[ed. note: Michael Jorrin, who I dubbed “Doc Gumshoe” years ago, is a longtime medical writer (not a doctor) who writes for us a couple times a month about health issues and trends. He does not typically focus on specific investment opportunities, but has agreed to our trading restrictions… as with all of our authors, he chooses his own topics and his words and opinions are his alone]
Here are three statements about the overall situation, which I hope are clear and accurate, and which essentially point in opposite directions:
One: Chronic pain affects more than one hundred million Americans – more than diabetes, heart disease, and cancer combined. This is according to the National Institute of Neurological Disorders and Stroke.
Two: The most effective treatments for pain are drugs that address the μ opioid receptor.
Three: Almost one hundred million Americans used or misused prescription analgesics containing opioids, and opioid abuse killed about one hundred and seventy five of us every day in 2016.
If you are reading this in the hopes that Doc Gumshoe has any answers to this quandary – and it is a quandary, I hope you’ll agree – I’m sorry to disappoint you. But perhaps I can point to some glimmers of light.
To start with, let’s look at the groups of players in the mix, each with its own goals and concerns:
- Patients who are experiencing pain want relief for their pain symptoms, to state the obvious, but they have at least heard about the perils of opioid addiction and certainly do not want to go down that path.
- Doctors who treat these patients also want to provide pain relief for their patients, but they definitely do not want to be identified and branded as over-prescribers of opioids and thereby contributors to opioid addiction.
- Health insurers often put themselves in the position of knowing better than everybody and sit in judgment as to what works and what doesn’t, with regard both to pain relief and also to minimizing addiction – but their eye is generally on the bottom line.
- The authorities – police and elected officials – pay much more attention to the problems of addiction, which they have to contend with, than with the problems of people undergoing pain, which is not their affair.
- The media focus on the new part of that quandary – pain has been around since the dawn of time, but opioid addiction is hot news.
- And the public at large mostly goes with the media.
I left out one group – people who take opioids not for pain relief, but for their own pleasure or satisfaction of some kind. I try to make a distinction between this group, on the one hand, and individuals who started out using opioids for pain relief, found it difficult to reduce the dose (“wean off”), and ultimately became addicted. My focus in this piece will be on the second group.
We hear from all quarters that opioid abuse is a national crisis. In contrast with the drug addicts of former times, who were regarded as something like common criminals, individuals who have fallen prey to opioids abuse are frequently seen as unfortunates who are in need of treatment, particularly if their initial exposure to opioids was as pain medication and not as a recreational drug. The problems that recreational drug users present to society are not viewed sympathetically. We know of a young woman who was seen exchanging the food stamps (on which she relies to feed her two young children) for a packet of opioid pills. To the best of our knowledge, her introduction to opioids was not as treatment for pain, but as a party drug. Some form of treatment is required for her, without doubt, but she is not part of our quandary.
That’s a far cry from the way the many individuals who fell into opioid abuse following severe pain episodes are currently seen. The (fictitious) case histories below may explain why this is so.
Case history number one: Manny
Manny is a healthy, fit male of about forty years of age. He drives a truck for a company that supplies water-softeners to homes and small businesses, and he delivers water softener salt, in forty-pound plastic bags and also in steel cylinders that weight upward of a hundred pounds. He normally carries two bags at a time – one in his right hand and the other over his left shoulder.
One day, while making a salt delivery to a regular customer, he slipped on the stairs leading to the cellar where the water softener was situated and fell to the cellar floor. No matter how he tried, he could not get up from the floor. The customer tried to help, but to no avail. The ambulance crew had a hard time getting Manny up the cellar steps, while Manny writhed in agony.
When they got Manny to the hospital, the good news was that no bones were broken, and he had managed to avoid a concussion. But he had sustained a severe sprain of his left ankle, and some of the ankle bones were dislocated, causing tears in the bursa, which are the envelopes that hold them in place and prevent friction.
After a few days in the hospital and two weeks of physical therapy, Manny could move around a bit, with the aid of crutches and an ankle brace. But it would be a while before he could go back to work.
In the meantime, he was in pain a good bit of the time. In the hospital, he had been given a combination of pain killers, including opioids and acetaminophen (Tylenol). He was also given a prescription for a time-release opioid – enough, according to the hospital physician, to carry him through the two weeks of physical therapy, after which the recommendation was that he could switch to an over-the-counter pain killer, such as acetaminophen or a non-steroidal anti-inflammatory drug such as ibuprofen or naproxen.
The opioids Manny was prescribed took the edge off the pain, but not much more. He figured he could live with it. However, when the prescription for the opioids ran out, he found that the OTC pain killers did very little. He telephoned the hospital where he had been treated and asked to speak with the hospital physician. He was only able to leave a message for the physician, saying that he was still in considerable pain, and asking whether the prescription for the original opioid pain killer could be refilled, since that medicine at least seemed to help to some degree. In response, he got a telephone call from a nurse saying that the prescription could not be refilled, and suggesting other remedies such as ice packs in addition to the OTC medications.
At this point, Manny began getting pressure from his employer to go back to work. In response, Manny told his boss of his plight – that he was still in considerable pain, and the doctor would not renew his prescription for the drug that seemed to help. His boss made what seemed to Manny at the time a very helpful suggestion: the boss knew of a local pain clinic that specialized in cases such as Manny’s – helping people overcome pain problems so that they could “get on with their lives.”
Manny went to the pain clinic, where he was given another opioid – this time not a delayed release opioid, but immediate-release oxycodone, whose effects he began to feel more quickly, within about 20 to 30 minutes. He also had weekly physical therapy appointments at the pain clinic.
Thus provided, Manny figured he could go back to work.
For the first few days, Manny took his pain killers exactly as prescribed. The pain didn’t go away, but it was better, and he was able to cope with the demands of his job, carrying the 40 pound bags of salt, and being especially careful on cellar steps. But one day, the pain got to be a bit too much, and he took his next ration of pills a bit earlier than scheduled. Then, on another day, instead of taking two of the 5 mg pills, he took three. And he felt better. And then, on another day, he took four.
When he noticed that his supply of pain pills was running low, he headed back to the pain clinic and asked about a refill. No problem. The pain clinic dispensed medications directly. And when this happened again, again there was no problem.
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Six months after his accident, Manny was still taking opioids, but now the quantity of opioids he was taking was about three times greater than the amount he had been given when he left the hospital. He was almost completely recovered from his accident, but he was reluctant to cut out his pain pills completely. He occasionally felt twinges of pain, and it didn’t seem as though his pills were doing him any harm. In fact, all in all, he felt pretty well. After a hard day’s work, his pain pills helped him relax.
Manny had certainly heard of opioid addiction, but he was quite sure that he himself was no addict.
Case history number two: Moe
Moe is in his mid-fifties. He’s a high-school football coach, and he played football in high-school and college. He’s big and strong and tough. But for the past several years, his knees have been giving him considerable trouble, and the palliative treatment he has been receiving – steroids and lubricants injected into the joints – have stopped helping. He really can‘t continue to manage his job as a football coach if all he can do is hobble around the field. He figures he took a lot of punishment as a young man, and his excess weight didn’t help. So, with the advice of his doctor, he has decided to have total replacement of both joints at the same time.
His doctor wants him to be aware that doing both knees at the same time makes the recovery process more difficult, and warns him that the most difficult time for him will be the months immediately after the surgery. He will need intensive physical therapy to recover the ability, both to bend his legs and to straighten them, and the physical therapy invariably causes pain, so he has to be prepared for that.
Moe is confident that he can stand pain. He played football, he sustained injuries, he’s not a sissy.
The doctor is willing to go ahead with the double knee replacement based on Moe’s assurances that he’s prepared to deal with whatever comes along. But he is also somewhat apprehensive regarding Moe’s ability to handle the necessary pain medications he will need. The doctor knows that Moe is not abstemious when it comes to strong drink. He is one of those men who drink stout ale and go to bed quite mellow. Moe thinks of himself as being able to handle just about anything, including strong drink, and probably also, strong drugs. Moe is not going to be cautious and sparing with regard to his pain medication. Therefore, the doctor is going to be conservative with Moe’s post-surgical drug regimen.
The surgery itself was uneventful, and during the first couple of days in the hospital, Moe had no real problem coping with his pain level. When Moe was transferred from the hospital to a residential rehabilitation facility, the pain medication prescribed for him by his doctor was hydromorphone (Dilaudid) at the lowest dose, along with other analgesics – acetaminophen (Tylenol), and an NSAID such as naproxen. And the pain came on strong!
Moe was more than a bit conflicted during his first few days at the rehab place. He thought of himself as a tough guy, able to handle pain. But the pain was quite a bit worse than he had anticipated. He did not want to whine and complain to the nurses, who were treating him with the greatest kindness. He made up his mind to grin and bear it.
After the third night at the facility, during which he got very little restful sleep, his resolution broke. When the nurse appeared in his room in the early hours of the morning to check his vitals and give him his first round of medications, he told her that he didn’t think the pain medications were working all that well, and begged for more – either a higher dose, or a more effective pain pill. The nurse, of course, referred this to the resident physician at the rehab facility, who came to Moe’s room and had a little chat with him. This physician discussed a range of non-drug interventions, starting out with ice packs, but made it clear to Moe that he could not change the prescription or increase the dose without the approval of the surgeon who performed the procedure.
Moe hoped for the best.
The resident physician then had a talk with the surgeon, who was highly reluctant to change Moe’s pain medication regimen. His reasons were precisely that Moe had expressed total confidence that he would not become addicted to opioids. Moe had an extremely low opinion of drug abusers of any kind, and total confidence in his own ability to deal with opioids. Moe’s over-confidence presented a threat. The two physicians agreed that in all likelihood, Moe’s pain level would decrease over the next few days, and he could get through that period with the medications he was taking, plus some intermittent icing and gentle physical therapy.
The next ten days at the rehab facility were not fun. The physical therapy sessions were torture. He slept very poorly, and was in considerable pain nearly every moment. After the first few days, he graduated from being transported in a wheelchair to getting around by himself with a walker. He saw, however, that other people in the facility were getting around using only a cane, and he questioned whether he had made a mistake in getting both knees done at the same time.
When he was discharged from residential rehab, he was given a prescription for the same pain medication, which he was instructed to take three times a day. The prescription was for a ten day supply.
At the end of three days, he had exhausted the ten day supply. He telephoned his doctor for a refill. And, to Moe’s surprise, the doctor was anything but accommodating. The verdict was that he would refill the prescription for another ten days worth of the pain pills, but the new prescription would have to last the full ten days. It would not be refilled prior to the ten-day marker.
At this point, Moe’s wife enters the picture. She has been increasingly concerned about Moe – not only his progress after the knee replacement and his nearly constant pain, but his state of mind. Moe is depressed and short-tempered. His usual optimistic affect has evaporated. Moe’s wife confides in her best friend, who also happens to be the wife of Moe’s assistant coach, the football team’s trainer. And her friend tells her that getting pain pills is no problem at all. He husband has plenty, because he doles them out to injured players on the football team.
Moe’s problems, for the moment, are solved. His assistant coach can supply pain pills as needed. Moe’s recovery from the knee surgery picks up speed, his pain level drops markedly, and his overall disposition changes from bleak to sunny. There seems to be no problem with a continuing supply of pain pills, and all is well.
How long Moe will continue to take large doses of opioids is completely uncertain. He could taper down as his pain levels recede. Or he could become addicted.
Case history number three: Jack
Jacqueline, known to all as “Jack,” is a sixty-year old self-employed graphic designer. Like just about everyone, she had chicken pox as a kid, and like lots of people who had chicken pox as kids, she developed a severe case of shingles some fifty years later. But, like a fairly small minority of persons who are afflicted by shingles, she went on to be assaulted by an extremely painful case of postherpetic neuralgia.
The clinical details are well known. Chicken pox is caused by the varicella zoster virus. The chicken pox episode is bothersome, but not dangerous. Kids are warned not to scratch, because scratching the itchy little pustules will likely lead to scarring. Aside from that, chicken pox is not much more than an excuse to miss school for about a week. Except that the varicella zoster virus doesn’t go away – it stays in the body, and in about one percent of individuals who have had chicken pox, it re-emerges as shingles, which is a condition in which the virus travels along nerve pathways, affects more or less the same kinds of skin cells as the chicken pox did, forming rashes and little pustules. But the chief difference between chicken pox and shingles (or herpes zoster, as it is officially referred to) is that shingles can cause really severe pain. Estimates are that about one million persons a year in the United States are affected by shingles.
Initially, shingles is usually treated topically, sometimes by the application of soothing lotions such as calamine to the affected area. If the pain persists after the initial rashes recede, topical analgesics such as lidocaine patches may be used on the affected area. Systemic antivirals (acyclovir, famcyclovir) are also used to quell the virus, and steroids may be used to dial down the immune response.
But in a minority of cases, the activity of the herpes zoster virus persists as postherpetic neuralgia. This is a really nasty condition that can cause severe pain that may last for months, or even longer. And that’s what landed on Jack.
Jack had consulted a dermatologist when she developed shingles and continued under the dermatologist’s care when shingles morphed into postherpetic neuralgia. The derm initially treated Jack with an antidepressant, amitryptaline (Elavil), in addition to the lidocaine patches which had alleviated the shingles pain to some degree. After about six weeks of treatment with the antidepressant, Jack found that she was perhaps having problems with the drug – her heart was beating abnormally fast, and she was almost always unpleasantly aware of it.
Jack’s dermatologist then prescribed pregabalin (Lyrica), a drug originally developed as a treatment for seizure disorders such as epilepsy. Pregabalin is essentially a more effective version of gabapentin (Neurontin); both pregabalin and gabapentin were developed and marketed by Pfizer. These drugs were found to be effective treatments for nerve pain, and thus appropriate for postherpetic neuralgia.
However, Jack’s health insurance company presented a major obstacle to the pregabalin prescription. Her doctor would have to certify that several other drugs had been used prior to approving pregabalin. Approval would likely be slow in coming, even after the derm had filed the necessary paperwork, and in the meantime, Jack’s nerve pain would continue unabated. And even if the pregabalin prescription were ultimately approved, Jack would have to shell out considerable money in co-payments – about $500 per month, which she didn’t think she could afford.
Jack’s response to this was, “Why on earth would I have to go through this? Isn’t there something else you could give me that could take care of this awful pain?”
The derm then tried a prescription for Suboxone, which is buprenorphine with naloxone, a reasonably effective pain killer compounded with an anti-addiction agent. It was similarly denied.
In the meantime, the derm had given Jack a prescription for OxiContin, which he gave her with the proviso that he didn’t want her to stay on that drug for an extended period, but it would help her cope with her elevated level of pain until he could get a more appropriate long-term treatment approved by her insurance company. OxyContin is a controlled-release form of oxycodone, appropriate for persons with chronic pain, but formulated in such a way that it does not produce the immediate sense of gratification that the immediate-release oxycodone supposedly gives the opioid-addicted.
The OxyContin worked pretty well for Jack. After a few days, her pain had dropped to a tolerable level. She told the derm that she saw no reason to keep looking for something different. She was okay with OxyContin.
The derm agreed to continue the OxyContin prescriptions, with the warning to Jack not to exceed the recommended dose. His long-term concern was that postherpetic neuralgia can go on for a year or even longer, and that the Jack’s response to the pain medication could very well diminish over time, such that she would simply up the dose on her own. He anticipated that she would come back to him to renew her prescription at increasingly shorter intervals, and that, despite his worries over the possibility that Jack would become addicted, he would have very little option except to go ahead and provide her the needed pain medication.
Will Manny, Moe, or Jack become opioid addicts?
The great likelihood is that they will at least become habituated to their opioid medications. Manny, after six months on a high daily dose of an opioid, is already habituated. Up to this point, he has not taken a sufficiently large single dose of his preferred opioid to give him the kind of “opioid high” that addicts crave, and, fortunately, he has not taken a large enough dose to risk an overdose reaction. But he’s on the edge. He might try something risky.
Moe and Jack present similar problems. Moe has no objection to being just a bit “tiddly,” – which is to say, he enjoys the effects of mild alcohol intoxication. Given the easy availability of opioids from his assistant coach, he, too, might try something risky.
For Jack, the basic question is, how long will her postherpetic neuralgia persist? The sooner it subsides, the better her chances are of totally escaping addiction. Her derm will continue to urge her to scale back the dose, and she will likely continue to be under the care of a caring and involved physician, unlike Manny or Moe. Remember, in Manny’s case it was the need to go back to work that sent him to the pain clinic, and in Moe’s case, it was the somewhat rigid physician that gave him little choice but to go outside the medical system. Jack stands a better chance, as long as she continues to consult with her derm.
But, without question, it is a real quandary. Patients in pain require treatment, and the most effective treatment options can be addictive.
What about those people who abuse opioids for recreation?
It is certainly the case that some of those individuals, who began using opioids for pain management, develop a craving for the sensation they experience as the opioid takes effect, and progress to being full-fledged junkies. This is what terrifies the medical establishment and leads, in some cases, to the under-treatment of pain. But there is another cohort, evidently quite large, that simply takes opioids for pleasure. Recreational opioids came into wide use as a “party drug” because, at least initially, they were free from the lower-class onus of “street drugs” such as heroin, crack cocaine, and the like, and they didn’t have to be purchased from unsavory characters who were obviously crooks. They were legitimate prescription drugs, and the people who diverted these drugs from legitimate channels were doing nothing more than offering people something that would help them have a good time.
But, in order to get the desired sensation from the opioids, recreational users may need to overcome the safeguards that the pharmaceutical companies have tried to incorporate into the opioid formulations. So they pulverize the delayed-release pills and inhale the opioid through their noses, or dissolve the pills in liquid and inject the solution, so as to deliver an immediate hit. Experts maintain that no opioid formulation that is intended to deter abuse is immune from the kind of tampering that overcomes the intended deterrence mechanism.
A lethal newcomer to the opioid category is fentanyl. Fentanyl is actually not a newcomer, having been around for half a century or so, and having been legitimately used as an anaesthetic and in the form of quite effective pain-relieving patches. It’s at least 50 times more potent than morphine, and some fentanyl analogues are up to 10,000 times more potent than morphine.
The potency of fentanyl doesn’t make it inherently dangerous, if it is used with extreme care, meaning that the dose used is proportionate to its potency. Whereas the dosage of other opioids is generally given in milligrams, that of fentanyl is given in micrograms. Of course, that potency makes it relatively easy to overdose.
What makes fentanyl potentially lethal is that it’s the ideal medium for drug traffickers. They can sell tiny amounts for a lot of money. They don’t need to smuggle suitcases full of the stuff to make a killing. And it’s relatively easy to synthesize, meaning that there are illicit labs turning out fentanyl just about anywhere in the world. The quality and purity of the stuff the traffickers are peddling is a black hole, and it’s frequently adulterated with other substances, including heroin.
Another factor that contributes to the menace is that fentanyl is said to result in less feeling of euphoria in users as compared with heroin. Instead of the heroin high that the drug users desire, what they feel is sedation and somnolence. And that, in turn, leads to overdosing. “Maybe I just didn’t give myself a big enough dose,” the users say to themselves. And the next dose kills them.
In case you didn’t know …
… what the symptoms of an opioid overdose are: one simply stops breathing. Even moderate doses of opioids depress respiratory function, and when the dose goes high enough, the parasympathetic nervous system just turns off, and breathing slows to a halt. If victims are not revived in time, guess what?
Opioid overdoses can be reversed by agents that are antagonists at the μ opioid receptor such as naloxone (Narcan) and others. These agents are injected or delivered intranasaly, and frequently multiple doses of the agent are needed, because the effect of opioid itself lasts longer than the effect of the antagonist.
Although the naloxone itself is inexpensive, the delivery systems that are provided to police and emergency responders are far from inexpensive, and some small communities where opioid abuse is common are finding that the cost of these kits is a considerable burden on their budgets, sometimes crowding out other equally vital needs. An egregious example is an auto-injector kit similar to the EpiPen. A single use device lists for $2,250. The value of the auto-injector is that a totally untrained person can use it, making it appropriate for emergency use by any bystander. Some activists have proposed that these kits be available in public places, so that any person experiencing an opioid overdose can immediately be given emergency treatment. The idea has not caught on, can’t think why!
What about the “glimmers of light” that Doc Gumshoe referred to earlier?
There’s no room in this installment to describe them, but here’s a hint: there are several ways of managing pain without the use of drugs that have been effective for some patients. And there’s an opioid currently approaching FDA approval that is – based on solid evidence – fundamentally not susceptible to abuse. How can this be? I’ll explain in my next post.
* * * * * * *
I keep being surprised and gratified when Doc Gumshoe posts from several months back keep attracting new comments and new controversies. Many thanks for all comments, whether in agreement or the contrary. Best to all, Michael Jorrin (aka Doc Gumshoe)
As a physician for 40 years, with a large pain and palliative caseload, I have to say that I have been increasingly impressed by the effects of marijuana derivatives. I was sceptical at first, I will admit. Interested to see where this discussion will lead-recognise all the characters above.
Absolutely. Smoking pot is becoming a thing of the past. Thr ability to make full spectrum oil thtough co2 extraction makes the use of powerful cannabanoids in the form of oils a very effective treatment for pain. The genetic manipulation of cannabis through targeted and often complex combination of specific strains which has been mastered by amateur and professional cannabis growers for decades can and does produce plants with prperties best suited for pain, sleep disorders, seizure and spasticity etc. I note in Doc’s article the reference to the opiods having an initial pure pain relief effect necessary in the early stages of recovery but the contimued use to ” take the edge off” or feel ” better” or relax as that area in which those 3rd or 4th refills come into play and the danger of addiction begins to ramp up. Transitioning to the use of cannabanoids in this intermediate stage would make much more sense.
As a retired ER nurse, I am too familiar with both types, chronic pain, and the addictive results, and the recreational user. Thank you for your insight into this matter, and I’m waiting for your next word about this problem
I went down with severe depression & anxiety in 2011. My psychiatrist tried many prescriptions over a three year period, with no relief. By coincidence a friend had given me a hydrocodene pill for a bad headache. It did not relieve my headache but for the first time in 3 1/2 years I had no anxiety. Upon my next doctor visit he was at wits end over my condition and was talking commitment. My wife was with me and asked what about that pill your friend gave you. I was reluctant when my doctor asks what I had taken. I told him hydrocodene. Unexpectedly, he said if it worked let’s try it. He prescribed it to me that day, 1 pill, 4 times/day. It has continually to work, I only take what’s prescribed and am now able to function as a normal person. It strangely relieves my depression & anxiety but if I have pain of any sort, I must take some OTC medication! Don’t know, it corrects what he called a brain chemical imbalance but not physical pain! I have been using it for 3 years now and fear opioids regulation will prohibit my ability to continue taking it. The thought of lying in bed in a fetal position again scares me!
not promoting illicit substances here but in
https://www.vice.com/en_us/article/vvzy38/i-asked-a-psychopath-how-to-stop-caring-about-rejection
i came across:
“… one of the key areas of the brain associated with dread, and fear is called the “middle cingulate cortex.” … it’s not certain this is the part of your brain that’s associated with rejection, but I’d say it’s possible. In tests, that part of my brain is turned off, so it makes sense.
Is there a way to manipulate this part of the brain?
Well, there’s a paper that came out last year that showed that there was one drug that turned it off. That is, an experiment was done with cancer patients who are afraid of dying. They have this sense of, I’m going to die, and there’s going to be nothing out there. Just this existential dread. But when they were given psilocybin the fear went away.”
… and, conversely, antidepressants provide reasonably good relief for many people with chronic pain. The mechanisms in our brains are linked.
To Louis, your story sounds similar to a good friend of mine. 10 years of trying every antidepressant with NO relief. Then he blew a back disc, had simple surgery but ended up in unexpected 4 days of incredible pain that could not be stopped. They gave him morphine, the doubled it. NO relief OR side effects. They added dilaudid and NO effect so doubled that, still NO effect, then added a fentatyl patch, NO relief, added another patch! NO relief BUT NO side effects either. These doses would have killed some people!! Point of story, his Dr finally figured out he had a rare condition where your body hypermetabolizes entire classes of Rx’s. Come to find out, ALL those anti depressants had the same Rx digestion code(?) as all those pain killers so he now knows what Rx will not work via asking the Pharmacist to check the alpha numeric codes. There are tests for this but test not overly reliable, at least not 10 years ago, maybe better now. Odd thing is that vicodin was taken when he got home (had old Rx that used for past back injury) and after 4 days of incredible pain with no relief from Hospital one simple vicodin had him up and 90% pain free in 45 minutes! It was the damnest thing to see him go thru that mess. Only thing now is that the vicodin is the only thing that fixes his chronic back pain AND depression issues almost gone for 6 hours per dose. He says it does not get him high, it just lifts the depression and kills pain, even helps with anxiety. Too bad this is so bad on a persons kidney/liver and so addictive. Check and be tested to see if you too have that rare condition via a special blood test (also note, many Dr’s are unaware of this hypermetabolization issue so you may need to ask a few Dr’s. Hope this info is helpful in understanding your own body.
I had taken opiates for many years for pain wanted to get off I was told by pain management I’m doing well on the medication but I felt sick and it wasn’t working anymore I looked up Suboxone doctors and went on Suboxone after proving to the doctor that I was not an addict abusing the opiates he put me on Buprenorphine 8 mg if you get a single care app on your phone you can get it at Walmart 30 pills her $50 don’t let them talk you went to rehab if your insurance doesn’t cover and less you need it Harm on you print off anything for pain I don’t have any side effects you can stay on it for pain
Michael – A terrific article! Thank you!
jk
The Pep Boys – LOL
Thank you for this article. One problem not commented on is seniors who sell pain killers. Laws are changing and these seniors are now being tested in N Y. If they don’t have the chemical in their bodies, their scrips are not renewed. I myself am allergic to most. After a very bad accident I was placed on morphine for many months. I learned great empathy for addicts. What I found is as I no longer had pain and began weaning off the morphine, my mind kept telling me I needed it. I have talked to addicts and they have all said the same. The craving in the mind far outweighs the physical need. I had to throw away all pills. I couldn’t even keep two as my mind obsessed about them.
Malignant Opiophobia is a cultural condition unique to US culture. We insist on seeing harm where none is occurring.
Inside every living eukaryotic cell, are organelles called Mitochondria. About a billion years ago, if the fossil record can be believed, Eukaryotes first formed, by capturing bacteria and giving off chemical signals to control the rate at which those bacteria digested food and turned the energy in the food, into adenosine triphosphate (ATP). The control mechanism that speeds up and slows down metabolism, in every eukaryotic cell, is now known to employ three substances: Nitric Oxide, Ethanol, and Morphine.
(GT Stefano and R Kream, Interactive effects of endogenous morphine, nitric oxide, and ethanol on mitochondrial processes, Arch Med Sci 2010; 6,5 pp. 658-662).
Every living thing that can be seen with the human eye, be it a tuna fish or an oak tree or a tomato or the Governor of New Jersey, secretes the drug morphine in it’s own cells and uses that drug to control it’s food metabolism. A malfunction in that system can cause dysfunctions, such as the Governor’s obesity.
Mindlessly attacking every last molecule of this life-sustaining substance, as if it were a hazard to life, can only harm our health and diminish our understanding of disease. Yet, that’s precisely what Doc Gumshoe’s ignorance of endogenous morphine, has done to his thinking.
Daily about 11,000 Americans die of various causes. Some of the causes are sudden and unpredictable. Those whose deaths are from lengthy, painful illness, often took medication to ease that pain. A postmortem examination will reveal that about half those people, perhaps 5,500, die with pain medicines in their system. The analytic data actually published, reveals only 175 of these dead people to have had opioid pain medicines in their system. Doc Gumshoe ludicrously jumps to the conclusion that these 175 people died because they took pain medication. His irrational fears will escalate as that 175 number is adjusted upward to 5500, where the real number should rest, and that paranoia will worsen, because he completely ignores all the benefits that are happening from the use of the pain medication.
The Unintentional Deaths Initiative at the Centers for Disease Control were much more cautious in their wording. They characterized these 175 daily deaths as “opioid-related”, meaning that opioid medicines were found in the dead person, not that the opioids actually caused the deaths.
The reality is that most people die faster when left to die in horrible pain. The pain exhausts the nerves, elevates the blood pressure, and causes heart disease and stroke. The use of medicine to control that pain and lengthen life, is not harmful. It only seems harmful, because in our culture, we insist on imagining these medicines to be a hostile, foreign, invasive substance…a tradition that began in the 1870’s when cocaine was being promoted to Civil War veterans as a “safe” pain reliever that did not cause constipation.
Yet the scientific reality is that unless we’re prepared to make synthetic food entirely from carbon, nitrogen, and hydrogen, we have to eat plant and animal products that contain endogenous morphine, and our own bodies are going to use endogenous morphine to regulate how fast we metabolize what we eat.
Since I have been dealing with chronic pain, the inability to sleep longer than 2-3 hours has plagued me. Prescription sleeping pills are awful. They leave you lethargic with a medicine head type of feeling.
In the last 5 years I have had 2 heart attacks and most recently have had shingles. The doctor that treated my shingles said that lack of sleep can seriously compromise your immune system and a weakened immune system leaves you open to many other maladies.
Opiates are not my problem. Denying me a safe and effective pain treatment is causing me many problems.
Not sure I get your point. Opioid overdoses will essentially paralyze the respiratory system and lead to death. Fentanyl will do the same thing, but in quite small quantities. Engogenous morphine is not a threat, and exogenous morphine, in carefully controlled quantities, is an excellent analgesic. How is this, in your words, “malignant opiophobia?”
I have an intricate knowledge of opiates and an intricate knowledge of chronic pain.
First a background on my condition.
I have damaged ulna nerves that have required multiple surgeries. The scarring that my body creates, has surprised the surgeons that have operated on me. The original surgeries that I had were to decompress my ulna nerves. The succeeding operations were to remove the scar tissue that compressed my nerves and to relocate the nerves in an attempt to stop the recurring scar tissue growth and compression of my ulna nerves.
I live near Syracuse NY. Syracuse Orthopedic Specialists have some of the most talented and capable doctors in the country. Dr. John Fatti has performed most of my surgeries. Other surgeons have told me that if Dr. Fatti can’t fix it, it can’t be fixed. That speaks for his reputation.
After numerous surgeries over a period of about 6 years, physical therapy and non-narcotic pain relief, Dr. Fatti referred me to New York Spine and Wellness. I was originally started on non-narcotic treatments, including multiple nerve blocks.
Eventually I was prescribed 40 mg. per day of Oxycodone along with Gabapentin and the muscle relaxer Tizanadine.
Over a period of about 4 years, my opiate intake was increased to a combination of long and short acting opiates, (Oxycodone and Oxycontin) totaling 135 mg. per day . I remained stable at that level for over 4 years. This was an effective and safe treatment.
The CDC out of the blue, decided that doctors should not prescribe more than 60 mg. per day of Oxycodone which is the equivalent of 90 mg. per day of morphine.
Even though these guidelines were intended for primary care physicians, the pain management doctors, in an effort to protect themselves, decided to follow these guidelines.
Dr. Tiso, one of the doctors at NY Spine and Wellness tried to persuade me to switch to methadone instead of Oxycodone for my chronic pain. I refused due to the side effects of methadone. All of my arguments that I was stable and my treatments were safe and effective were refused. Dr. Tiso told me that he was not going to lose his license for me.
That is the crux of the problem as it pertains to chronic pain patients. The pain management professionals are not free to prescribe the best treatments. The CDC had an advisory board that was loaded with addiction specialists and did not give the pain management community equal weight in the decision making process. The raids and prosecutions that honest doctors, that strive to help their patients have endured is immoral.
In the end millions of people like me have been forced to decide to switch to less effective drugs that seriously impair their quality of life, or have their prescriptions reduced to the point that they have to decide which part of a day that they can function and must endure untreated pain for the rest of the day.
I am certain that the misguided CDC efforts have created a whole new class of illegal drug users.
I have been to Dr Tiso and left. Ny is a medical marijuana state. Tisa is not going to send you to another doctor as pain is what puts food on his table. There is an office in Brittenfield where you can go. I would suggest you begin there.
Macky,
Is it part of CNY family care? Do you have the doctor’s name or the name of the practice?
I would love to find someone that was more concerned about their patients.
It seems that Spine and Wellness considers you an account more than anything else.
This is sad and just shows how insensitive our Federal government has gotten to big to govern in such issues. Attorney General Jeff Sessions has no idea. And this is just one of many issues of the Fed needs to have States deal in such matters.
My dear Javi, what is truly important is that Dr. Thomas Frieden’s last minute launch of a campaign agains pain patients begun with recommendations from a secret panel stuffed with rehab interests, accomplished his goal of finding a glorious new job. Previously he was not too interested in the CDC, though he did show up for video and photo ops when Ebola and Zika afforded the opportunity.
In eight years he could have launched a formidable campaign to reduce back pain incidence by teaching correct posture and exercises from birth to death.
In contrast, his predecessor , Dr. Julie Geberdering, applied herself throughout her term to purge the CDC of those would research the safety and efficacy of vaccines. Now she is the powerful head of the Merck’ vaccine division.
Surely the long term wealth and prestigue of our bureaucrats is far more important that shooing pain and suffering from the American landscad
I for one am tired of the war on people in pain. Why should people who have real pain have to suffer because some people abuse pain killers. Humans will always seek out drugs to abuse. And the rest of us should not have to suffer for it. How many people need to kill themselves because they have too much pain to want to continue to live? Giving them over the counter meds is a joke. And marijuana only helps some..usually lesser…amounts of pain. And it is still illegal. I personally know one person who committed suicide due to lack of decent pain control. And then there was my father. After two unsuccessful back surgeries he was put on Vicodin for his pain. And he was able to continue his life for another relatively pain free twenty years. Able to retire and enjoy his kids and grandkids due to good pain control. Without vicoden he might have killed him self instead of living to 87 and dying of unrelated causes. They never discuss how many suicides that good pain control prevents. Or how miserable people’s lives are who have chronic debilitating pain. The war on people with pain has to stop.
diane Thank you for mentioning the suicide angle. I have personal knowledge of 3 who killed themselves for relentless pain and nearly everyone i talk to on the subject knows of someone. I think that is vastly underreported or misreported as an OD.
Commonly alcohol & some drug combo or just alcohol and highspeed single vehicle crash.
Has anyone heard of LETTUCE EXTRACT. It is on the internet if you search for “Lettuce Extract heroine ” you will find it.I It is supposed to be a natural remedy pain killer and an antidote to heroine addiction. It is supposed to relieve the craving for heroin. It is a natural remedy for headache pain and stress also. It is not and addictive substance. I’m not sure what the active ingredient is. It comes from a wild lettuce plant that you find in your yard. It’s worth checking out. I do a lot of research on the internet and came across it. It is available on Amazon. Very cheap too. Anyone with an addiction – it may be worth a try. I will order some and check it out next time I have a headache. I am all into natural remedies. I will check out the active ingredient also to see what it is. They say it is a non-addictive substance and a remedy for heroine cravings.
Kratom is another alternative that some reportedly find effective for pain and for reducing opioid cravings judy2017.
Quick Fact: The U.S. comprises less than 4% of the world’s population and consumes 80% of the world’s opioids. Do the math.
US comprises 4% of the world and consumes 80% of the food, gas, clothes, DVD’s, Guns, exercise equipment, etc. Things are available in the USA and we have a larger portion of the population that can afford to spend foolishly, without regard for the future. Or, that does spend without regard. If you are a producer of anything, America is the place to be selling.
We also produce more per capita than anyone else. Maybe it’s that fact that causes the pain in the first place? I don’t know?
True maybe but come on. Ground Control to Major Shorty! -https://youtu.be/cYMCLz5PQVw
Those of you at wits end with the medical establishment may want to look into a tree that has been in use since the caveman, Kratom. It’s related to coffee, non-narcotic, and as far as can be determined, nearly harmless, and almost impossible to overdose. You will vomit before you can eat too much. It’s been used also to wean off narcotics to good effect. There is no buzz to speak of. I can’t tell I am taking it, but it makes my pain meds last longer. There are several groups on facebook where you can lurk or ask questions. Do some research and decide for yourself. I am thinking about firing my pain Dr cause he has been under dosing me for years. Then get this. When Prince died he took me off oxycodone. HE replaced it with oxymorphone, believe it or not.
I was run over by a car and I also have crohns disease. My pain levels where and are extreme from time to time. Needless to say I became addicted to painkillers over a period of time. Trust me it’s not fun. The VA got me off them and now I take none. However my pain sucks and I do think about how well painkillers worked so well. But you have to take more and more to get relief. Anyways I rather suffer then be an addict because that’s what I was and I was not fun to be around. If they could make a drug that does the same pain relief without getting high or addicted then that be the wonder drug
I am 60, was diagnosed at age 19 for degenerative disc disease when applying for a job with Western Pacific Railroad. Doctor told me to get a job working with my head, not my hands, or I’ll be cripple by the age of 50. I am now a health insurance broker for the last 32 years. I have many clients who have pain, but one client about my age and same condition told me about Blue Green Algae…I will not live without this stuff. https://www.puritan.com/green-food-057/klamath-lake-blue-green-algae-500-mg-002542
I saw an interesting report indicating about 40% more opioid compications/ODs in states that increased Medicaid access. As an oncologist, I prescribe opioids pretty freely but was surprised to discover (about 15 yrs ago) that the oncology dept was a small player in the overall rx within our VA of oxycodone and morphine. No easy answers though
opioid currently approaching FDA approval that is – based on solid evidence – fundamentally not susceptible to abuse. How can this be? I’ll explain in my next post. Can’t wait to read about this.
I’m going to be a spoiler for Doc Gumshoe. I believe it is Nektar Therapeutics -NKTR – passed safety drug liking with flying colors. Also had 65% (I believe – memory now) better pain control for lower back pain. It is a opioid but they changed a molecule to make it non-addictive. I have been waiting for over a month for Doc to discuss it as he promised back at end of August.
Correct! Nektar’s drug, so far named only NKTR-181, is not yet approved, but is FDA fast-tracked. I’m working on my next blog right now, should finish in a couple of days, & will have quite a lot more to say about that promising drug, as well as other possible ways around the opioid dilemma.
Well, let me be the judge of my own pain. Most doctors don’t feel my pain, in fact, none of them do. But I can agree with the person two letters below here, that the drug “Hydrocodone” does not do what it’s supposed to do.
I had bone surgery in 1991, the doc gave me hydrocodone, and I took one of
them, and it did nothing. I took another, and it did nothing for the pain.
I thought, hey, this is supposed to be a pain medication, and I took another,
and then another. It did not cut the pain, but it started to make me have trouble breathing. I stopped taking it, because from my purely anecdotal experience “Hydrocodone” will first kill you (by shutting down the central nervous system, including breathing) before it starts doing anything for pain. The drug company that invented that is simply wrong or lying. I never took Hydrocodone again. I still would love to take the doctors, lawyers and FDA officials that approved a dangerous, yet worthless drug, to task, but they are in charge, and I am not.
I have come to believe that the natural drugs such as the actual opium poppy sap, natural aspirin from the willow trees, and likely also marijuana,
are working better than the artificial drugs, and they are forbidden only because the drug companies a) want to make money, and b) would rather kill you than help you. I am now not taking any pain pill, except may be
an occasional ibuprofen or aspirin. Nothing else, oh, yeah, of course a glass of red wine is highly recommended to make you feel better for a while.
As you say in your opening about pain. Let everyone use what pain medication works best for them.
most pain is the result of body response to inflammation. Instead of using opiates and other pain blocking methods you should treat the inflammation and this would naturally reduce pain. Bromelain – This harvested from the stem of the pineapple plant and it has been used for years to treat
Papain – Papain aids in digestion and it is also used to tenderize meat and used to treat inflammation.
Citrus Bioflavonoid Complex – This is an inflammation ingredient believed to have anti-oxidation properties.
Rutin – Believed to strengthen blood vessels and promote healing.
Boswelliaserrate – It is used to treat arthritis and calm inflammation. It can be used both orally and topically.
Other pain and inflammation treatments are: – Ginger Root, Turmeric extract, Devil’s Claw, Vitamin E, L-glutathione, Serrazimes
This is a very sensitive debatable topic without one simple answer. I have smoked cannabis years ago and if a molecular substance in it or combinations of substances it should already on the market. And if a opioid is currently approaching FDA approval and not susceptible to abuse then great. Won’t say in this technology dispensation of time it’s not impossible.
The recreational users are often self- medicating for emotional pain. If that gives them relief, why should others think they have the right to meddle with people’s choices.
Did those who died, die because they had access, or because they did not have an assured continuing access equal to their needs? I suspect the second.
I agree Empath -The people over dosing with these non pharmacy drugs and not under doctors care are wreaking havoc on the health industry. Better regulation are being put in place now. The thing with prescription’s is follow the directions as stated on prescription. Do not deviate from dosage by taking more sooner than needed. Good doctors prescribe with body mass index (BMI), and skip dosage if not needed. Take as needed accordingly to direction on bottle. This is very important. Also search on internet to read experiences of people’s nightmares of not following prescription’s directions. If following and have issues talk with doctor and talk certified pharmacist about your medications.
CANNABIS OIL, WITH THC NOT CBD IN LARGE DOSES WILL DEFINITELY WEAN AN ADDICT OFF OF OPIODS, REIEVE PAIN AND THE MENTAL HIGH IS FAR SUPERIOR TO ANY OPIOD INDUCED STATE. THC CAN THEN BE SUBSTITUTED COMPLETELY FOR PAIN RELIEF GOING FORWARD AFTER BEING WEANED. I AM 79 YEARS OLD AND HAVE USED CANNABIS SINCE .1965. I USED CANNABIS TO GET OFF OF ALCOHOL WHILE I WAS A PHOENIX COP. I HAVE BEEN USING IT EVERY SINCE.
Bad thing about cannabis or any derivative and being on Social security is that it is handled at the federal level. And it is against federal law to use illegal substances. And could possibly disqualify you for social security disability or retirement benefits. Don’t know this for a fact but would look into it before I used it. Even if it’s leagal in the state you live.
Cannabis use also makes purchase (possession?) of firearms a federal felony, even though cannabis itself is legal in some states. Sooner or later, this dichotomy will have to be rectified.