[Pmb (OP)]

Hi everyone,

I've mentioned before that I have degenerative disk disease which results in chronic pain. If you've had to live with this yourself for years on end then you know what a terrible thing its to live with. You also understand why others can't understand what it's like to live with it unless they too have chronic pain. It's a fact that the suicide rate increases for people with this problem. People who are suffering with it obviously has worse depression without it. Unfortunately very insensitive people have gotten their dirty mitts into it and it seems that they are trying to make doctors afraid to prescribe opiates (aka opioids, narcotics).

The New England Journal of Medicine published an article called Opioid Therapy for Chronic Pain. The article makes note of this problem, i.e.

The legal use of opioids was thus placed entirely in the hands of physicians, who were, and still are, liable to lose their medical licenses and risk criminal prosecution if they prescribe these drugs inappropriately. The immediate effect of such strict regulatory control was that physicians became reluctant to prescribe opioids, and as a result pain was woefully undertreated.

Woefully undertreated is what this thread is all about. On the same page the authors note

The recognition that opioid therapy can relieve pain and improve mood and functioning in many patients with chronic pain has led experts on pain to recommend that such patients not be denied opioids. Despite this recommendation, many physicians remain uncertain about prescribing opioids to treat chronic pain and do not prescribe them.

Here I note the part which states such patients not be denied opioids.

It is accepted that adults are responsible for their health and when a new medication is started that they become educated in their proper use, side effects and problems that should be monitored and controlled. It is understood that the patient is intelligent enough to make his own decisions when it comes to being treated using opioid therapy. It's known by the patient that they can become addicted to it and they are warned about it. The medication is prescribed when the benefit outweighs the risk. Nobody has ever claimed that nobody shouldn't be careful when taking narcotics. And if serious problems arise the patient can then reassess and if they so choose then they can stop taking the medication.

To start off this discussion I have an opening question: To the people who don’t believe that patients with chronic pain should be allowed to take opiates is why do you believe that it’s worse than living with moderate to severe and thus untreated chronic pain?

[RD]

Physiological tolerance does occur rapidly with opioids ... http://en.wikipedia.org/wiki/Opioid#Tolerance

i.e. increasing doses are required to produce the same [analgesic] effect, so tolerance will inevitably become an issue if opioids are used daily to manage a chronic condition.

[Pmb (OP)]

Physiological tolerance does occur rapidly with opioids ... http://en.wikipedia.org/wiki/Opioid#Tolerance

i.e. increasing doses are required to produce the same [analgesic] effect, so tolerance will inevitably become an issue if opioids are used daily to manage a chronic condition.

Yes. That goes without saying but I'm confused as to how it applies to the question posed, i.e.

To the people who don’t believe that patients with chronic pain should be allowed to take opiates is why do you believe that it’s worse than living with moderate to severe and thus untreated chronic pain?

Are you a person who doesn't believe that a patient with chronic pain should be allowed to take an opioid for the pain, etc.?

[RD]

Are you a person who doesn't believe that a patient with chronic pain should be allowed to take an opioid for the pain, etc.?

If it were used to treat very painful episodes of short duration, [ "breakthrough pain" ], weeks apart, within the course of a chronic illness, then it seems feasible.

But if used daily, tolerance will occur within a few weeks :  the dose then be insufficient to provide pain-relief and you will be back at square one, but now with opiate side-effects and the prospect of withdrawal symptoms if you were to reduce the dose.   

In the UK there are "pain management" clinics/centres in the private and public health sectors, who specialize in managing chronic pain.
There seem to be similar facilities in your area ... https://www.google.com/search?q=massachusetts+"pain+management"

[Pmb (OP)]

I'm curious as to the silence this thread has met with. I hope its not because I take pain meds and you're concerned about offending me? If so then don't worry about please.

[CliffordK]

Pete,

Without having met you and reviewed the entire medical history, it is difficult to determine all the treatment options, what has been tried, what hasn't.  Why.

Dealing with pain is a problem with many people.  But, the pain affects each person differently.  So, for example, one might expect post surgery recovery to affect 2 people the same, but it doesn't.

The experience of pain is very subjective.  While one might notice facial expressions or tightening of muscles, it is difficult to judge exactly what another is feeling.  Perhaps fMRI and PET scanning will lead to more insights into pain in the future, but at the moment, it is somewhat of a black box.

As RD mentioned, patients build up a tolerance to opiates and related meds quickly, and they can be highly addictive.  They may also cause a rebound effect upon withdrawal.  They are best used in:

• Acute events, and occasional break-through pain
• End of life palliative care.

Other meds such as Tylenol and various NSAIDS have much less addictive and tolerance effects.  They, of course, also all have side-effects, especially when taken chronically in high doses. 

Some people believe that NSAIDS are an important component for the treatment of arthritic pain, for example, do to their anti-inflammatory effect, and thus, they should be taken all the time, independent of pain levels. 

My father always believed that Voltaren (diclofenac) was one of the most effective NSAIDS for his chronic knee pain.

As with all NSAIDS, Voltaren may have a negative impact on platelets and the stomach.  Did you ever have a good diagnosis for your headache hypothermia issues earlier?  NSAIDS may also be contraindicated if there is any risk of cerebral aneurysm/hemorrhage.  And they can interact with other medications.

Many elderly are literally snowed under with the meds they are taking.  But, again, it varies from person to person.  A choice to chronically take slowly increasing doses of opiates, and perhaps laxatives, and etc should not be taken lightly.  One may choose to turn in one's drivers license, and accept an increasing mental disturbances.

The only substance I can say I have been addicted to is coffee, espresso, and caffeine.  What is obvious is that taking it on occasion can increase alertness, but taking it chronically doesn't, in fact, it can cause wicked rebounds.

I've had low level chronic back pain for years.  I've never "thrown out" my back, but it has always been a little achy.  One quickly learns to avoid the pain.  For example, belts can cause pain, so I rarely wear belts.  Certain beds are extremely painful, and I always choose a very firm bed.  Or, I've found that sleeping in my favorite chair paradoxically is less painful than many beds.  Gentle stretching and exercise is always helpful.  There is always the "use it or loose it" which is very real.  And, last of all, I never let it stop me.  For the most part, the strongest med I ever take is aspirin.

Surgery for back pain can have mixed outcomes.  If you have pinched nerves causing numbness and weakness in the arms and legs, then surgery can be very helpful.  But, outcomes are much less clearcut for chronic back pain.

[CliffordK]

Are all the COX-2 drugs off the market now?  Again that is a place where the sufferers of chronic pain aren't even given the choice, assuming they are fully informed of the risk.

Perhaps you should try some escargot!!

[Pmb (OP)]

I'm still looking for quantitative information about opiate tolerance. I met with a pain specialist yesterday and left feeling like I wasted my time. He claime that opiates weren't right for me. I asked why and he said that I'd develope a tolerance to them quickly. When I asked how quickly he said in just a few days. I had no respect for him after that because I had been on opiates every day for at least a week by that time and showed no hint of becomming tolerant to them. In fact I've been using them on and off for years and its only when I'm on them to I have any piece of mind from the break from the pain.

[tom25702]

having chronic pain from any reason is the one of the worst thing in the world. but i wonder fo it possible to reach the the source of  chronic pain, i dont know a lot about the technological innovations in this field, but iv read over the net some article about tools that could maby help find newbielink:http://www.medoc-web.com/applications/clinical-use/pain [nonactive] to help with the treatment
thanks

[CliffordK]

Unfortunately I don't have any first hand knowledge about the tolerance of the opiates.  Somewhere there must be some studies, but I wonder if the pain specialists are also weighted heavily by anecdotes.  I have heard that the meds can cause a rebound effect where withdrawals make the pain seem worse.

For some reason, NSAIDS aren't considered to build up the same tolerance.  Perhaps because they also help reduce inflammation. 

Both of my parents thought that Voltaren (Diclofenac Sodium) has been effective for knee and arthritis pain, and believed that it was important to take a regular daily dose.

Apparently there is also a Voltaren/DMSO mixture for topical treatment of arthritis pain that my mother has also found effective for break-through pain, although I believe it is only being prescribed for peripheral joints at this time.  I don't know if it should be used for chronic pain.

[Karen W.]

PMB I have degenerative disc disease also. I also have a severe Lyme arthritis from 18 plus years of having it and not knowing so it had gone untreated until about a year + ago. I have taken nsaids for several years for pain relief. I have two shoulders racked with arthritis and severe deterioration.  Same for my hips and back neck and tail bone sciatic area...My pain is intolerable 24/7 and my only relief has come from my Kadian..(morphine) I take it in 30mg with one norco every morning and
evening. With a lower 20 Mg dose mid day to get me by till the evening..these are all 24 hour doses that we split.. we have been trying to find the right dosage...its been difficult I have some relief but still in pain even though I use the morphine.. I have not been able to be fully free of the pain..but having the edge off has made an incredible difference especially while at
rest.. trying to move around even with walker, or canes is still excruitiatingly painful.. so we are still in adjustment mode....hoping to hit on proper dosage!.. I would rather be on this opiate and have some relief, where as
before the nsaids, there was not that relief.. even in huge doses. So if not
for opiates where do we go when all the other pain meds and mind over matter trying things like distraction and meditation along with other numerous wholistic suggestions  fail to work and all that's left is to lie in a bed unable to curl up but having to lie there in such pain because thats all that's left! Cries of intense horrible pain and tears untifl your body is nothing but a huge puddle of pain cause there is nothing left of you but the tears and pain..you are no longer able to stay in your body mentally..Its a horrific experience...I feel for others and I believe in the opiates..as far as them offering a patient significant reliefof the pain...even if its not perfect.. its better then the alternative..being 24/7 pain!  I have better not worse clarity of thought whereas, when I am in all the pain I loose all thoughts! Good luck with your medicine adjustments and cheers to you for speaking up and doing all you can to
keep your wits about you... I also think that if you are not a person who is or has been in chronic severe pain, then you should not be the one of the authorities who would be denyieng the patients alternitives like the relief that the opiates can provide for them. Those people have no business trying to make these decisions for us.. some people handle pain very differently then others which is a most important consideration in this issue!

[LayedBack]

Are you a person who doesn't believe that a patient with chronic pain should be allowed to take an opioid for the pain, etc.?

If it were used to treat very painful episodes of short duration, [ " newbielink:http://en.wikipedia.org/wiki/Pain#Breakthrough_pain [nonactive]" ], weeks apart, within the course of a chronic illness, then it seems feasible.

But if used daily, tolerance will occur within a few weeks :  the dose then be insufficient to provide pain-relief and you will be newbielink:http://en.wikipedia.org/wiki/Back_to_square_one [nonactive], but now with opiate side-effects and the prospect of withdrawal symptoms if you were to reduce the dose.   

Hey, here's an idea, let's quit spreading misinformation about a serious health condition and medication that you don't understand that effects 116 million people in America alone.

The truth of the matter is that for most of us with chronic pain, opioids are actually the only thing that works effectively and on the long term. However we are undertreated because of the media circus, the DEA, and personal bias and ignorance towards opioids.

I'm here to tell you right now, as a person who has had chronic pain for 5 years, that I managed to treat it for 3 years on the exact same dose, and then for 2 more on a slightly increased dose. And yes, it's true that if you suffer with the disease in an extreme way, or for 20-30 years, you will eventually need a high dose. But so what? If it helps chronic pain, then that's all that matters. Tolerance most certainly does not render opioid pain relief ineffective within weeks. For most, it's simply a matter of finding the right medication and the right dose, and increasing that dose once every year.

When you say opioids are not effective, what you're saying is that people with CP might as well just suffer and die. Because for most of us, the truth is just the opposite, opioids are often the only thing that does work.

Please educate yourself before you do more harm, it's possible that 100 people read your comment and now believe that opioids are not effective for chronic pain. Thanks a lot.

FUN FACT! - Chronic pain does damage to the nervous system and every organ in the body which shortens life expectancy. So when people suffering from the disease are under treated, their Doctors are being negligent and doing direct harm to the patient both physically and mentally.

FUN FACT! - It's estimated around 5 million people abuse prescription drugs in the US. It's also estimated that 116 people suffer from chronic pain in the US. What should be more important, stopping the abusers, or treating the sick who outnumber the abusers over 20 to 1?

[CliffordK]

FUN FACT! - It's estimated around 5 million people abuse prescription drugs in the US. It's also estimated that 116 [million] people suffer from chronic pain in the US. What should be more important, stopping the abusers, or treating the sick who outnumber the abusers over 20 to 1?

Some of the stats are here.

That is 1 in 3 people in the USA have chronic pain?
I can just imagine the Soma Generation

It sounds to me as if the country needs to do better with other forms of pain treatment and management.

Here is some information that I've found earlier: indicating that 36% to 56% in patients treated with opioids for chronic back pain have substance abuse issues, and in general, patients treated liberally with opioids for chronic pain have generally lower activity levels and worse outcomes than those that aren't treated with opioids.

Of course that is all statistical averages, but one should explore other solutions.

[LayedBack]

As far as seeking other solutions first, I agree entirely. But that doesn't change the fact that for a darn good portion of us (likely a majority), the only thing that adequately treats our pain is opioids. I personally have tried 14 different non opioid medications, as well as steroid injections and none of them worked at all. My widespread chronic nerve pain started at age 19 and with nothing else to relieve it but opioids, what do ya expect me and others to do when we are put into a situation where it's either - suffer a lot and no longer enjoy life at all, or take opioids deal with the side effects and get real pain relief and a periodically okay life?

Bottom line is, we as human beings should have a right to choose what health care and medications we want to take. Unfortunately, there are 116 million of us CPers and many of us can't even find a single doctor willing to prescribe the opiates we need, and many of the ones that do often under prescribe and act like they are gods and don't care what we have to say.

These days we are treated like dirt and automatically suspected of being lying addicts by doctors, pharmacists, and even ignorant peers and family members. And some of the good doctors are just too scared of the DEA or too busy to want to take on a patient with a lifelong condition that can't be fixed and comes with all the baggage. Chronic pain isn't even really taught about in medical school for PCPs, and there are only like 5000 pain specialists in the nation, half of whom don't even prescribe opiates at all so they are incompetent or even criminally negligent in my eyes.

With so many people dealing with this condition, what we need is a darn union or government agency completely dedicated to supporting chronic pain and management research, protecting patients rights and standing up to the DEA etc.

But it's so hard for us sick and poor people to accomplish much of anything, we could really use the help of people who can actually get things done and care enough to do it. Unfortunately most people don't wanna hear about it, they only want to hear about the drug war and how many addicts overdosed this month. Even if the next person in line for the chronic pain train could be their own mother or son, or maybe even themselves.

[CliffordK]

Not all of the 100 million people with chronic pain in the USA need to be on opiates.  Perhaps only a small minority of them.

Certainly for a few individuals, opiates can be a wonder med.  However, as mentioned, the drugs are very addictive, and can cause rebound pain.

There are about 38,000 drug overdose deaths in the USA each year, of which just under half of them are due to prescription opiates. 

There are about 34,000 automobile related fatalities a year (less than drug overdoses).

And, about 150 Tylenol deaths per year.

I suppose when you consider the 300 million population in the USA, the number of opiate deaths are a small fraction of the whole, but there are still far too many.

[alancalverd]

Whose life is it?

IMHO every adult should be allowed to shoot, sniff or swallow any damn thing he likes.

If the pain gets too bad, the law won't object to your jumping off a bridge or blowing your brains out, so why should anyone object to selfmedication that prolongs your useful life?

[LayedBack]

Whose life is it?

IMHO every adult should be allowed to shoot, sniff or swallow any damn thing he likes.

If the pain gets too bad, the law won't object to your jumping off a bridge or blowing your brains out, so why should anyone object to selfmedication that prolongs your useful life?

Exactly. CliffordK are you really saying that people who live every single day with chronic pain, don't even deserve to decide for themselves? I do believe if a person can get by without opiates and live happily then they certainly should, but at the same time I'm quite confident that a majority of people with CP do actually deserve and need opiates.

Also, those overdose figures are way, way too high. Guess you didn't realize that when a person happens to die with drugs in their system, it's often ruled as an overdose because it's easier for them to just write it off. I wouldn't be surprised if the real overdose figures were freakin' 1/10th or less of what they actually say it is.

And really, I don't see what irresponsible people overdosing has to do with people in chronic pain who need to responsibly use opiates medicinally anyway.

Isn't it a little arrogant of you to just assume you know enough about chronic pain and opiates to know how many people actually need it? It's easy for doctors and people without the condition to say just "tough it out", it can't be that bad. But really, who is anyone else to decide how much pain I am in and what I can or cannot do about it? My major point here is that chronic pain patients should have the choice to decide for themselves. We're the ones living it. We're not incapable of thought, most of us know about our conditions better than our own (mostly) incompetent doctors do. We know when we're starting to break and absolutely need relief.

[Timfox]

Dear,
 I can understand and completely agree that such kind of chronic pain are unbearable at times,but not to lose hope. I have not experience such pain but your words have made me felt the same. I would rather suggest to consult some more doctors as technology has advance definitely they will be having alternative for you. Keep Your self positive and mentally strong this would surely help you to deal with the situation in right manner. Also intake of proper nutrition from foods will help you.
Regards,
Tim

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