Neuropathic pain is estimated to affect anywhere from 30 percent to 90 percent of people with multiple sclerosis (MS) at some point in their lives. There are different types, causes, and treatments for pain due to MS. It is important to treat pain whenever possible to help people with MS retain physical and mental functioning, well-being, and quality of life.
With careful management, prescription opioid drugs can treat moderate to severe pain. However, the clinical use of opioids is a highly controversial topic, and opioid abuse is a public health crisis in the United States. With questions about long-term efficacy and side effects and increasing issues like opioid-related addiction, abuse, and overdoses, many doctors do not consider opioids a safe treatment option for MS pain.
Here’s what to know about the potential risks of opioid use, as well as what your other options are for treating different types of MS-related pain.
Opioids are a class of drugs that are developed naturally from the opium poppy plant and are also formulated synthetically in labs. These drugs work to block pain receptors in the brain, the spinal cord, and the rest of the body. This action results in a variety of effects, and the most valuable therapeutic benefit is an analgesic effect (pain relief). Other effects include feelings of relaxation and happiness.
Opioids are usually prescribed for pain management after surgery or an injury but are sometimes used to treat severe coughing or diarrhea. Opioids have also been found valuable in treating moderate to severe cancer pain.
Mild opioids or opioid-like agents such as tramadol (sold as Ultram or Ultracet) may be used in addition to medications like aspirin, acetaminophen, or nonsteroidal anti-inflammatory drugs (NSAIDs) to address moderate to severe pain. Severe pain that is unresponsive to these treatments may require stronger opioids like morphine or fentanyl.
Prescription opioids may be used for pain that is neuropathic (nerve pain) or somatic (a type of musculoskeletal pain). The most commonly used prescription opioids include:
Because of their risks, prescription opioids are typically reserved as a last resort when no other pain management therapies have worked. The U.S. has state and national guidelines for prescribing opioids. Other factors like the severity and duration of pain, environmental and genetic risk factors for opioid abuse, and mental health status also help doctors to decide whether an opioid should be used for pain management.
Efforts to combat the opioid crisis have created restrictions and put pressure on doctors to limit the prescription of opioids for people with chronic pain. Members of MyMSTeam have commented on how the opioid crisis has affected them personally, often barring them from receiving the medications that were effective in managing their severe pain symptoms.
“My family doctor keeps trying to cut down all my meds due to the opioid crisis. Every month, she takes away more, and then I can accomplish less and less. Wish they could feel what we feel,” wrote one MyMSTeam member.
Although it poses challenges for pain control, doctors may limit the use of these drugs for good reason. Prescription opioids present several risks, including dependence, tolerance, and addiction. The opioid crisis is underlined by an increase in misuse and overdoses. According to the Centers for Disease Control and Prevention (CDC), from 1999 to 2019, overdose deaths that involved prescription opioids more than quadrupled.
When using opioids, there is a risk of growing dependent on them. This means that over time, the body may develop a physical dependence, or need, for the drug. The physical dependence on a drug is usually defined by the presence of specific withdrawal symptoms with cessation (stopping) or decreased dose of the drug. Opioid dependence in itself is not necessarily considered dangerous, but dependence can lead to addiction.
Another risk of using opioids is the potential for tolerance, by which your body grows accustomed to the dosage of opioids over time. If a person grows tolerant to a drug, they will need an increased dosage of the drug to feel any effects. Tolerance and taking higher doses of opioids may increase the risk of overdosing.
Addiction is a serious concern with the use of prescription opioids. Addiction is defined by the American Pain Society as “a primary, chronic, neurobiological disease … characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.”
People with other behaviors like pseudoaddiction and diversion may present as having addictive behaviors. Pseudoaddiction is a condition when someone’s pain is undertreated, and they exert behaviors like seeking pain-relieving drugs, which mimics the behavior of someone with an addiction. Diversion is the act of obtaining prescription drugs for illegal purposes (selling them).
Although addiction is a major concern, the use of prescription opioids is not a predictor of becoming addicted to them. Researchers acknowledge the controversy in that opioids can be harmful but are among the most effective treatments for moderate to severe pain.
Addiction and the opioid crisis have furthermore created a stigma around taking opioids for pain. Members of MyMSTeam discuss how they are sometimes treated like drug addicts when they tell doctors about their pain. “Today, it seems that anyone who needs pain medication is treated like an addict … when you are in pain, the last thing you want is someone telling you that you aren’t,” a member said.
Although side effects are not the most concerning risk of opioid use, they do exist. Common side effects include:
Due to the risks opioids pose, other medications and therapies are often used as the first lines of treatment for MS pain instead. Treatment for MS pain depends on the type, duration, and severity of pain.
Sensory pain is commonly reported in people with MS and is described as burning, tingling, or tightening sensations usually in the hands and feet. It can also present as sharp, shooting pain.
This type of pain is treated with antiepileptic medications like gabapentin (Neurontin) and pregabalin (Lyrica) or tricyclic antidepressants like duloxetine (Cymbalta). Nonmedical treatments include acupuncture and meditation.
“I take gabapentin for nerve pain. My dose at night helps me to fall asleep as well,” wrote a MyMSTeam member.
However, members of MyMSTeam also discuss how gabapentin doesn’t always work for them or causes troublesome side effects like weight gain.
Central pain in MS may result from demyelination and damage to the nerves in the central nervous system. Treatments for central pain also include tricyclic antidepressants like amitriptyline (Elavil), nortriptyline, desipramine, as well as antiepileptic (or anticonvulsant) drugs. Intermittent central neuropathic pain, like trigeminal neuralgia (which affects the trigeminal nerve in the face), is treated with the anticonvulsants carbamazepine, oxcarbazepine, or lamotrigine, or the antispasmodic baclofen (Lioresal).
Muscle spasms, spasticity (muscle tightness), and nociceptive pain (musculoskeletal pain) in MS are also usually treated with medications like ibuprofen or naproxen sodium, or physical therapy is prescribed before doctors consider prescribing opioids for treatment.
“I know every person is different, but ibuprofen helps a lot,” wrote one MyMSTeam member on how they address pain in their legs.
There is not a lot of research or clinical trials on the effectiveness of opioids for MS pain specifically.
Two studies found that the opioids morphine and levorphanol relieved pain in people with MS, but only when using higher dosages of the drugs. The study that evaluated the effects of morphine found no impact on MS pain with low doses of morphine, and so their results didn’t support the use of opioids to treat central pain in people with MS.
A recent examination of the prevalence of opioid use in people with MS found that 1 in 5 people reported taking prescription opioids. So, although there is not much evidence on the effectiveness of opioids for pain relief in MS, a good amount of people with MS use prescription opioids. This research study further noted the need for better pain management options for people with MS pain.
“I’ve gone through every possible option before reverting to opioid use about six years ago,” said one MyMSTeam member. “Eventually, the pain was so overbearing that I couldn’t move. I have now been on opioids, Neurontin, and naproxen for over five years, just to lower the pain from a 9-to-10 rating, down to a 5-to-7 rating depending upon time after use.”
Ultimately, when dealing with pain from MS, you should seek treatment and support from a doctor, neurologist, or a pain specialist. Your doctor will work with you to find the best method for treating your pain that presents the fewest risks and side effects.
A great tool for coping with pain from MS is connecting with others, especially those that may understand what you’re going through.
MyMSTeam is the social network for people with MS and their loved ones. On MyMSTeam, more than 190,000 members come together to ask questions, give advice, and share their experiences with others who understand life with MS.
How do you cope with MS-related pain? Share your experience in the comments below, or start a conversation by posting on your Activities page.