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Posted: Sun Mar 23, 2008 11:18 pm Post subject: Why not just take narcotics for my chronic pain?
I received this letter today. I don't know if was asking my opinion or challenging me to a debate. In either case it is worth publishing, because the issues are important. There are no straight right or wrong answers for some of the questions. The writer's questions are in italics; my responses are not.
Why is it wrong to take pain medications for pain? Especially if you have INTRACTABLE CHRONIC PAIN, what is there because detox.
Medications for pain are not ‘evil’—the only way I approach the issue is from a quality of life position. There are many problems with pain meds as they are now. At some point I expect we will find a way to avoid tolerance to opiates—that will truly revolutionize pain treatment. But as things are now, tolerance is the basis for the problems with chronic use of narcotics for pain. Any person taking narcotics, either for pain or for ‘fun’ (although there is nothing fun about opiate dependence after the first few weeks), will become tolerant to the effects. The medication will become less and less effective, requiring increases in dose to get the same pain relief. The dose cannot be increased forever—eventually the patient would be chewing on pills every minute of the day—and so the doc must limit the pills. If I give enough medication to satisfy a person who is 40 yrs old, what will I do when the person is 42 years old? Tolerance develops very quickly—this leads to tension between doctor and patient, and eventually the patient takes too many and asks for early refills. This annoys, angers, or frightens the doc, who therefore eventually stops the narcotics or quits seeing the patient. The patient, meanwhile, thinks he is being deprived, and gets mad at the doc, mad at all docs, and mad at the world. Finally, pain meds get inside the head of everyone who takes them, whether they are being taken legitimately or not. The patient becomes more and more focused on the meds, getting the meds, the pain, and the withdrawal. Relationships suffer. Depression develops. The patient eventually becomes a one-dimensional shadow of who they once were, where the biggest relationship in the patient’s life is the relationship with the pain pills. I have seen this all happen many, many times, with every patient who takes narcotics. I do treat with opiates, but I do tell the patient all of this, so they understand what they are taking on. This is why opiates are always the last resort. Any good pain doc will tell you that they have seen patients who complain of terrible back pain, who ask for narcotics repeatedly and think they need them… who get detoxed for some reason and after getting past the withdrawal are surprised to find that the pain is gone, or very small. I have seen it many times, and I cannot explain it, other than the body trying to trick the person into thinking he needs pain pills as part of an addictive process.
For cancer pain, by the way, none of this is relevant—with a limited life span the doc should just give what is needed to control pain. But for non-malignant chronic pain, I have never seen opiates improve a person’s quality of life in the long term. And I have seen many lives destroyed. The patient may not see it—he may insist things are great on the pain pills, even as his marriage falls apart and his kids disappear.
Why would you want to withdraw, if the pain was being controlled and it lowered your blood pressure?
We have plenty of ways to lower blood pressure—narcotics should never be used for that purpose, except in the case of acute myocardial infarction, when morphine has a number of helpful effects including lowering blood pressure.
What if the patient was limited, and could not do alot of physical therapy to get the benefits of endorphins to work for them.
Patients can do much more than they think with physical therapy. They need to be taught patience, and they need to work at it every day at home—not only at the therapy center. Physical therapy is so valuable—but patients generally look for short term solutions. That is unfortunate. As far as endorphins go, I caution people against getting wrapped up in thinking about what their brain chemicals are doing. It is much more complicated than magazines suggest-- endorphins, for example, do many things besides pain control—including things that have nothing to do with pain. Yes, they have been shown to be released by exercise, but… so what? We don’t know if that release actually does anything helpful for people.
Like you said, there is a difference between dependency and addiction. My family members suffer from chronic pain due to chronic pain conditions, that we were either born with or developed.
There is a difference early on, but over time the differences go away. A person who I see for a congenital pain condition who takes loads of narcotics has very few differences with a person who started pain pills ‘for fun’ and who takes tons of narcotics. If anything, the addiction is worse in the pain patient, because they are convinced they need the pills, and cannot see the destruction they are causing. A person who starts ‘recreationally’ is more likely to truly hate the pills, and is often willing to go to greater lengths to get off of them. That person hates the pills, where the pain patient thinks he loves them.
So, intervention should come, if I am just lying around getting HIGH in a chair, like the rubbish I have been reading.
I don’t know what you mean by this sentence. If you are referring to addicts as ‘rubbish’, you are off base. Yes, some addicts have bad characters, just as some non-addicts have bad characters. It sounds like you see a difference between ‘good people’ on pain pills and ‘bad people’ on pain pills. That difference does not exist. Over time, any person on pain pills becomes a slave to them, and desperately wants to be free from them. For some people, it takes longer to seek freedom; some people never seek it. I can assure you, though, that opiate addicts are not sitting around enjoying themselves—not after they have been doing it for a few months. They are scrambling for money to get something to avoid being sick—stealing, prostituting, whatever.
OR should it be, I take the pain meds, and I can walk around in the house, function a little better than suffering in pain.
That is your decision. But it is more complicated than you would like to believe.
Posted: Mon Mar 24, 2008 6:09 pm Post subject: Goading?
Sounds like it to me, and I think its the opposite though this is only my experience, I was placed on methadone for pain management, and it was the worst experience of my life. As I tried to do a slow taper, as it did nothing for my pain, I kept myself in withdrawal for so long it caused real permanent damage to my body. When I finally realized I was merely taking it to find moments of normalcy in the day that never came, I got on suboxone and was relieved immediately, now I'm healthy, though I have to remain on hydrocortisone for life,as I went into adrenal failure. Two weeks ago I returned to my neurologist, that saw me 4 years ago, when I first started methadone, I told him it wasn't helping. He said nothing because I couldn't afford the EMD he said he had to perform to assess for real pain. On my return I told him my nightmare on methadone and only wanted to see if he could do the test now and see if I could get more restoration in my arm. I did PT on my own and regained some use back. He did the EMD and said the damage is permanent and it is what it is. Then he offered me pain pills. I said no thank you. So I disagree with the person that says if you use them recreationally you end up hating pain pills. I found the exact opposite to be true. I would never go through that again. I worked in hospice and agree completely, when terminally ill you do what it takes to get them comfortable. Sounds like someone's mind was effected by their drug use. _________________ Just trying to get my story out there
Posted: Sat Apr 05, 2008 8:23 am Post subject: Apology
It's been a while since I posted, when I looked at my answer under opiates and chronic pain, I thought to myself, that's a little harsh, as I am not in that person's shoes, and my last sentence was inappropriate. I just think both patients and doctors should be more informed when making medical decisions. I have recently read where people are taking methadone for headaches and toothaches. I admit, I posted this in another forum. Why would a Dr. put someone on a very addictive narcotic, that you can't hardly take anything else, without risking your life? Especially for acute pain. Believe it or not I believe in pain management. I know the benefits of not living in chronic pain. This is by no means a bash on the medical community. I know this is a suboxone forum, so from here on out I'll leave the methadone part out. If you've read my posts, you know my feelings on suboxone, and I think it is a great tool for recovery. I am still new to total recovery and am entering my 4th month. I am still learning everyday. Thanks _________________ Just trying to get my story out there
Posted: Sat Apr 05, 2008 8:25 am Post subject: Apology
It's been a while since I posted, when I looked at my answer under opiates and chronic pain, I thought to myself, that's a little harsh, as I am not in that person's shoes, and my last sentence was inappropriate. I just think both patients and doctors should be more informed when making medical decisions. I have recently read where people are taking methadone for headaches and toothaches. I admit, I posted this in another forum. Why would a Dr. put someone on a very addictive narcotic, that you can't hardly take anything else, without risking your life? Especially for acute pain. Believe it or not I believe in pain management. I know the benefits of not living in chronic pain. This is by no means a bash on the medical community. I know this is a suboxone forum, so from here on out I'll leave the methadone part out. If you've read my posts, you know my feelings on suboxone, and I think it is a great tool for recovery. I am still new to total recovery and am entering my 4th month. I am still learning everyday. Thanks _________________ Just trying to get my story out there
Posted: Fri Dec 12, 2008 6:59 pm Post subject: Re: Why not just take narcotics for my chronic pain?
suboxdoc wrote:
I received this letter today. I don't know if was asking my opinion or challenging me to a debate. In either case it is worth publishing, because the issues are important. There are no straight right or wrong answers for some of the questions. The writer's questions are in italics; my responses are not.
Why is it wrong to take pain medications for pain? Especially if you have INTRACTABLE CHRONIC PAIN, what is there because detox.
Medications for pain are not ‘evil’—the only way I approach the issue is from a quality of life position. There are many problems with pain meds as they are now. At some point I expect we will find a way to avoid tolerance to opiates—that will truly revolutionize pain treatment. But as things are now, tolerance is the basis for the problems with chronic use of narcotics for pain. Any person taking narcotics, either for pain or for ‘fun’ (although there is nothing fun about opiate dependence after the first few weeks), will become tolerant to the effects. The medication will become less and less effective, requiring increases in dose to get the same pain relief. The dose cannot be increased forever—eventually the patient would be chewing on pills every minute of the day—and so the doc must limit the pills. If I give enough medication to satisfy a person who is 40 yrs old, what will I do when the person is 42 years old? Tolerance develops very quickly—this leads to tension between doctor and patient, and eventually the patient takes too many and asks for early refills. This annoys, angers, or frightens the doc, who therefore eventually stops the narcotics or quits seeing the patient. The patient, meanwhile, thinks he is being deprived, and gets mad at the doc, mad at all docs, and mad at the world. Finally, pain meds get inside the head of everyone who takes them, whether they are being taken legitimately or not. The patient becomes more and more focused on the meds, getting the meds, the pain, and the withdrawal. Relationships suffer. Depression develops. The patient eventually becomes a one-dimensional shadow of who they once were, where the biggest relationship in the patient’s life is the relationship with the pain pills. I have seen this all happen many, many times, with every patient who takes narcotics. I do treat with opiates, but I do tell the patient all of this, so they understand what they are taking on. This is why opiates are always the last resort. Any good pain doc will tell you that they have seen patients who complain of terrible back pain, who ask for narcotics repeatedly and think they need them… who get detoxed for some reason and after getting past the withdrawal are surprised to find that the pain is gone, or very small. I have seen it many times, and I cannot explain it, other than the body trying to trick the person into thinking he needs pain pills as part of an addictive process.
For cancer pain, by the way, none of this is relevant—with a limited life span the doc should just give what is needed to control pain. But for non-malignant chronic pain, I have never seen opiates improve a person’s quality of life in the long term. And I have seen many lives destroyed. The patient may not see it—he may insist things are great on the pain pills, even as his marriage falls apart and his kids disappear.
Dr. Junig, thank you so much for posting this. This is exactly what happened to me, and it's refreshing to see a doctor acknowledge that long-term opiate use (other than for cancer pain) is always a bad idea and that this happens to non-addicts like me who end up needing Suboxone to safely ween them off. I just wish that I could have read something like this before this all started or that my doctors could have as well and/or been more vigilant in finding the source of the pain instead of just doping it up.
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