Holly…I fully appreciate your knowledge on this subject. I also agree that even my situation might have called for a little better pain management. But do you have any experience with chronic pain as stated in the OP? As I’ve stated before, I’m no health care professional, but I’ve seen more then just one or two people strung out on pain meds. All of them from some type of back pain. What do you know of this? Aren’t there some alternative treatments or therapies? I’ve seen people stay on this stuff for years with their situation never improving.
Sorry, Needs2know, I was off on a three-day weekend.
You raised some interesting questions.
Absolutely not! Opiates produce cross-tolerance. Someone who is addicted to heroin, for example, will need a proportionately higher narcotic dose than a non-user for pain relief. This is probably the reason the people in that study were undermedicated. We ask people about drug habits on admission to the hospital so we can specifically plan for this.
Sorry, doesn’t make sense to me. Pediatric opiate doses admittedly are tricky. As far as ‘problems inherent,’ frequent monitoring is what’s called for. One of the possible side effects is respiratory depression. There is a drug called Narcan which is an opiate antagonist - when administered IV it virtually immediately eliminates the effect of the narcotic. That study reinforced what Holly was saying about recovery, pneumonia, etc. It said that “recent studies show that careful pain treatment of infants reduces surgical stress and postoperative deaths.”
I have witnessed abuse of pain medication, but not that much. I have seen instances where people are getting prescription narcotics from numerous doctors, and were found out. But it really is a lot of work for someone to keep getting their fixes from doctors/hospitals. If you keep showing up at ERs all over town, people notice.
There are numerous conditions that cause chronic pain - back problems, arthritis, fibromyalgia, endomietriosis, vaarious neuralgias, post-injury syndromes, etc etc. There are new and improved non-narcotic anti-inflammatory pain medicines coming out all the time. The truth is that most of these people do not prefer to live out their lives in a narcotic-induced haze. (Granted there ARE a few people who would rather just take Percocet and stay in bed.) With chronic pain I think it’s a quality of life issue. There are physicians and institutes that deal with helping these people through exercise, physical therapy, ADL modifications, etc. Sometimes surgery, steroids, nerve blocks, or antidepressants are indicated.
I agree wholeheartedly with Dr. J when he says
As for pain tolerance - absolutely, it’s extremely variable from person to person. I think it’s a combination of pysical and psychological makeup and is also situational. If I’m hungry, tired and unhappy I hurt more than if I’m fed, rested and happy. This might piss people off but in my experience (and that of most nurses I know) women have a higher tolerance for pain than men. I think that’s partly for cultural reasons.
To use your example of back pain and irresponsible drug use and go back to the OP - I would hope people don’t take the easy way out, and are willing to work at a solution. Exercise and therapy help a lot of these people. If they’ve been working with health care providers, nothing seems to help, and they’re in considerable pain, I say it’s their call if they want an occasional Tylenol #3 or 2. However, as far as continuous narcotic use, with tolerance, dependence, ever-higher doses and the physical consequences…well, I just don’t think that should be an option. Not one their doctor should provide them with, anyway.
Are there really any good solutions for people with severe chronic pain? My mother-in-law has a hereditary form of rickets, which in practical terms means she has disproportionatly small legs (and especially knees) and has had degenerative arthritis which set in probably at birth. She is a nurse, and until recently worked 12-hr shifts on her feet. One knee was much worse than the other, and she had that replaced, which has since been 100% better. Until that point, however, she was in serious, serious pain and the only thing that seemed to work was Percoset. However, her tolerance was increasing and the pills were becoming less effective, which is why she had to have the knee replaced, even though at 48 she is young to have that done–the replacement knees evidently only last about 20 years, and she hopes to live longer than that. She made the doctors keep the knee so that she could see it afterwards and she said it was just horrible looking–it had degenerated almost completly.
Up until the replacement she was in almost unbelievable pain. Several people have mentioned that better, non-opaite treatments for these things come out “every day”, but is there really anything else out there that can keep people with that level of chronic pain functional? I have to say that if the pills remained effective I don’t see anything inherently wrong with the pill addiction–what worried my mother=in-law was that the pills would cease to work ans the addiction would still be there.
Thanks Sulla…My 30 year old sister recently discovered that she has a cracked vertebra. She has been in pain off and on for a year now. She is currently using an anti-inflamatory. My sister was very physically active and had to discontinue her martial arts classes. She was about a month away from being tested for her black belt in Tae Kwon Do. We’ve talked about her condition on several occasions. The original knowledge that she would have this condition for the rest of her life was daunting, no doubt. But we’ve talked about allowing things like this to give us a reason for giving up. So while she has opted not to have an operation at this time, she has remained active by changing her physical activity to swimming, and walking. She has also enrolled in physical therapy. She knows that while she may have to deal with some pain now at 30 without adopting some kind of lifestyle approach to this condition her chances of enjoying the same relatively pain free lifestyle at 40 are very slim without it.
I hate to agree with you but yes, I do think women are a little more pain tolerant than men. I would think that we perhaps evolved that way. But then that’s another debate huh? I must also admit that because I do seem to have a high tolerance for pain perhaps I am not always as sympathetic as I could be to those who don’t.
My area of specialty lies more with acute pain, but I do have experience with patients with chronic pain, too. The problem is, doctors (and nurses) don’t usually get a whole lot of education in pain control. Sure, they know the various medications available, but they’re not specifically educated in pain control.
Maybe because the population is aging and chronic conditions are becoming more commonplace, this is changing (see Doctor J’s post). Some doctors are very, very good at treating pain. Some specialize in it. Rather than throwing pills at the problem and dismissing pain as unimportant, more doctors are learning about new methods. Exercise, physical therapy, diet, non-narcotic drugs and nerve blocks like sulla mentioned, etc.; there are many options and combinations of options. What works for one person doesn’t necessarily help the next.
Pain is supposed to be a signal to you that something’s wrong. In Manda Jo’s mother-in-law’s case, the pain was indicating that her knees were disintegrating. She was fortunate, in a way, because knees can be replaced relatively easily, with good results. It’s more complicated if the source of the pain cannot be removed.
I would encourage anyone who has chronic pain to consult a pain specialist, the same way you’d consult a cardiologist if you had a heart problem or an oncologist if you had cancer.
Thanks…I’ve enjoyed this thread. I myself had a relatively severe orthopedic injury two years ago. I was advised that this injury would likely lead to arthritis later. My surgeon was very good and admitted that the job he did in repairing the injury would have a direct effect on my developing this problem later. Looks like he did an excellent job. But I have also realized that in order to prevent problems later in life I must do my part. One of the things I am constantly at war with is my weight. I realize that if I allow my weight to creep up and do not keep my muscles strong, I may not be getting around as well in the next 10 years. So I try to be vigilant.
I do think some people believe that they can do just about anything they please, abuse their bodies, ignore warning signs and then modern medical science will somehow fix them. Perhaps those days are part of the past with the emphasis of preventative medicine so much in the spotlight. Perhaps what people don’t know is that even after injury there is hope with the right kind of care and determination on the part of the patient to still have a good quality life.
Thanks again especially to Sulla and Holly who are obviously caring and compassionate as well as knowledgable in their fields.
The rate of addiction among chronic pain patients is a fraction of one percent. When addiction does happen, it can be easily managed in a medical environment by just regulating the dose.
The effects of depriving them of their medication is usually far worse than the effects of addiction.
These medicines allow pain patients to live a normal productive life and the Department of Health and Human Services has issued two reports saying the undertreatment of pain in the US is a “national tragedy”. They found that two-thirds of all terminal cancer patients did not get adequate pain medication – for reasons connected with the war on drugs.
No, this really doesn’t have much to do with the problem of undertreatment of pain. Pain is undertreated because the Federal Government has had a dedicated plan for decades to discourage doctors from using opiates, even legitimately. You can read all about it under “Jailing the Healers and the Sick” under http://www.druglibrary.org/schaffer - Historical Research.
There are relatively few of those. The far greater problem is underprescribing, as the Department of Health and Human Services has repeatedly said.
The Department of HHS says that opiates are the best way to manage chronic pain and that patients should be given opiates in the amount they want, as soon as they report that lesser pain killers no longer work. You can find a ton of scientific data on the subject under http://www.druglibrary.org/schaffer – under American Society for Action on Pain.
The rate of addiction in medical use is a small fraction of one percent (four people out of 12,000 in one Johns Hopkins survey). When it does happen, it is generally easily managed in a medical environment.
That happens, although it is fairly well understandable when these people live with severe pain 24 hours a day.
The laws against the opiates were a major mistake from the very beginning.
It is true for about 99.7 percent of all such patients.
No, the reason they are hesitant is because the doctors were systematically bludgeoned into accepting the rules laid down by the Federal Bureau of Narcotics, even though the FBN was acting in direct opposition to a 9-0 Supreme Court ruling (Linder v. US, 1925) which stated specifically that the FBN had no right to interfere in the prescription of narcotics, even if that prescription was solely for the purpose of maintaining an addict on their drug of choice.
See “Jailing the Healers and the Sick”, referenced above.
European doctors consider the US to be a “third-world country” when it comes to treatment of pain. That’s because there is such a huge problem with undertreatment of pain in the US. That problem arises out of one major cause – the campaign by the Federal Bureau of Narcotics to stamp out heroin maintenance programs during the 1920s.
In doing so, the FBN acted in direct violation of a 9-0 Supreme Court ruling that the FBN had no right to interfere in the legitimate prescription of narcotics, even if the prescription was for the sole purpose of maintaining a drug addict on his drug of choice.
When they lost the ruling, the FBN went out and indicted thousands of doctors for prescribing opiates but never brought any of them to trial. They knew that, if they came to trial, they would lose, but that just the indictments alone would force doctors to come into line with their rules. Ever since, we have had medical policy made by narcotics agents who know nothing of the problems of pain patients, and care even less. They make their promotions by busting doctors, and that’s what they do, whether it is legitimate or not. It is only in the last few years that the Federal narcotics authorities have come under heat for their actions.
Anyone who wants to really understand how we got to this point with our drug laws should read the best book ever written on the subject – the Consumers Union Report on Licit and Illicit Drugs. You can find it at http://www.druglibrary.org/schaffer/Library/studies/cu/cumenu.htm
The first twenty chapters tell the story of heroin and the opiates and how we got these laws. The opiates were first outlawed in 1914 with the Harrison Narcotics Act and it was a disaster from the very beginning, not only for pain patients, but for addicts and law enforcment as well. It is a fascinating story, and not at all what you probably expected.
When opiates/opioids are used they do a fantastic job at killing pain. The drugs in question mimic natural painkillers in the body. After prolonged use, the body comes to the realization that it doesn’t need to produce its own painkillers. So your body is now depending on recieving its painkillers from an external source. Once the painkillers wear of withdrawal starts. This is a powerful addiction both physical and mental. Having been though it myself–I can say it really sucks big time. Another danger is as you become addicted your tolerence builds and you need start taking ever increasing amounts of the stuff to get “the effect.” The margin of the amount of opiate to ellicit an effect as compared to the amount that causes death is pretty small. It can get real ugly, but when opiates are used for short periods of time, to treat pain, there is not typically a problem.
To reply to someone (I forget who), there IS an addictive personality (assuming you mean one who oftentimes self-medicates in order to reduce psychological distress), but it is called Borderline Personality Disorder.
That aside, Opioids in general are HIGHLY addictive even for “stable” people as someone mentioned.
Having “chronic pain” is obviously a lamentable disorder, and I tend to believe in cases of terminal illness, a possible opioid addiction is the least of a person’s concerns. For one without terminal illness, there are a number of ethical, legal, and practical constraints on Doctors for prescribing opioids.
To add some fire to the pot, there is also two psychological conditions that are of concern to doctors. One is “Pain Disorder” in which pain symptoms are experienced by a patient, but no physical cause for the pain exists. Also there is “Factitious Disorder” in which a person pretents to have symptoms in order to be prescribed medications. Pain disorder is not always easy to tell from legitimate chronic pain (unless the cause is obvious). And many times what begins as a legitimate healing response (i.e. pain) might degenerate into pain disorder.
Doctors are under ethical obligation to “do no harm” and I think in most cases inducing an opioid addiction would be construed as “doing harm”
For people with severe chronic pain, they are dependent on receiving additional painkillers from an external source, anyway. That’s why they have chronic pain.
That is a problem in less than one percent of people with chronic pain and when it occurs it is easily managed in a medical environment.
Chronic pain patients report that the withdrawal symptoms are often nothing in comparison with the pain they feel from their original problem.
Only partly true. Addicts who are given the choice of taking unlimited amounts will stabilize their use at set levels, and won’t want more.
No, that’s not true. See “The Heroin Overdose Mystery” in the Consumers Union Reports on Licit and Illicit Drugs at http://www.druglibrary.org/schaffer/Library/studies/cu/cumenu.htm The result of that research was that they were unable to find any instance of an “opiate overdose” that was really an overdose. See also the comments of the doctors in Liverpool who prescribe heroin routinely to patients, at http://www.druglibrary.org/schaffer/misc/60minliv.htm As one says, “Pure heroin is not a dangerous drug.”
Even when they are used for long periods of time, there are typically no problems. I suggest you read the first twenty chapters of the Consumers Union Report, above, for a better understanding of the problems with opiates.
As I said in my first post–to one degree or another, patients who are given opioid drugs WILL become physically dependent, in that they will experience symptoms of withdrawal. (This is the definition of physical dependence.) It is predictable, and it is treatable.
Cliff is trying to argue that these constraints are often unneccessary. (I agree.)
Also known as “psychogenic pain”. It is often difficult to identify a specific cause of pain, and even when you can, it is impossible to objectively define the severity of the pain. You have to trust the patient.
Not quite. Factitious disorder is the exaggeration or faking of symptoms without seeking an external gain. These are people who like being in the role of patient, and enjoy having diagnostic tests or unnecessary surgical procedures done. When it is very severe and disruptive, it is known as Munchausen’s Syndrome.
Those who fake symptoms for external gain–drugs, insurance money, to get off work–are “malingering”.
It would be doing harm to do so and not then treat the dependence when the pain meds are no longer necessary. It would also be doing harm to allow someone to unnecessarily stay in serious pain.
First regarding Factitious Disorder, you were correct of course, my error regarding their motivation. Of course it is still a diagnosis to be concerned with. One would still not to hand out opioids to them like candy.
As far as the other points I would tend to disagree:
As far as Pain Disorder…while I certainly agree one shouldn’t call the patient a bald-faced liar, neither should one simply naively TRUST (not exactly the best choice of wording, but I hope you know what I mean) the patient either…if a pain disorder is suspected. The whole point of being a doctor/shrink is to be able to point the patient toward appropriate treatment. In the case of pain disorder that treatment is therapy, not opioids. Then they would be getting two diagnoses instead of just one.
I can KINDA agree with you when you say let them get dependent, then treat the dependence. You scored a point or two with me…but I still have an icky feeling. Lemme sorta sound out what I am thinking…don’t promise it is gonna be coherent. Seems to me we are assuming that the “opioid addiction” in these cases is gonna be all peaches and cream…all pain relief and no bad stuff. But a person with chronic pain can still be a contributing member of society…I am not sure someone with an opioid addiction could be. I suppose if you qualified your argument by suggesting that there was an opioid dependence with no negative side effects to the patient or society at large, I would agree with your premise, however I find that to be a dubious assertion.
To make an semi-analogy…I would support specific incidents of individuals taking THC to relieve nausea due to chemotherapy, etc…but I wouldn’t give it to everyone with nausea if there were other treatments available. I dunno, my thoughts are wandering, I appologize.
Oh and let me point out that for treatment of opioid dependence in street populations, the recidivism rates is REALLY bad. Of course in that population, the dependence is hopelessly confounded with other AXIS I disorder, as well as personality disorders, but still it is something to be aware of.
I disagree. Someone in chronic pain is not going to be a terribly productive member of society, either.
The bottom line is that you’re going to err one way or the other. It’s really not that tough to spot most malingerers and factitious disorders–most patients are not terribly good actors. The problem with psychogenic pain is that it’s pain nonetheless–if you really, honestly believe that you hurt, you hurt. That’s a harder call to make. No doctor is going to be able to perfectly separate those patients who honestly need strong opioids from those who don’t, so you can either have a few patients on them who don’t need them, or a few patients in severe pain who aren’t getting the drugs they need. Too many doctors err on the latter side.
Street drugs are a totally different animal. As you said, the Axis I’s are all over the place. Heroin and other street opioids are usually given IV, which leads to a much stronger psychologic dependence because of the nearly immediate onset and the dramatic act of putting a needle in your vein. (This is much of the rationale behind methadone treatment–if you can break the psychological addiction, it’s easier to break the physiologic one.) Also consider that the conditions that made them take the drugs in the first place are still there after they get clean.
I, too, apologize if I am unclear. It’s late, and I’ve had most of a six-pack of my drug of choice.
I should point out, since the definitions were never very clear to me: psychological dependence means that you keep taking a drug because you like the good effects. Physical or physiologic dependence means that you keep taking a drug because you don’t like the bad effects that you get when you don’t take it.
As far as I know, no one does hand them out like candy. Quite the opposite, in fact. But, if you had read any of the history of this subject, you would know that, at one time, opiates were available over the counter with no age restrictions, so children could buy them as freely as they bought candy. In fact, heroin was even included in some baby colic remedies. Even under those extreme conditions, we didn’t have the problems with those drugs that we do now.
According to the Department of Health and Human Services, the problem is massive undertreatment of pain, not misdiagnosis of those who are faking it.
That’s no reason to deprive legitimate pain patients of medicine, which is the far more common occurrence.
Why don’t you try actually reading something on the subject so you aren’t wandering around with so much misinformation. See the first twenty chapters of the Consumers Union Report on Licit and Illicit Drugs at http://www.druglibrary.org/schaffer/Library/studies/cu/cumenu.htm If you had read it, you wouldn’t be saying many of the things you are saying here.
Don’t worry. I didn’t expect it to be coherent. I have read your stuff before.
Who, besides you, ever said such a silly thing?
Not without medication, they can’t. In case you are interested, you are talking to one of the founders of the American Society for Action on Pain – a nationwide group of several thousand pain patients – so I am somewhat familiar with the subject.
Then you obviously haven’t read much on the subject. Heroin maintenance clinics are active in Switzerland right now and the majority of the addicts have become productive citizens. I guess you also weren’t aware that the “father of modern surgery” was an opiate addict during a period of forty years when he invented most of the basic techniques of modern surgery. You can read all about it in the Cu Report, above, in the chapter titled “Some Eminent Narcotics Addicts”. Of course, if you had read it, you would also know that, prior to the time these drugs were outlawed, most addicts were productive members of society.
Do some reading before you post again, OK?
I don’t know of anyone (besides you) who has suggested that it should be given to everyone with nausea. Different people with different conditions require different drugs.
Try doing some reading on the subject before you wander again. It will help you understand the issues and get your facts straight. See the Consumers Union Report, above, for starters.
That’s not news. Addiction is a chronic, relapsing disorder no matter what drug is used. If you had read the information about the heroin maintenance clinics in Europe, you would have found that the objective of those clinics is to keep the addicts alive and relatively healthy until they can mature out of their addiction.
CliffSchaffer, I suggest you read some other material. Reading some silly online book (like that stupid Consumers Union Report) does not make you an expert. In quoting everything I said I see you made no real good points. I’ll come back some other time and prove my points…gotta get to bed…
