Ya know…some people do suffer from chronic pain. Not due to any pills. They just live in pain.
I question this. A simple alternative is to just buy the drug from another pharmacy and methadone is a moderately cheap generic.
Here’s my thought, because I am still on the fence with this issue. You agree that the opioid addict has real physical pain when he withdraws from opioids, yes? You would agree that the doctor could perform x-rays, scans, etc. and not be able to discern a physical cause for the pain, agreed?
If so, then is it not possible that a person could otherwise be in chronic pain, undetectable by medical equipment? Or is opioid withdrawal the only type of undetectable pain?
Small aside, and I hope it isn’t too much of a hijack. How does alcohol and opiate abuse harm your hip joints? A weight issue?
No, it’s not the only type. Another common cause for pain with no apparent physical root is depression.
I think that having people whose pain has no apparent organic cause attempt addiction treatment and go on anti-depressants and at least see if that works before committing to an open-ended opiate prescription would be a good idea and a compassionate, practical way to address the rise in opiate addiction.
I’d also ask the people who don’t think that chronic pain is often rooted in the brain trying to get the person to use more opiates where they think addiction comes from. Is it your impression that people choose to ruin their lives with powerful drugs for no reason, as opposed to because the effects of the drug initially do something for them such as address pain? Do you agree that there is an “opioid crisis?” Who do you think are the people involved in this crisis, if everyone who has “chronic pain” is in fact someone who “needs” to be on opiates indefinitely and “isn’t the problem?”
Okay, I should have qualified my statement. Say someone seriously injures his back at work. Has surgery. The surgery is successful. Is it your contention that once the injured part of the back looks normal under a scan, then it is not possible for that person to be in physical pain any longer due to the back injury? IOW, does the scan speak for itself and is conclusive?
Again, not a gotcha. I’m straddling this fence. If that is your contention, could the doctors in this thread please reply?
I’m not sure what kind of answer you’re looking for. I’m not a doctor, but many people who are doctors will observe the same thing that everyone else has in reflecting on how drug addiction has affected people they know and society at large, which is:
*There are several million people who are opiate addicts in this country, if we define addict as “someone who is having severe life problems more attributable to the drug use and drug-seeking than to whatever problem the drug is allegedly treating” and just set it at a range of “several million” rather than trying to arbitrate every edge case
*The existence of some number of people who actually have “a problem with their back that no one in the medical profession can properly diagnose, doesn’t show up on any method used to detect organic problems, and persists after multiple surgeries” doesn’t change the above, and it seems impossible that the number of such people is even 1% of the number of people whose problem is addiction
*The number of people in that category who have attempted to avoid opioids long enough to get past physical withdrawal symptoms and still have “back pain” is surely much smaller still
*There’s no explanation for who the addicts involved in “the opioid crisis” are if we are to put everyone who claims to have idiopathic chronic pain in the “can’t be an addict because they need it” category, and seemingly no follow-up from the people advocating that position on whether they think there is a “crisis” or what should be done about it
*Social problems arise because everyone has their own individual excuse for why their or their friends and relatives’ behavior is OK, and on a scale of millions these excuses matter less than the behavior. “Those people over there are addicts, but I have idiopathic chronic pain” is one of the most striking instances of this fact.
*None of the above constitutes denial of the disease model of addiction or the need to treat it compassionately.
I don’t doubt any of that. None at all. I agree with it. It is a terrible crisis.
But I was trying to drill this one point down. You are not a doctor, I understand, but you seem to be saying (which is why I asked) that physical pain can be detected by physical means (after we’ve ruled out psychosomatic causes) and therefore if the alleged pain cannot be shown by instruments, then the person is either lying or it has a psychosomatic cause and opioids are not appropriate.
If this is what you are saying (which is why I asked), it seems a bold statement not being a doctor, and I would like to hear what the doctors on the board have to say about this contention. I honestly don’t know which is…you guessed it…why I asked. 
Probably not, but I an not a real doctor and YMMV. Common is Vicodin, aka Hydrocodone/acetaminophen, and in there, the acetaminophen actually does most of the pain relief. Vicodin is not very useful for LONG TERM pain relief. Most Long term Vicodin users are simply addicted.
But if you do have a terminal condition, why not?
I’m not sure why you feel it’s important to declare this person is not addicted. My guess is that they are addicted to the (highly addictive) drug they take regularly.
I’m addicted to caffeine. I don’t experience cravings, but i get horrible headaches and find it hard to get anything done if i skip my daily dose.
So i take caffeine every day. I am a high functioning person, and my daily pot of tea is not a health risk, nor very expensive. So this is a perfectly okay solution for me.
But i don’t feel the need to deny that I’m addicted to caffeine.
I think one problem we have in treating the opioid epidemic is that we try to draw a sharp line between “good” people who “aren’t addicts” and “bad people” who are. I really think it would be more constructive to instead assume that most people are trying to live a decent life, and some have complications that interact with opiates. And those should be treated compassionately, whether the underlying cause is organic pain, addiction, or a combination of the two.
I’m in agreement with UltraVires; when it comes to pain, the alleviation of it is paramount. Let the patients get the morphine, big doses if need be. And it is totally ludicrous to withhold morphine in larger doses from someone who’s terminally ill for fear they may get addicted; that’s akin to the prisoner on death row who ate his last meal (full of greasy stuff and whatnot) and joked “Man I got to start eating healthy.”
Are we talking about people dying of cancer, or people who have no identifiable organic problem but insist they need painkillers anyway?
There really are a lot of accepted pain syndromes that have no detectable source or a very difficult to detect cause. For example, a small number of people who undergo laser eye surgery have a complication where nerves grow back improperly. It is undetectable under standard ophthalmology equipment. Years ago, it was considered a complete mystery. You can look it up if you want: post LASIK corneal neuralgia.
Something like that could possibly be happening with a back surgery and we’d never be able to get a microscope on it.
I kind of have a. . .thing. . .about painkillers now. In 2014, My Crohn’s went nuclear, but I didn’t have insurance. I had to wait until January for my insurance to kick in to have anything serious done - and I started having real problems in July. I suffered through with large doses of prednisone (which would come back to haunt me later), but In the fall, I developed an (undiagnosed) internal fistula that tried to tunnel its way through me, from back to front.
Pain and problems escalated. I just needed to get by until January. Well, my incompetent bastard of a GI prescribed me 30 hydrocodone. So, for about 4-5 hours a day, I felt good enough to take care of the house and my mother(who has dementia). The other 20 hours were just pain. I told him this on my next monthly visit, and he gave me 60 hydrocodone. So, for about 8-10 hours a day, the pain was manageable. When I went back for the last time before I went into the hospital, I told him how much the two pills a day were helping - so he gave me 30 hydrocodone again. Bastard. Towards the end, I was just fetal on the couch.
Now I live in fear of a repeat; another doctor that will just let me suffer rather than give me pain medication.
But how does the doctor distinguish between someone like that and an addict?What do you think you are describing here? This is exactly what “the opioid crisis” is - people with insurance and access to the legitimate medical system who live in nice suburban neighborhoods and think that “addicts” look like someone else. “Chronic pain” is a symptom of opioid addiction, not a disease to be treated with medication.
Are you joking? There are numerous conditions/injuries/diseases that cause chronic pain. Just because it’s used as an excuse to get drugs for an addiction does not invalidate the many people who genuinely suffer chronic pain.
Whatever the cause, there is still a distinct difference between someone like that and drug seeking behavior, which is what was being discussed. The question was how a doctor can tell the difference.
The reality is that doctors often can’t tell. There is no clear definition of ‘pain’, different people experience it differently, some are more sensitive, etc. This is why they developed the ‘pain range’ chart you see in ERs & why doctors ask you to rate your pain, because only the patient can really evaluate their pain.
Because we’re now treating those who are dependent as if they are addicted, you get into all of the bad ways we treat addicts. You get the callousness and refusal to try and help.
Worse, it’s made the doctor/patient relationship adversarial. Our area has a huge opioid problem. Ten years ago I was working in a group home for intellectually disabled people and escorted a client to the hospital because he kept making what seemed to be awful grimaces of pain (pain seems to be a universal expression). The client was nonverbal & unable to understand or respond to questions so I explained to the ER doctor why I thought he was in pain. I also explained why I believed the pain was likely caused by an infection & that it wouldn’t be obvious in the blood tests due to other conditions the client had. The ER doctor did a urine test & a simple blood test, declared the patient fine, refused to listen to my objections to that conclusion & discharged him. As a result, the client almost died – he did, in fact, have a severe infection, was in severe pain, etc. Only later did I realize that the ER doctor behaved as he did because he assumed I was using the client to score pain meds for myself, though I never once mentioned drugs. I wonder how many people have died as a result of this attitude.
Pain, it turns out, is a pretty complex phenomenon, one that docs and other experts don’t fully understand. So while it’s easy to dismiss chronic pain in particular as merely depression (which actually is the cause in some but not most cases) or the result of addiction, surely we can agree that the causes are likely myriad and that one or two blanket theories are almost certainly insufficient.
I offer my own pain experience as a case in point. I’ve had four corneal transplants. The docs were mystified as to why the pain from the third one actually worsened after a week and remained severe for months. There was no visible cause, yet the struggle to concentrate over the constant pain so I could care for my kids and teach classes was exhausting. I was pretty happy with my life otherwise, but for the first time I really understood why people in chronic pain could choose euthanasia. Simply put, I would not have been able to live for years with that level of pain. After six months, the pain suddenly and inexplicably started to diminish. Nothing else had changed in my life. Docs could offer no explanation.
I did not take antidepressants. I was not addicted.
Maybe it’s quixotic to think we can adequately treat pain when we don’t fully understand it.
In this case, this guy was homeless and had been living on the streets for a long time
Which means being on your feet all day and-more-importantly-not feeling what is going on inside your body because you anaesthesize it constantly. I’ve seen a lot of street addicts who, while in detox, developed all kinds of aches and pains, a lot because of withdrawal, some because of underlying conditions that became manifest once they were off drugs. These people can have a double pneumonia and not be in pain because they’re on methadone. Very tricky, because those same people will make up all kinds of conditions just to get you to write a prescription.
This is about definition. At least in the DSM5, addiction Does not only mean you use it regularly, but that you need more constantly to achieve the same effect, that there’s a loss of control when it comes to actual use (always ending up using more than you intended) and that a large part of life consists either of getting a fix, being under the influence or dealing with the after effect, so not being able to work/take care of loved one’s because you’re too wasted/hungover. I’m not sure how much this definition was influenced by the pharmaceutical industry, who have a stake in not having all their patients stigmatized. At the same time, we don’t call someone who’s dependent on insulin an addict, nor someone on antidepressants, even though abrupt discontinuation causes problems.
As for the chronic pain, there are many somatic diseases that cause pain. Cancer, artritis, Crohn, diabetes, to name a few. There’s a multitude of neurological afflictions that cause pain, like migraine, cluster headaches, multiple sclerosis, neuropathy, HMSN, you name it. Plus complications after surgery, as other posters have described. Depression is a psychiatric disease that sometimes manifest as pain, anxiety disorders can cause muscle tension imbalances that lead to pain.
Plus depression exacerbates any pre-existing pain by messing with experience(gate control theory)
I hope this makes clear that it’s a complicated, multi-layered issue with no quick fixes. What complicates the issue even more is that even when there’s a known cause, like artritis, you can have two people with comparable damage on eg an X-ray, who experience very different levels of pain. Pain is subjective, the amount of impairment experienced because of pain is even more subjective. Which means doctors don’t always have more information than patients give them about their experience. Of course, doctors will focus at first by excluding the most dangerous causes of pain (cancer, acute injuries that need to be addressed) After that, there’s a very large grey area with very few definitive answers. Which doesn’t mean the pain isn’t real, just that we cannot explain it. Like @nelliebly remarked, there’s a lot still unknown.
Even then they might not believe you. Back in 2006 I ended up at the ER with what turned out to be a peritonsilar abcess. They asked me to rate my pain and I said maybe 2. My then-stepmother was not in the room; she joined me later. She is a doctor. When I was discharged she volunteered to get the prescriptions filled while the other members of the family took me home. Because she did not hear me say my pain was a 2 and I never saw the prescriptions she filled them all. Including unnecessary heavy duty pain killers. I never took them and they sat until I could drop them off at one of those drug returns things.
Thanks. I see the definitions have all changed since my 6th grade “drug ed”. Wikipedia has a good breakdown, which seems consistent with what you say
Addiction and dependence glossary[3][4][5][2]
- addiction – a biopsychosocial disorder characterized by persistent use of drugs (including alcohol) despite substantial harm and adverse consequences
- addictive drug – psychoactive substances that with repeated use are associated with significantly higher rates of substance use disorders, due in large part to the drug’s effect on brain reward systems
- dependence – an adaptive state associated with a withdrawal syndrome upon cessation of repeated exposure to a stimulus (e.g., drug intake)
- drug sensitization or reverse tolerance – the escalating effect of a drug resulting from repeated administration at a given dose
- drug withdrawal – symptoms that occur upon cessation of repeated drug use
- physical dependence – dependence that involves persistent physical–somatic withdrawal symptoms (e.g., fatigue and delirium tremens)
- psychological dependence – dependence that involves emotional–motivational withdrawal symptoms (e.g., dysphoria and anhedonia)
- reinforcing stimuli – stimuli that increase the probability of repeating behaviors paired with them
- rewarding stimuli – stimuli that the brain interprets as intrinsically positive and desirable or as something to approach
- sensitization – an amplified response to a stimulus resulting from repeated exposure to it
- substance use disorder – a condition in which the use of substances leads to clinically and functionally significant impairment or distress
- tolerance – the diminishing effect of a drug resulting from repeated administration at a given dose
I guess i am “dependant” on caffeine, not “addicted” to it.
On the one hand, perhaps the pharmacy industry pushed to avoid stigmatising its customers. On the other, it does seem useful to distinguish between a condition that can reasonably be managed by “just keep taking that substance” as distinct from one that can’t be so simply managed, and is damaging your life. Although i wonder how many opiate “addicts” could, in fact, do fine with daily methadone.
In the Netherlands this has long been the treatment of choice in heroin addiction. It works a bit like a nicotine replacement patch, it keeps the withdrawal at bay but doesn’t give a rush. The latter is important because rush reinforces addiction. At the same time that also leads to combined use, because the rush is what people miss and crave. Craving is the psychological part of addiction, and usually the hardest to overcome. Heroin not only has craving, but physical withdrawal as well, that makes you really sick. So methadone is part of the solution.
Back in the early 00s we started treatment in the form of heroin provision instead, for a small group that kept relapsing, and that works well in the sense of harm reduction (less crime, less OD, less nuisance for the wider community).However, the moral objections especially from Christian politicians (linked to the gluttony association) remained in larger society. Luckily this is an evidence based treatment and recognized as such, so it’s still in use today in the Netherlands, but only if all else fails.
Apart from that, sometimes going for full abstinence is unwise because of underlying conditions, especially psychosis, which can really exacerbate due to abstinence, even when people receive antipsychotic medication.
Heroin use has been declining quite steadily in the Netherlands, with 14.000 addict in 2020. the average age of users is climbing, being >40 years of age for quite a while. Because of that, the mental health organization I work for has opened a living facility for elderly drug users a few years back, where they can use as long as they behave, and are provided with food and shelter.
As far as I know, Switzerland was the first country in Europe that started providing clean needles, condoms etc for addicts to reduce harm. With us that’s still the case as well. We used to have mobile methadon provisions (the so-called methadonbus) where street addict could get their methadone, condoms and such, and if they were able to behave (not pick fights, not abuse personnel, no dealing or hustling) they could come to the outpatient facility.
I’m not sure how many Dutch are addicted to prescription opiates, but the data I can find points to a marked increase in presciptions. However, opiate related hospital admissions and deaths remain comparatively low.