opioids Archives


The BMJ (what used to be called the British Medical Journal) just published an article stating that acetaminophen (ie Tylenol) has been found to provide no relief in low back pain (compared to a placebo). Acetaminophen was also related to a risk of having an abnormal liver test. The article included data from 13 randomized controlled trials (RCTs).

An RCT to evaluate a drug is a research study where one group of people receives the actual drug (in this case, acetaminophen) and the other group receives a placebo (a pill with no active ingredient, generally a sugar pill). Then, data is collected from both groups to see if either achieved any painTylenol relief. In this analysis, it shows that whether you receive acetaminophen or a sugar pill, you had the same amount of pain relief – meaning that active drug had no real pain relief effect.

Although most of the patients I see find no relief from acetaminophen, a small percentage of patients do, so don’t completely dismiss this drug when it comes to helping your pain. However, if you do take acetaminophen, make sure that you’re not taking too much. The FDA recommends taking less than 3000mg a day. This means if you’re taking Extra Strength Tylenol (500mg), you can only take 6 pills a day, or regular strength, 300mg, 10 pills a day. Higher amounts can lead to liver damage that could even be life-threatening.


What To Do When Back Pain Causes Overdose?

“We don’t appreciate what we have until it’s gone.” If only we had a dime for every time we heard this. Perhaps the reason it is such a common expression is the simple truth in it. This certainly applies to our health, but specifically our backs. We probably all take our good health in vain, until something goes wrong. By the time we are in our forties over twenty percent of us experience some form of back pain. And what do we do when we experience pain? Well, unfortunately many people will turn to strong painkillers. This means opioids, morphine-like painkillers. And, while we have written about this topic in the past, there is something new on the horizon. Evzio, the brand name of injectable Naloxone, is a prescription medicine that can block the effects of morphine and related painkillers. Approved by the FDA in April 2014, it allows a patient to quickly treat themselves or be treated by a family member if the patient has overdosed on opioids.Evzio

In the past, Evzio was difficult to obtain due to its high cost. However, recently The Clinton Foundation announced that it has negotiated a lower price for Evzio (see NYT article). This will allow municipalities to more easily purchase this medication, making it more available to those who need it.

It is a sad reality that many people will turn, in desperation, to painkillers as an answer to their aching backs. We, at the Norman Marcus Pain Institute, only use opioids as a last resort. Our method of finding the source of the pain and treating it has eliminated back pain for thousands of patients.. Nevertheless, with the rise of overdoses each year, the increased availability of naloxone to non-medical personnel will allow lives to be saved.




Because of the growing problem of addiction, misuse, and diversion, 49 states have now adopted a state prescription drug database.  You may have read an article recently in The New York Times about Missouri being the only state that has not adopted such a database. In New York, as a prescriber of controlled substances, each time a patient is prescribed any type of controlled substance, I must log into the NYS website to confirm that a patient is not receiving other medications from other doctors.

prescriptionsI found a few patients who had not been honest with me and had received medications from other doctors. Unfortunately, the small occurrence of dishonest behavior has obliged all doctors to be alert for the possible misuse of medication.  At the Norman Marcus Pain Institute, I implement several rules for patients receiving any type of controlled substance from me. Here are a few of them:

•             Only one physician can prescribe all pain medications.

•             Only one pharmacy should be used to obtain all pain related medications.

•             All medications, including herbal remedies and over the counter medications, need to be reported since all medications can interact with one another.

•             Medications must be kept in a safe and secure place, such as a locked cabinet or safe.


Following these simple rules will help protect my patients and their families from improper use of pain medication.


From 1991 to 2009, the number of prescriptions written for the strongest pain medications tripled. These medications are collectively named opioids and include morphine, oxycodone, and hydrocodone.Opioids are a type of pain drug that may cause serious side effects. From 2005 to 2009, the number of emergency room visits for nonmedical use of prescribed pain medication doubled. Therefore, the states and federal governments are acting to try to limit the amount of pain medication being prescribed.

At NMPI, we focus on finding the most effective treatment to relieve our patients’ pain – without surgery, steroid injections, or heavy painkillers. However, when a patient complains of severe pain and is not responding well to other pain medications, stronger, prescription opioids will be given.

Pain pills blog-Norman Marcus Pain Institute-blogSome opioids, such as oxycodone, are often combined with Tylenol (acetaminophen) in one pill. Some examples of these combination drugs are Lorcet, Lortab, Norco, Vicodin (are all hydrocodone and acetaminophen), and Percocet (oxycodone and acetaminophen). Most often, severe pain is related to a condition that will improve over time. Ideally, all prescription pain medications should be given only while severe pain persists. Like any medication, there are risks and side effects:


• Opioids can make you drowsy – which raises the risk of falling and severe injury
• Opioids when mixed with alcohol, anti-anxiety medication, seizure medication, muscle relaxants, or sleep-aids can be deadly.
• Opioids cause constipation and can lower sex drive.
• Patients can become physically and psychologically dependent on opioids.
• Overtime a patient with chronic pain can develop a tolerance for the opioid and need a higher dosage.

Keep in mind that not all pain requires such strong medication, and most patients with pain can be managed with drugs such as acetaminophen (Tylenol) and aspirin-like drugs, called non-steroidal anti-inflammatory drugs (such as ibuprofen and Naproxen). When taken as directed, these less powerful drugs may be all that you need. (There are potential serious side effects with acetaminophen and NSAIDs, which I will discuss in a future blog.) For certain pains, some drugs are better than others. Sometimes we find that a drug we have been using may not actually be effective. A New York Times article on July 23, 2014 reported that for treating low back pain, acetaminophen was no better than a placebo.

Physicians have a responsibility to properly care for patients in pain. Some of these patients may appear to be at a higher risk to abuse opioids. Occasionally, patients complain of non-existent pain to obtain opioids for its mood-altering affect, called a “high.” The fact is that physicians who had been writing too many prescriptions for pain medication are now wary of prescribing any potentially habit-forming pain drugs. This has resulted in a decrease in emergency room visits for drug overdose and deaths from overdose, but it has also resulted in depriving many patients of medication they legitimately need to function normally.

At NMPI, when we treat patients in pain who have a history of drug abuse or who test positive on a written test to determine the risk of abuse, I believe that these two basic American traditions should be the guiding principles:

1. Innocent until proven guilty; and

2. In the words of Ronald Reagan, Trust but verify. Those patients who have problems or are at risk to not properly use pain medication need extra attention, not condemnation. They may be more difficult to treat, but that is why there are specialists to deal with complex pain problems.


Opioid Induced Hyperalgesia (OIH)

Patients who receive high, escalating doses of opioids (for example: morphine or oxycodone) may experience an increase in pain as a result of their medication.  This phenomenon, called Opioid Induced Hyperalgesia (OIH), is different than developing a tolerance to medication in several waysPain pills blog-Norman Marcus Pain Institute-blog

  • The nature of the pain is different than the pain for which the opioid was originally prescribed.  Often, pain becomes more diffuse, or widespread.
  • The location of the pain is different than the pain for which the opioid was originally prescribed, and often extends to more locations.
  • The quality of the pain is different than the original pain.  For example, the patient may experience allodynia, a condition in which normal sensation, such as touch, becomes painful.
  • Pain sensitivity can increase
  • Pain tolerance decreases
  • Whereas patients who have developed opioid tolerance may have transient relief from additional opioids, patients with OIH will have an increase in pain from additional opioids.[1]

Theoretical explanations for OIH include the roles of microglia and mast cells.  Though the mechanism by which this occurs isn’t fully understood yet, use of ultra low-dose Naltrexone has been reported to be effective in decreasing opioid side effects and facilitating reductions in dose. It is clear that long-term maintenance on opioids can do more harm than good for some patients.  Therefore, it may be wise to periodically attempt to decrease the amount of opioids to see if this either results in no increase or an actual decrease in pain.

[1] Lee, Marion, Sanford Silverman, Hans Hansen, Vikram Patel, and Laxmaiah Manchikanti. “A Comprehensive Review of Opioid-Induced Hyperalgesia.” Pain Physician Journal (2011): n. pag. Print.


We see that in some patients who have central sensitization, treating the peripheral pain generators may results in a decrease or elimination of the widespread pain.

Widespread pain is often addressed with medication. It is common for a patient to be given an anticonvulsant, such as pregabalin (Lyrica) or gabapentin (Neurontin), or a serotonin-norepinephrine reuptake inhibitors (SNRIs), such as duloxetine (Cymbalta) or venlafaxine (Effexor).  These drugs affect the neurons transmitting pain-related signals in the central nervous system.nerve bundle-Norman Marcus Pain Institute blog

Another possible target in the nervous system is the glial cells. The glia are non-neuronal cells that provide support and protection for the neurons.  90% of the central nervous system (spine and brain) are made up of glial cells.

Two cells types, microglia and astrocytes, recently have been found to play a role in pain processing. These two types of cells are stimulated in response to damaged or dying cells. Astrocytes produce inflammation, while microglia initiate both inflammatory and anti-inflammatory activity. An inflammatory response in the microglia results in pain-producing chemicals, adding to the patient’s overall pain. Chronic pain and opioids, such as morphine and oxycodone, can also stimulate the microglia to produce these same pain-producing chemicals.

This may be one of the reasons why opioids are ineffective in patients with long-standing pain, as with fibromyalgia (FMS). Interestingly, drugs that block opioids, such as naltrexone, in very small doses have been found to be effective in decreasing pain in FMS (http://www.ncbi.nlm.nih.gov/pubmed/23359310). The mechanism appears to be blocking the pain producing effect of the microglia. Since the doses are so small (~4mg/day), the typical blocking of the mu receptor (the receptor that is known to be typically stimulated by opioids) doesn’t occur. What we often find as a result is pain relief and a decreasing need for opioids.

Since microglia also play an anti-inflammatory  role, in our search for drugs to affect the microglia, we need to find a balance in which we can maintain their protective anti-inflammatory roles while also reducing their inflammatory pain producing effects.  (http://www.nature.com/nrn/journal/v10/n1/abs/nrn2533.html)


Back Pain: Opinion vs. Evidence

I Googled back pain and got 649,000,000 hits. I am sure that the opinions of all those who posted their successful approaches were in there.

Overall I would say the consensus, based on cost and outcomes analysis, is that we do too much treatment of low back pain. Back pain is a symptom that may be caused by a variety of factors.

Deconditioning, muscles, tendons, operable lesions of the skeleton and neuraxis, are all possible causes. It is important to recognize that all the clinicians who posted their very different theoretical models and treatment approaches, believed they were achieving success with a majority of their patients.  How could this be true unless each clinician was treating a unique subgroup of back pain patients?  A recent article (http://bit.ly/1fjuCUT) demonstrated that pain clinicians publishing their outcomes reported an approximately 300% greater success rate than non-pain clinicians reporting on the outcomes of the same procedures.  We are invested in believing that what we do works.

I try to consult the Cochrane Library of Systematic Reviews (www.thecochranelibrary.com) to get a sense of the validity of various approaches for the treatment of back pain. The literature on prolotherapy, trigger point injections, nerve blocks and surgery for chronic low back pain uniformly is found to be inadequate to make a case for the routine use of these approaches.

We need randomized controlled studies that report on function as well as pain intensity and with adequately long follow up data to improve our ability to know what works and for whom.


Opinion vs. Evidence on Long Acting Opioids

Do you believe that long acting opioids should be used routinely when patients are taking round the clock meds?  A recently published study http://bit.ly/18y6RXL concluded that long acting but not short acting opioids were associated with hypogonadism in men.  Boxed warnings on long acting opioids now read that if short acting opioids are effective they should continue to be used rather than switching to long acting.

Without large studies to prove a concept and insure the absence of unwanted effects, the standard of care has been that more expensive long acting opioids were preferable because they were assumed to be less likely to lead to abuse and addiction. I experienced this opinion as a mandate when a mail- in pharmacy my patient was using, said that if I didn’t write for long acting opioids they would no longer dispense meds to him. Opinion based guidelines, rather than evidence based guidelines, unfortunately is driving much of the practice of pain medicine.

30 East 40th Street - New York, NY 10016
Tel 212-532-7999 Fax 212-532-5957
Help Desk Software