The results challenge common ER practice for treating short-term, severe pain and could prompt changes that would help prevent new patients from becoming addicted.
The study has limitations: It only looked at short-term pain relief in the emergency room and researchers didn’t evaluate how patients managed their pain after leaving the hospital.
But given the scope of the U.S. opioid epidemic — more than 2 million Americans are addicted to opioid painkillers or heroin — experts say any dent in the problem could be meaningful.*
I’d like to see some statistics that separate street-drug addicts on the one hand, versus prescription pain-killer drug addicts on the other hand.
We hear too many horror stories, even here on this board, of severe pain patients who can’t get their pain meds, largely driven by the currently-popular hysteria about drugs. But I want to know how serious the “epidemic” is for pain patients versus street-drug addicts, and I’m not getting a clear read on that from all the news stories I read.
Having recently suffered from three herniated cervical discs I can say, with great confidence, that OTC pain relievers do NOT work for my serious pain. Perhaps they do for other people, but popping a Motrin or Tylenol for debilitating pain is akin to taking a Tic Tac. Taking OTCs for a sprained ankle, achey joints, and so on is entirely workable.
Something I haven’t seen discussed much: Motrin is horrible on the stomach and intestines and Tylenol can damage the liver. Opioids that contain OTC meds, when used wisely, limit the dosage of these meds (and some opioids don’t contain either Motrin or Tylenol).
Part of the challenge is that a lot of the current street drug addicts got that way by being given prescriptions for unneeded meds.
Which, because they were overkill in either quantity or potency, provided a high in addition to pain relief. And when the initial supply ran out the person was hooked enough to want to continue with meds until such time as the doc/pharmacy cut them off at which point they turned to street drugs.
The other factor is that one hell of a lot of the supply of “street drugs” are in fact diverted prescription pharmaceuticals.
The whole center of the crisis reaction is how do we provide sufficient, but not excessive, pain relief to a population that’s prone to addiction with only a very slight over-prescription.
The current clamp-down on “pill mills” isn’t creating heroin addicts out of clean-livin’ ordinary folks; it’s creating heroin addicts out of what were, e.g., Percocet addicts. Regardless of whether the Percocet addicts were getting their Percocet from the pill mill directly or from some on-street intermediaries.
What would be interesting is to see a breakdown of
A. Started with street drugs and are still abusing them.
B. Started with prescription meds and are now abusing them through legit supply channels.
C. Started with prescription meds and are now abusing them through illegit supply channels.
D. Started with prescription meds and have switched to abusing street drugs.
If we can stop the “get hooked on prescription opioids” part, we can drive B, C, and D to much smaller numbers. That’s what’s behind all the FDA/DEA efforts of the last couple years.
I’m an opioid prescriber and a treater of pain, including acute (and its subset, postop/posttrauma), chronic, and malignant pain. I’ve also suffered all but malignant pain myself. And there are pains that will not be tamed by anything other than opioids and their ilk. My post-operative rotator cuff repair was one such item.
I’ve been opposed to the overuse of opioids for well over a decade, including when it was not fashionable to do so in the medical community. But I fear that the pendulum is swinging too far in the opposite direction now.
There’s something called sundowning that can happen with pain. I’m not actually sure what causes it. Maybe it has to do with getting tired, and that making everything worse, or maybe your ability to produce endorphins exhausts itself toward the end of your wake cycle.
But pain is easier to tolerate in the beginning of the day, and gets worse as the day goes on. This is something that is true with just about every person I’ve known with chronic pain. So a lot of these people are at the doctor for a routine exam early in the day when their pain is not as bad, and never in the evening when the pain is at its worst.
Also, IANAD, but I have had serious injuries, and I know that some of them don’t reach their maximum pain immediately. I don’t know whether it has to do with swelling, or with the release of endorphins immediately when you are hurt, or the traumatized area going numb (that happened to me when I broke my ankle-- it was numb for several hours). So I’m not surprised at all to know that OTC painkillers help in the hospital immediately when you are injured. That doesn’t address whether or not you will need something stronger the next day.
I think part of the problem is they give you too many at once for what will be a one time incident. I have a stock pile of hydrocodone because of this. I’ll give you my examples:
broke my leg. It was a very minor break with more serious soft tissue damange. Given 30. Used about 5.
Hernia surgery: Given 30. Used 25. This is the one time I really needed them. And, I was totally scared of addiction and kept very detailed notes of when and how much I was taking and made sure to “wean” myself.
2 wisdom teeth pulled. I think I was given 20. Used 1 or 2.
That puts me at about 50 or so unused. I even asked about getting a smaller amount for my teeth and it was something like “it’s a pain to refill so we give you enough”.
I have an upcoming dental procedure and I already know hydrocodone will be prescribed. I won’t fill that prescription but I’m guessing it will be 20-30 more available.
This is all within the last 5 years.
It seems it should be easier to prescribe a couple and then renew if there are problems for things like pulling teeth.
LSLGuy’s and QtM’s posts are together very much on point.
Few deny that opioids have a place in pain management. And few would deny that many physicians have been poor stewards in the prescribing of them and that poor stewardship has been a significant contributing factor to this major health crisis.
The kid who drinks too much and smokes too much pot may have tried an opioid for the first time because mom or dad was prescribed much more than was appropriate for post-op pain that may not even have needed any opioid in the first place and the extra was stored in the medicine chest. Most “nonmedical use” opioids were obtained from a family member who in general got the medicine from a single legit prescriber. Second most is abuse by those who were themselves prescribed the medicine by a single provider. Third is the bought some, such as from the other kid who harvested that overprescribed amount from their parents’ bathroom. And the person who got hooked after benefiting from some opioid medication but who was prescribed more than was needed and monitored inadequately, would not have gotten hooked if the prescriber was a better steward.
Poor stewardship seems to be according to local geographic and to demographic norms. It is much more common within Appalachia and in both the South and the West and prescriptions for opioids are more cavalierly handed out to Whites than to Blacks. Interestingly the latter at least is in parallel with poor antibiotic stewardship in which White patients are more frequently given antibiotics (inappropriately) too.
You make a good point. I had a root canal redone and they gave me hydrocodone , which I filled. Based on the fact that right now Acetaminophen is handling the pain, and when I can take it my 800 mg Ibuprfen pills will almost certainly handle the pain, but what if in the middle of the first night they don’t and I need those pills? So I fill it, take maybe one, and put the rest aside.
For me, that is the main benefit of hydrocodone- it allows one to sleep.
Why do you think those two groups are separate? I have no statistics, only anecdotes, but my anecdotes are that out of the dozens of heroin addicts I have known, only two started by using illegal drugs, and to make it two I have to count myself. The rest all started with a legal prescription.
My husband recently had artificial disc replacement surgery and has spent time since then tapering ever so carefully off of opioids. He is currently entirely off of them (for a couple weeks now) but is still dealing with the last of the withdrawal issues. On his most recent visit to his pain management doctor, in order to help with these withdrawal issues, the Dr wanted to prescribe MORE opioids. HELLO! He’s trying to get off of the crap and they want to give him more?!?!? WTH?
“and their ilk”. What are those ilks? Has anyone ever tried low doses of ketamine for pain relief?
You once mentioned that some opioids will create dysphoria and that some addicts will prefer that to feeling nothing. Can you explain the state of mind which would prefer to feel dysphoria to feeling nothing? It reminds me of cutting.
I don’t know how accurate my presumption is but I presume that a lot of opioid addicts are self-medicating anxiety/depression/PTSD, correct? One of the partially effective treatments for those is meditation. One of the possible goals during meditation is to have no significant thought or feeling or at least not get caught up in them. Yet opioid addicts will prefer to feel dysphoria with its concomitant thoughts. Can you clarify that for me?
Aside from tapering, how did he deal with withdrawal?
There’s not a lot that is more miserable than opioid withdrawal. While not directly harmful in itself, it does cause some people to commit suicide, or can wear them down so badly they become subject to chronic pain syndromes, sleep disorders, and depression. And all too often, it can last too damn long. Especially if a person has been taking something like methadone.
So there’s definitely a role for re-introduction of opioids if a person is suffering from a prolonged withdrawal. Buprenorphine slowly tapered over a week or two can save a LOT of misery.
Ketamine, with its need for IV or sub-Q or nasal dosing, is not a realistic med for most pain needs. Nor will you find many docs willing to, or trained to administer it.
Otherwise, by “their ilk” I mean any drug which causes significant euphoria. Pain plus stimulation of the pleasure centers of the brain = pain that is generally tolerable by the patient.
That’s more tongue in cheek than an actual axiom; we addicts so often just want to feel other than what we’re presently feeling, and we’re willing to take a bit of a risk that we’ll feel worse rather than better. While I don’t claim to speak for all addicts, most opioid addicts just want to avoid pain/fear/anxiety. We want to avoid negative feelings.
And most opioid addicts are feeding their addiction by that point in their illness. Magically cure their depression or PTSD or chronic pain or anxiety and they will still compulsively use opioids due to the loss of control characteristic of the disease of addiction.
Sometimes not even “in addition”. At one point my mother was given a course of medication which was completely wrong (total misdiagnosis) and which included opioids. She became addicted right quick but still hurt all the time. The combination did not make for a pleasant caretaking experience; she actually was less unpleasant when they were weaning her off at the hospital.
I’m an insomniac, and sometimes when I go to bed, my mind races. Sometimes I put in the TV (with auto-off) or listen to a book on Kindle Audible. I also take .25mg of clonazepam and some melatonin. I might add a Benadryl.
People are always recommending meditation. I cannot imagine anything scarier. Meditation is like saying “Try not to think about the things that worry you,” so of course, they all come crashing down. I may punch the next person who suggests meditation.
Meditation might be [del]workable[/del] helpful, but it’s definitely not a short-term solution. Doing meditation right takes years of practice.
Remember that Vietnamese Buddhist monk that set himself afire in a public street to protest the tyrannical Diem regime? He meditated for weeks ahead of that to prepare himself. (Cite: One of the books by Thich Nhat Hanh, who was one of his fellow monks.)
I attended one half of a day-long beginner’s meditation class given by U Silananda, many years ago in the S.F. area. In that short time, I got the clear idea that it takes years of steady practice to really get the hang of it. But even the little I learned then served me kinda-sorta okay years later, when I used it to get myself through some serious Worst Headache Evah events. (I still wouldn’t want to have to do it again though.)
Mindfulness meditation is a very underutilized tool for dealing with chronic pain and anxiety. It’s sure safer than narcotics. But people have to invest in the concept, then learn to do it. That takes dedication.
