain messages to the brain. These pain messages to the brain run throughout, triggering neural networks ranging from those involved with fight-or-flight, to those responsible to assessing this pain in context of similar pain, to so many more too numerous to count.
And this is where it can get “complicated.” If the brain attaches fear to the event – say fear about what you’ll be able to do now that you’ve broken your foot, or it attaches anxiety to the injury event – say anxiety about doing something, like exercise, that might make the pain worse, or it attaches worry about the prognosis for a full recovery, the brain starts to get the pain messages linked up with the emotions. So that if a person feels that twinge of fear when they move their foot, the brain “reads” it as pain. Additionally, if the brain is under major emotional stress around other things going on at the time of injury, say loss of a job, it can attach those stress-related feelings to the feeling of pain, as well. Thus when another job application they’ve submitted is declined, for example, their brain “feels” that old “pain.”
Not only this but pain often interrupts sleep and gets in the way of wanting to exercise. Both lack of sleep and lack of exercise in turn change brain chemistry, which in turn can lead to depression or a brain mapping that further inhibits sleep and exercise. And why would this be such a problem? When the brain does not get the powerful brain benefits of restful sleep and exercise (these actually “do things” to various parts of those strands of holiday lights), it interrupts normal neural network activity, which then exacerbates the problem.
Not only are there all of these sorts of emotion / thought-related mappings going on, BUT there are the brain maps around the chemical interruptions to the neurotransmitters and receptors’ portions of various neural networks. These interruptions are caused by the chemicals in the drug compound, itself.
How Opioid Pain Meds Work in the Brain | Body
A portion of the pain med compound binds to receptors at the injury site. A portion of the pain med compound binds to opioid receptors found throughout the brain and nervous system – the receptors on neural networks involved with the “complicated” bit above. And a portion trigger massive releases of dopamine neurotransmitters – the neurotransmitters responsible for the brain’s pleasure/reward neural networks.
With the surge of dopamine component of an opioid pain medication, the pain is not being “killed,” per se – rather it’s being overwhelmed by the content, euphoric, satisfied feelings that dopamine neural networks provide. And, of course, the brain likes that feeling, so it maps the desire for pleasure (which comes with the pain meds), in addition to all of the other brain mapping going on.
This is where the strand of holiday lights analogy comes into play, again. Between the “complicated” stuff described above and the brain / body pain med interactions, there are so many strands (neural networks) with frayed wires, loose bulbs and power surges, that a person’s thoughts and behaviors and what they feel and how they react / respond is out of wack.
Acute vs Chronic Pain
In the case of acute pain, which is normal, and lasts anywhere from a week or two to a few months, pain medications help calm all of the opioid reliant neural networks involved with injury pain. Once the injury site is healed, the brain no longer feels pain and the person is weened off their pain medication.
BUT, in the case of chronic pain, the continued feeling of pain MAY be being triggered by the “complicated”-related brain mapping around fear, anxiety, emotions related to other events going on at the time and the “ah” feeling mapped around dopamine described above. The brain can actually be hijacked, if you will, because it has maps that “tell it” that pain meds are the answer to “pain” – pain which is now triggered by emotions, memories and the drive to feel good – all of the cues it has mapped to be “answered” by the pain med. The brain goes after the meds with cravings for the medication that can be 3-5 times stronger than the instinctual drive to eat food when hungry. In this manner, loss of control - the ability to “just stop” or to cut back – is another problem as the brain sets up the desperate seeking and using of the drug that it mapped as making it all feel better; yet the original dosageno longer works because of the chemical and physiological imbalances caused by abuse of the pain medications. Additionally, the chemical imbalances that occur as neurotransmitters are depleted and receptors become less sensitive set up tolerance - meaning a person can consume quantities that are far greater than what a “normal” person could handle. When these characteristics (cravings, loss of control, tolerance and physical dependence, explained next, are present, it’s likely the person has developed addiction, a chronic, often relapsing brain disease.
[Strong disclaimer #1: this is NOT to suggest that all pain is related to this “complicated” description. Arthritis and cancer, for example, cause very real chronic pain for which opioid pain medications are the “answer.” Strong disclaimer #2: there are a host of reasons that have nothing to do with pain that can cause a person to develop an opioid addiction.]
As for what to do, see the last section of this post.
Opioid Pain Medication Withdrawal Symptoms
Withdrawal symptoms are the result of the body’s physical dependence on the pain medication. This is because it takes time for the liver to metabolize the chemicals in opioid pain meds, so while it’s “waiting” to metabolize, it is sitting in lots of body organs that are highly vascularized (meaning lots of blood vessels) – not just the brain. In this manner, these other organs demand the pain meds to avoid the awfulness of withdrawal symptoms described in the following excerpt from Opiods911.org/safety:
“Opioid withdrawal is not harmful or life threatening, but it can be very unpleasant and even painful. Going through opioid withdrawal is somewhat like having a bad case of the flu. It can take 6 hours or much longer after reducing or stopping an opioid medicine, or starting a new medicine or product that interacts with the opioid, before withdrawal starts. The amount of discomfort, and how long it lasts, depends on the type of opioid medicine that was taken, how long it was used, and the dose.??Here is what to watch for…
“It is important to understand that tolerance and withdrawal are not signs of addiction in a person who is taking opioid medicine correctly, as prescribed for pain. If your medicine seems to become less effective in relieving pain, or you experience opioid withdrawal at any time, even mild discomfort, contact your opioid prescriber. Never take extra opioid medicine on your own.” Source: http://www.opiods911.org/safety.php
What to Do
- Talk to your doctor, and if you are not satisfied with their response, seek another opinion.
- Understand addiction. The National Institute on Drug Abuse (NIDA) has an excellent explanation, “Drugs, Brains and Behaviors: the Science of Addiction,” and The Addiction Project, a collaboration of the NIDA, the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the Robert Wood Johnson Foundation and HBO.
- If it is the “complicated” stuff described above and the person actually has developed addiction, it will take “re-wiring” neural networks, which first requires removing the pain medications and then getting appropriate treatment. NIDA has written an excellent guide, “Principles of Effective Treatment: a Research-Based Guide (Third Edition),” that can help.
- If it’s not the “complicated” stuff, work with your doctor on what to do to ween you off the medication and/or prescribe another that won’t have the same withdrawal or side effects as what you are currently experiencing.
- Check out FAQs answered by OpioidSafety911, as well as their section, titled: “How can I prevent problems with opioids.”
- Take the time to watch this excellent, less than 5-minute video on chronic pain and what to do about it.
©2014 Lisa Frederiksen. All Rights Reserved. Much of the above are excerpts from two eBooks that will be published as part of my upcoming Quick Guides collection.