Experimental data strongly implies that CDO use leads to increased experience of pain, rather than an improvement. So what happens if CDO patients stop using their opioids? Reports from many sources indicate that pain improves! In a study of 25 relatively high opioid using patients, every single patient had an improvement in his/her reported pain score after tapering off of opioids.⁸

We now have hundreds of similar anecdotes in our own practice that echo this phenomenon. "I just spoke with a patient who was referred for medication management two months ago for peripheral neuropathy. He was clearly hyperalgesic on high dose oxycodone. I told him our philosophy. He tapered his meds to off. He is endorsing little to no pain at this time and just called to tell us that he hadn’t agreed with our philosophy, but is now a 'believer'."⁹ While it is unusual to get such good pain relief from tapering off of opioids, more modest improvements are extremely common.

So why is it so hard for patients to understand the ineffectiveness of CDO? In my view there are two main reasons: the withdrawal syndrome and intoxication.

CDO is associated with opioid dependence and a characteristic withdrawal syndrome. Opioid withdrawal is a painful state, and patients with an underlying pain syndrome will experience an increase in their typical pain during early withdrawal. Every patient has forgotten to take one of their pills on time because he/she was focused on the business of life. At some point she experienced markedly increased pain, and then remembered the forgotten pill. Taking the missed opioid immediately lessens the severity of the withdrawal. The patient thinks that the opioid is treating the underlying pain, when in reality it is treating the withdrawal symptoms."¹⁰

Patients cannot tell the difference between withdrawal pain and their underlying pain syndrome. Most patients cannot tell the difference between emotional or psychic pain and their underlying pain syndrome. If he/she takes an opioid and he "feels better," he usually interprets this as somatic analgesia, when in reality he may only be getting a mild intoxication. His depression or anxiety is more tolerable, at least for a couple of hours. He may report feeling "energized" or more "peaceful." This lessening of psychological pain is usually associated with short-acting opioids that have a rapid rise in blood levels after consumption. These patients will report significant benefit from immediate release oxycodone, but little to no benefit at all from a higher dose of long-acting oxycodone like the new formulation of oxycontin. It is not the presence of the drug, per se, that they like; it is the rapid changes in blood level that they like.

Using opioids to treat depression, anxiety, and other psychological ills is not well studied, and we believe is fraught with potential hazard, as we are seeing in our communities at the present time. A recent Wall Street Journal article quoted the lead author of the 1986 study previously mentioned: "Clearly, if I had an inkling of what I know now then, I wouldn't have spoken in the way that I spoke. It was clearly the wrong thing to do.”¹¹ This is a politically measured way of saying "I made a mistake."

Recently, the American Academy of Neurology published a position paper on CDO. They reviewed the published literature and concluded: "although there is evidence for significant pain relief in the short term (average duration of trials 5 weeks, range 1–16 weeks), there is no substantial evidence for maintenance of pain relief over longer periods of time, or significant evidence for improved physical function."¹² We believe that the absence of such evidence is because CDO simply does not provide the expected benefit over the long term.

Daniel Faber, MD, is a member of the UMA Editorial Board. He is Board Certified by the American Board of Anesthesiology with added qualifications in both Addiction Medicine and Pain Medicine.