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Can Painkillers Cause More Harm By Masking Pain?

Ben’s story in When Is a Pain Doctor a Drug Pusher?, the NY Times Magazine article I wrote about yesterday, brought up something I’d never thought through: Opioids don’t correct the problem that causes pain; they just mask the pain. Couldn’t this cause more harm than good?

Ben, a farmer for whom “. . . years of pushing 800-pound bales of hay wore out his back,” said:

“They [opioids] helped my pain. I could get out and work, use the bulldozer. I was working a 250-head cattle herd. I was doing everything relatively pain-free because of the drugs. They gave me my life back.”

When there is a physical cause of pain, won’t doing activities that the injury made impossible cause further degradation in the damaged area? The same areas of the body are stressed as were before, but the body’s warning system can’t do its job.

Even when pain can’t be traced to a direct physical cause, as with headache disorders and migraine, masking the pain may still be harmful.

Say I have enough pain relief to return to my previous levels of activity. The “lifestyle management” tools I use now — regular sleep, exercise, minimizing triggers, etc. — would no longer seem as important. I’d probably let them slide. Why worry about triggers if they don’t affect my daily life?

But I’d still have chronic daily headaches and migraines, I just wouldn’t feel the pain of them. Getting rid of pain would not keep chronic daily headache and migraine from doing harm in my body and brain. The potential for long-term damage remains. Also, migraine has many symptoms other than pain that a painkiller can’t treat.

On the contrary, some argue that the brain learns to be pain and gets stuck in a rut. If something no longer causes pain, then the pressure on this mechanism could let up and allow the brain climb out of it’s pain rut. If this is the case, opioids make sense.

I’m not arguing that opioids shouldn’t be available for patients who need them. (My stance is the opposite.) However, treating an illness and treating pain caused by the illness require different approaches. Getting closer to the source of the problem when possible seems the logical place to start.

Addiction is the problem child in the realm of opioids. Sometimes the quieter kid really needs the attention.

Related posts

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Opioids for Chronic Pain & Questioning Pain Doctor vs. Drug Pusher

Pain specialist Ronald McIver is serving a 30 year sentence for drug trafficking. The drugs? Opioids prescribed for pain relief. NY Times Magazine looks into McIver’s case and the mess surrounding opioids for pain management.

The in-depth piece definitely supports the use of opioids for pain management. I’ve created a PDF of the article so I could highlight what jumped out at me. I didn’t highlight any details of McIver’s case.

I, too, believe that opioids should be available for people with chronic pain. However, the devil’s advocate in me jumped on a bunch of thoughts that I hope to explore this week:

  • Not feeling the body’s pain signals isn’t necessarily good.
  • The effects of long-term opioid use aren’t well known. Most research has been with cancer patients, who do not use the drugs for extended periods.
  • Building tolerance is not only your body getting use to the drug (called desensitization), but becoming more sensitive to pain overall, not just the pain that you are specifically treating.
  • When most patients (and some doctors) feel like they’ve tried
    everything, they haven’t. Often other treatments should be considered
    before turning to opioids.

Just reading this list may raise your ire. Please give me a chance to write about the topics before jumping down my throat. We’ll be able to have a more thorough discussion that way.

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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.