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Monday, November 10, 2014

Long Term Use of Opioid Pain Medications In The Endurance Athlete

In preface, there has not been enough said here in this post to fully clarify the effects of long term opiate use in endurance athletes.  One difficultly with publishing precise information is that opiate usage and endurance athletes is more or less oxymoronic.  However, there are a few of us (myself included) that have lived with the ability to train and compete while on a more than moderate amount of daily narcotic consumption over a very long period of time (> 2yrs).  But with time, training let alone competing became more and more difficult.  The motivation was present but the body was no longer willing.  I speak from experience and I am using my own experience to write this post - as a narcotic free athlete!  

I've been pondering this topic for a long time.  So, using myself as a lab rat, I began to problem solve my training and competing issues.  But first, to get straight to the conclusion, opiate pain medications will eventually hinder physical performance in an endurance athlete.  

Let's look at a specific scenario.  A competitive cyclist has had an accident and has injured his pelvis or back.  The injury is so severe as to require surgery.  Pelvis injuries are quite painful and take longer to heal than other parts of the body.  Because of the prolonged healing, the athlete may be required to consume narcotic pain medication for an extended period of time.  In many cases, the athlete will begin to compete again while still using the pain medication.  While being re-introduced to vigorous physical activity, the consumption of narcotic pain medication is not so uncommon.  Pain medication is taken prior to the activity in anticipation of neutralizing any residual pain from the injury and healing process.  Often the athlete will make a generalization of performing better with pain medications on board.  The thought process is that "I will be able to perform better due to being able to tolerate a higher threshold of pain during harsh physical activity".  Again, this assumption is wrong.

Narcotic Pain Medication Is Not An Ergogenic Aide or Performance Enhancing Drug (PED).
It Does Not Improve Performance But
 Hinders Performance

This topic became a strong interest of mine due to the fact that I have had several spine fusions and following the spine fusions (lumbar & cervical) I returned to competitive cycling.  I did stay on narcotic pain medications for quite some time.  I returned to my usual training schedule and began to compete.  But no matter how hard I tried, my performance plateaued well below where I should have been performing.  I was bouncing off of the walls trying to figure out why I couldn't improve my fitness and reach a competitive level.  Finally a light came on and I began performing a very in depth literature review regarding how opiates affect different aspects of the body including physical performance.  Let me tell you, there is certainly not a plethora of information on this topic, but what I did find was extremely enlightening. After becoming educated on this subject and applying physiological and medical principals, I went straight to my doctor and asked to be taken off of the narcotics.  The withdrawal off of the chronic use of narcotics alone is a very difficult and painful process to go through.  This can easily take several weeks to several months to complete.  You'll understand why later on in this article.  But what helped me through it was that exercise is mandatory during withdrawals in spite of how horrible you feel!  And it's not just me, it's anyone that is struggling with opiate withdrawals.  Moderate to vigorous exercise will speed your recovery and reduce the pain of withdrawals!  


First of all, an understanding of how opiates work in the body is essential in order to understand how opiates affect physical performance.  

Opioids and the Central Nervous System (CNS) 

Opioids attach to specific proteins called opioid receptors, which are found in the brain, spinal cord (AKA the central nervous system or CNS), and gastrointestinal tract. When the drugs attach to certain opioid receptors, they block the transmission of pain messages to the brain.  Opioids relieve stress and discomfort by creating a relaxed detachment from pain, desires, and activity. Opioids tend to produce drowsiness, reduce heart rate, cause constipation, cause a widening of blood vessels, and depress coughing and breathing reflexes.

Nerves carry information through the spinal cord to the brain about what is happening inside and outside of the body.  The brain processes the information and sends messages back through the nerves that control how muscles and organs respond.  This being said, I think we can all agree that the CNS controls our voluntary muscle contractions and involuntary muscle movement.  This means that our balance, fine motor skills, gross motor skills, and our ability to stand and sit without having to think about how to stand and sit or even walk are controlled by the CNS.  This touches on just a very small portion of what our CNS controls in the body. 

Consider the function of our CNS with the following and it's relevance to physical performance.  The CNS Controls (amongst a myriad of other functions):
  • Blood pressure when at rest or when exercising
  • Heart rate when exercising or at rest
  • Muscle recruitment for a specific task, i.e. whether to recruit fast twitch or slow twitch, and how much recruitment is necessary for a task.
  • With reference to this post, the CNS also decides which fuels in our body are to be used during a specific activity.  The CNS controls the use of adipose tissue for fuel, the conversion of liver glycogen to blood glucose for fuel, and the ability to utilize the necessary amount of oxygen to convert these fuel sources for muscle contraction (remember, opiates suppresses the respiratory system).

The CNS controls the conversion of food to absorbable nutrients and energy in the gastrointestinal tract.  Hormone production and regulation.  After mulling over the above mentioned specifics of the CNS, many of you can speculate on just how opiates will affect physical performance.  There is slower absorption of fuel in the gastrointestinal tract, respiration and blood oxygen saturation is less, muscle recruitment is being affected adversely, and heart rate and blood delivery can be affected.  Hormone production such as the feel good hormones like dopamine, endorphins, and enkephalins are violently affected!  Endorphins and enkephalins are small peptide molecules that are naturally produced and are important regulators of bodily pain.   In men, testosterone production is negatively affected and sex drive is significantly reduced.  

The Specifics of How Long Term Opiate Use Affects Physical Performance

Long term opioid use can have a very detrimental effect on physical performance.  The reason for this is that:
  • Opiates interfere with peripheral nerve transmission.  In other words, opiates reduce electrical activity in the body.   This in return reduces synaptic activity in the brain which causes signal reduction from the brain telling the muscle to work.  This causes significant muscle recruitment.  Over time this causes muscle weakness and atrophy.
  • Naturally occurring hormones in the body cease production.  This is because the opiate acts as a specific hormone.  Since the body senses the presence of the "supplied hormone", the body stops producing that specific hormone.
  • Opiates cause a reduction in appetite.  Therefore, prior to or after a hard workout a chronic user of opiates will typically not provide themselves with the appropriate nutrition needed to continue participating at a high level in endurance sports.
  • Chronic users of opiates usually have a very high anxiety level due to their dependence on the opiate.  Chronic users of opiates typically need to steadily increase the amount of medication just to maintain normal daily activities.  If that increase in opiates is not supplied, a person can become clinically depressed and develop generalized anxiety disorder.
  • Cortisol is a product of high anxiety and stress.  High cortisol levels in the body act as a catabolic hormone breaking down healthy muscle tissue.
The above listed are just a few affects that opiates have on an endurance athlete.  One could also argue that since the brains ability to send signals to working muscles is lessened, then the nerve to that muscle can atrophy as well.  The myelin sheath around the nerve can become thinned and only a weak or slow signal will reach the intended muscle.  

Earlier I mentioned how horrible a person can feel during immediate withdrawal and during the days or months following.  Depending on how long a person is on opiates is directly correlated with how long it will take a person to recover.  The damage done from opiates, fortunately, is not permanent.  The key to reversing the effects of long term opiate use is Moderate to Intense Physical Exercise.  It is a well known fact that vigorous exercise causes a sharp increase in the "feel good" hormones.  This includes those that were listed as being depleted by opiates - dopamine, endorphins, and enkephalins.  No matter how crappy you feel following detox from opiates, exercise is a major component for an absolute cure!  

All in all and with what is known, opiates will eventually hinder athletic performance, the ability to develop muscle, improve muscle strength, train fast twitch or slow twitch muscles, produce necessary hormones, and maintain training motivation and focus.  I am not a sport psychiatrist but I think that a study or several performed by an appropriate institution would give great insight on this topic. 

As usual, I can be reached at:

Happy Locomoting!

Brad Senska, PT, DPT, BS, ASTYM.