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Today I am Mad and Sad

Yesterday I was overjoyed to recognize that I’m doing the best I can. Today I’m curled up on the couch — head pounding, tummy aching, sensitive to light and sound — and I’m angry.

The farmers’ market has brioche doughnuts for a special bake sale today. Many extra vendors are set up, selling local crafts. I want to be eating deep fried buttery dough while strolling the aisles for a perfect gift. But, no, I’m at home for the fourth consecutive day with a level 8 migraine.

Hart’s cleaning the house for my mom’s visit, spending his free time taking care of me. He works, in part, to support me and keep me with health insurance. I bring in very little income, so he has to make sure the bills are covered. Instead of relaxing in his non-work hours, he does the full share of housework. And he doesn’t even get to listen to music while doing it because music is too much for my head right now. He’s not even sick and yet he suffers. He clams it is worth it to get to spend time with me. Today I find that hard to believe.

I’m mad that I don’t get to live the life I want to live and sad that my husband can’t either. I know it isn’t because of me, but it is because of my illness. I know I shouldn’t feel responsible, but I do. I’m mad and I’m sad and my freaking head hurts. And I can’t even comfort myself with a latte because coffee is a suspected trigger. Grr.

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Treating Pain With Opioids

multicolor pillsKUOW, one of Seattle’s public radio stations, had a program yesterday on treating chronic pain with opioids with an expert panel weighing in. I only listened to the first half, but what I heard was informative and interesting.

They discussed a recent rise in overdoses among chronic pain sufferers. These are thought to be accidental, resulting from the need to increase dosages when the the patient develops tolerance.

Something I didn’t realize is that, according to the panel, most of the studies on opioids and pain focused on cancer pain, not chronic pain. There’s a significant distinction between medicating people with progressive, potentially fatal diseases and treating people with lifelong pain. Addiction and dependence are concerns, but tolerance — and the higher doses it requires — is a big risk too (not to mention potentially fatal).

Not covered in the program was that opioids appear to change the brain so that the patient actually becomes more sensitive to pain. Building tolerance is not only your body getting use to the drug (called desensitization), but you actually become more sensitive to pain overall (referred to as sensitization), not just the pain that you are specifically treating. It also increases allodynia, which is already a migraine symptom.

This is a summary of the clinical implications of these findings:

“The diminishing opioid analgesic efficacy during a course of opioid therapy is often considered as a sign of pharmacological opioid tolerance. As such, an opioid dose escalation has been a common approach to restoring opioid analgesic effects, assuming that there are no contraindications and no apparent disease progression. . . . [A]pparent opioid tolerance is not synonymous with pharmacological tolerance, which calls for opioid dose escalation, but may be the first sign of opioid-induced pain sensitivity suggesting a need for opioid dose reduction.”

While I firmly believe that pain sufferers should have access to opioids, the issue is much more complicated than DEA intervention. They’re an easy scapegoat and a problem for sure, but the body’s roadblocks may be a greater obstacle. Perhaps we should listen to our bodies and not rely so heavily on opioid pain relief.

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Opiods: Addiction vs. Dependence (and Getting the Meds You Need)

Pain patients are highly unlikely to be addicted to painkillers (opiods). They are, however, likely to become dependent on a drug, which is very different than addiction.

If you stop taking an opiod, you may have withdrawal symptoms, including nausea, vomiting, diarrhea, sweating, muscle twitching and aches and pains, and increased pulse and blood pressure. Even though this list is reminiscent of the withdrawal scene from Trainspotting, it doesn’t mean you’re an addict. It means that you have a physical dependence on the drug.

You can develop a physical dependence and experience withdrawal symptoms with many different meds, including antidepressants, but you aren’t addicted to them. It works the same way with opiods. Docs make a schedule for to reduce the amount of a drug we take slowly to avoid these unpleasant symptoms, but they may be inevitable. Just as you might be nauseated and dizzy when you stop taking an antidepressant, you may have diarrhea and a racing pulse when you stop taking opiods. (For a personal tale of dependence and withdrawal, read Chapter 19 in All in My Head by Paula Kamen.)

Tolerance is another physical phenomenon that may cause fears that you’re addicted to opiods. Maybe a small amount of a drug relieved your pain initially, but over time you need higher and higher doses to maintain the same level of pain relief. Like dependence, tolerance is not a sign of addiction.

Patients who take opiods may exhibit addict-like behaviors (called pseudoaddiction) — like hoarding pills and being preoccupied with taking the next dose at the precise time it is OK to do so. Understandably, seeing a patient with these behaviors make a doctor very cautious. However, pain patients stop behaving like addicts when they get adequate pain relief.

That deserves repetition and it’s own paragraph: Pain patients stop behaving like addicts when they get adequate pain relief!

Pain specialist Scott Fishman sums up the difference between patients who are dependent and those who are addicted well: “The difference between a patient with opioid addiction and a patient who is dependent on opioids for chronic pain is simple. The opioid-dependent patient with chronic pain has improved function with his use of the drugs and the patient with opioid addiction does not.”

You may be reassured that you’re not an addict, but that doesn’t mean it will be any easier to get docs to prescribe opioids. Here are some thoughts for patients seeking pain relief with opioids:

  • It will probably take multiple visits to a pain specialist to get a response. He or she needs to get to know you and your case before prescribing opioids.
  • A specialist at a pain clinic rather than a pain specialist in a solo practice or one in a team of many different types of doctors may understand your pain better.
  • Pain specialists may not give you the time of day if you haven’t seen a neurologist or headache specialist first.
  • Patients who say they’ve tried everything to treat their headaches often haven’t. There are so many preventives and abortives available that there are probably many that you’ve never considered. This may be a sticking point with a pain specialist. (Although I know that many readers have tried just about everything.)

And some recommendations:

  • If your neurologist agrees that the next step for you is opiods, ask him or her to call or send a letter to a pain specialist to explain this.
  • Have your neurologist’s office send your medical records to the new doc before your appointment.
  • Look for a doctor who specialized in pain medicine during his or her residency (probably through a fellowship).
  • Seek out doctor who finished residency recently. He or she may be more afraid of legal repercussions, but may also have more current attitudes about pain management.

P.S. I’m afraid this reads like a tip sheet on feeding a prescription painkiller addict’s habit. Chronic pain management with opiods is absolutely necessary for so many people that I’m publishing it anyway. So there.