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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.

Related stories:

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Opioids a Major Topic at the American Academy of Pain Management’s Annual Meeting

Opioids were, not surprisingly, a major topic at the American Academy of Pain Management’s annual meeting, which was held last week. The three main areas discussed were opioid therapy and prescribing opioids, as well as the legal implications of both. The role of cannabinoids (more commonly known as medical marijuana) as a new class of analgesics was also considered.

I haven’t seen many news stories come out of the meeting. I’m hoping for more press releases now that the meeting is over. In the meantime, here are some morsels:

Opioid Prescribing At Forefront Of Pain Medicine Meeting
Opioid treatment is an essential component of pain care for many patients and can be delivered safely and effectively, according to Frederick Burgess, M.D., Ph.D., AAPM president, who estimates that 20 to 60 million Americans live with chronic pain.

“Knowing what the current drug diversion scams are can help physicians decide who is trying to take advantage of them,” says Burke, commander of the Warren County Drug Task Force in the Cincinnati area of southwest Ohio. “The vast majority of patients are not drug seekers and that is where the balance comes in. We do not want to deprive legitimate patients effective pain relief through legally prescribed medications because of the acts of a relative few.”

Scientific Research Highlights Of The American Academy Of Pain Medicine Annual Meeting
Despite media reports suggesting that the Internet is the primary source for illegally obtained prescription opioids, only a small percentage of opioid analgesic addicts who are seeking methadone maintenance treatment reported this as a direct source of their drug supply.

The most commonly reported sources for obtaining opioid analgesics included: dealers (79.96%), friends or relatives (51.3%), physician prescription (30.17%), emergency room visits (13.53%), theft (6.48%), forged prescription (2.48%), Internet (2.9%), and other (not specified) (2.7%).

. . .

[R]eports from the local sources indicated that hydrocodone and oxycodone (immediate-release and extended-release) were reported to be the most frequently abused and diverted opioid analgesics. . . .

Abstracts from the poster presentations are also available.

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SHOCKING Prescription Drug Scandal! *Gasp*

That’s my attempt at a tabloid headline; I’m sure the tabloids — and all other media sources — are having a great time with this one. Supreme Court Chief Justice William Rehnquist was addicted to prescription painkillers. (Could he look any more stoned in the photo?)

Chronic pain patient advocates are arming themselves to defend the use of opioids for pain management during the latest onslaught of painkiller addiction coverage. I’d like to think that when the scandal dies down, the public will have a better understanding of the use of opioids for chronic pain management. I have no doubt that I’m lost in Pollyanna land.

An advocate is never supposed to say this, but I can’t help but think the battle over prescription painkillers has already been won.

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Treating Pain With Antioxidants

Antioxidants have made the news a gazillion times in the last few years. After listening to the same information over and over again, I tuned it out. Today I’m paying attention.

Synthetic antioxidants nearly eliminated pain-like behavior in almost three-quarters of mice with inflamed paws. Mice aren’t humans, of course, but it’s an interesting start. Antioxidants are an emerging research interest; with findings such as these, the interest can only grow.

Right now pain treatments options are at extreme ends. OTC painkillers are on one side and opioids are at the other end, with little in between. Finding an effective middle-ground has been tough, but the antioxidant research appears promising (to my untrained eye).

Antioxidants neutralize free radicals, substances that damage cells. While our bodies constantly produce free radicals, healthy tissues inactivate these damaging substances and keep their levels in check. It’s when free-radical production somehow exceeds the body’s natural defenses that problems occur. Researchers have linked this excessive production to diseases like cancer and Alzheimer’s.

A handful of studies published in the last 10 years suggest that free radicals may also contribute to chronic pain. Left unchecked, free radicals build up in the body and can further damage already-injured tissue.

An equally small number of studies, including those by Stephens, suggest that antioxidants may fight chronic pain by helping the body to break down free radicals.

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Responsibility & Narcotics

Posting on the article Victim of Pain is Also Victim of Uncaring Doctor, Kevin, MD points out that “for every responsible narcotic user, you have another hundred who play the drug games.”

As a pain patient I want to kick and scream (and have), yet I know he’s right. (I’m not convinced it’s one to 100, but do believe that more patients come in seeking drugs than pain relief.)

The problem is impossible to solve. It’s great if the DEA gets off doctors’ backs, but drug-seekers remain. Doctors still have to decide which faction each patient represents. That’s no easy feat. And pain patients will continue to be undertreated.

In any case, the comments on Kevin’s post are of interest to any pain patient.

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