Chronic Pain Management: An Appropriate Use of Opioid Analgesics

[Justin]

The following resources are from the American College of Physicians and even though they are geared toward physicians, these resources have a lot of great information that I know will be of benefit to the Spine Patient community here.

This 8-page PDF is about chronic pain management and opioid therapy--it is a must read!

• ACP Internist Extra. Chronic Pain Management: An Appropriate Use of Opioid Analgesics

This is also a great resource for Spine Patients: it includes a chart with information about the

• Dosing and Conversion of Opioid Analgesics.

The following definitions have been agreed upon by The American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine. (Scroll down to the second page of the PDF.)

• This PDF explains the difference between addiction, tolerance and physical dependence.

[Terry Newton]

These articles are an excellent resource in understanding the treatment of chronic pain, opioid therapy, alternative pain management techniques, increased tolerance, physical dependence and, addiction.

I will also chime in here, with Justin, in the treatment of pain and the potential for addiction, withdrawal syndromes, how long-term opioid use can set a person up to become hypersensitive to pain which becomes cyclical in nature and, everything you wanted to know about; "The Betty Ford Center" since I was a therapist there at one point in my life.

Terry Newton

[Jack-of-all-trades]

Terry,

I don't mean to sound argumentative but there are many people that have been able to live meaningful lives because of opioid theraphy. Sometimes when we work in a place where we only see the negative we lose sight of the positive. Granted, there are many therapies that should be tried first but with adequate supervision and knowledge they can be very effective in long term chronic pain control. They can also be effective as an interim theraphy while under the care of qualified and trained pain management doctors.

My big squalk is there are to many practitioners who call themselves "pain management" but don't have adequate training in the use of opioids. My doc recently took over care of a chronic pain patient who was on very high doses of Actique, a oral fentanyl lolipop. This type of med should not be used for long term care. A responsible pain doc knows how to rotate opioids when tolerance builds to an unacceptable. From the physical effects on our bodies, opioids are quite safe when managed properly.

[Katie]

" how long-term opioid use can set a person up to become hypersensitive to pain" Terry, or others, can you tell me if that is what has set me up for the type of discomfort I feel from simply being touched?

For me, the ultimate pleasure had always come from simply being touched. A backrub, etc. just normal things. But now any of that is very uncomfortable for me. I can't say it is exactly painful, but it definitely feels bad. Like my skin is being rubbed with sandpaper or something...just weird. How can something so simple and nice be turned into more misery?

Are the nerves just fried or what?

[muddywaters]

I've been told that I'm inoperable, despite having "severe" foraminal stenosis that fortunately has been responsive to an epidural. Since I'm starting to auto-fuse to an unknown degree, pain mgt. is is utmost importance to me.

I have done some research on Medscape (great articles!) and elsewhere re: hyperalgesia. My sense is that this is related to tolerance and its symptoms apparently can be "rebound" pain where the pain site pain (did this make sense?) becomes worse; also, there can be pain that to me approximates Complex Regional Pain Syndrome in my extreme amateur opinion.

I"ve had to increase my Avinza dosage (it's been a blessing so far) but am now taking Neurontin that I"m told by a smart PA *can* diminish my nonstop/drill-bit back pain. We discussed the different types of pain and I questioned that Neurotin is mostly for neuropathic pain, not discogenic or straight-on mechanical (bodies rubbing against each other like discs on discs/spondylosis). He said that it can help.

So far, it has but I can see that I'm starting to get some Avinza tolerance but to a lesser degree than without Neurontin. I'm too busy to research this vast subject and imo, pain docs have varying philosophies. For instance, I saw one who said "no narcotics" whatsoever and I left her b/c she had an authoritarian personality that doesn't work well for me. Now I'm seeing a PM doc who is OK with narcotics but I don't know what he'll do if one's tolerance increases crazily or if one has symptoms that Terry describes -- hyperalgesia.

I also find the literature on hyperalgesia confusing but I will write to Terry or call him [where's your number buddy?] b/c this might indeed be an inevitable factor in long-term non-cancer opiate use that I will eventually face.

I wonder too if there is opiod hyperalgesia if detoxing (odd, I don't think insurance pays) would truly help so one starts again at "ground zero" for opiate therapy for those who have no choice. If another person gives me a Sarno book as a gift or recommends cognitive-behavioral means, I'll throw a chair through a window (if I could!).

This is an interesting topic that I wish I could learn more about. It's also intricate and I don't know jack about mu receptors, etc. and more physiology so the literature is more meaningful.

Wow, what a long post. I hope that I haven't bored people too much b/c I'm boring myself.

Chow ~ ans

[Jack-of-all-trades]

I've been told that I'm inoperable, despite having "severe" foraminal stenosis that fortunately has been responsive to an epidural. Since I'm starting to auto-fuse to an unknown degree, pain mgt. is is utmost importance to me.

I have done some research on Medscape (great articles!) and elsewhere re: hyperalgesia. My sense is that this is related to tolerance and its symptoms apparently can be "rebound" pain where the pain site pain (did this make sense?) becomes worse; also, there can be pain that to me approximates Complex Regional Pain Syndrome in my extreme amateur opinion.

I"ve had to increase my Avinza dosage (it's been a blessing so far) but am now taking Neurontin that I"m told by a smart PA *can* diminish my nonstop/drill-bit back pain. We discussed the different types of pain and I questioned that Neurotin is mostly for neuropathic pain, not discogenic or straight-on mechanical (bodies rubbing against each other like discs on discs/spondylosis). He said that it can help.

So far, it has but I can see that I'm starting to get some Avinza tolerance but to a lesser degree than without Neurontin. I'm too busy to research this vast subject and imo, pain docs have varying philosophies. For instance, I saw one who said "no narcotics" whatsoever and I left her b/c she had an authoritarian personality that doesn't work well for me. Now I'm seeing a PM doc who is OK with narcotics but I don't know what he'll do if one's tolerance increases crazily or if one has symptoms that Terry describes -- hyperalgesia.

I also find the literature on hyperalgesia confusing but I will write to Terry or call him [where's your number buddy?] b/c this might indeed be an inevitable factor in long-term non-cancer opiate use that I will eventually face.

I wonder too if there is opiod hyperalgesia if detoxing (odd, I don't think insurance pays) would truly help so one starts again at "ground zero" for opiate therapy for those who have no choice. If another person gives me a Sarno book as a gift or recommends cognitive-behavioral means, I'll throw a chair through a window (if I could!).

This is an interesting topic that I wish I could learn more about. It's also intricate and I don't know jack about mu receptors, etc. and more physiology so the literature is more meaningful.

Wow, what a long post. I hope that I haven't bored people too much b/c I'm boring myself.

Chow ~ ans

Some points to consider:

Unless you have been through some sort of medical training, AND been around for a while, don't get confused by reading studies. Most have not yet been verified by accepted test standards and reproduced by others.

People tend to read abstract signs and symptoms and jump to conclusions that may not apply. The medical community calls them 'zebras', meaning in the desire to impress by making a DR HOUSE type diagnosis we overlook the common most like causes. We can even do this to ourselves.

It's easy for us, in our desperation to find a solution, to grasp at straws. To some extent, the practice of medicine is an art form. God designed an amazing machine that we don't truly understand the many ways one part affects the other. We need to study to better understand and help plan what is needed to help our health care but ultimately need to accept the direction of a trusted healthcare provider. Doctors don't often try to treat themselves but seek the care of a trusted, experienced medical practioner.

Be aware that 'What F' is our enemy. Don't give him more attention than he deserves.

[muddywaters]

I agree that the literature is for insiders; my brother, a retired MD professor of Something Else told me not to try to read the literature but he was primarily thinking that many researchers do not disclose funding sources. I used to be a researcher in another field but I think that I'm capable of reading review articles but most definitely have lost the acumen in sorting out experimental studies e.g. how stats are played with, bias, etc.

The varying philosophies of pain management have directly affected me. My first pain mgt. doc the moment I entered the door while on 45 mg of Avinza said "no narcotics" and that "I'll have to taper you". I did not understand *why*. I told her that I would be in excruciating pain and told my internist this. He suggested another place who takes care of of a doctor colleague of his who goes to work everyday on "narcotics". I feel that I must clarify this b/c I take umbrage in being told not to play doctor. I must think for myself/sort it out b/c I do not trust any surgeon or PM doc implicitly.

I don't know what you mean about "F" and the enemy; sounds interesting.

Now, as a former PA-C (hey, I wanted to be one in the '80s!), can you answer the question? Sorry that I'm curious but that is me and if I have time on my hands, I will probe intensely.

Best ~ m

+ + +

Some points to consider:

Unless you have been through some sort of medical training, AND been around for a while, don't get confused by reading studies. Most have not yet been verified by accepted test standards and reproduced by others.

People tend to read abstract signs and symptoms and jump to conclusions that may not apply. The medical community calls them 'zebras', meaning in the desire to impress by making a DR HOUSE type diagnosis we overlook the common most like causes. We can even do this to ourselves.

It's easy for us, in our desperation to find a solution, to grasp at straws. To some extent, the practice of medicine is an art form. God designed an amazing machine that we don't truly understand the many ways one part affects the other. We need to study to better understand and help plan what is needed to help our health care but ultimately need to accept the direction of a trusted healthcare provider. Doctors don't often try to treat themselves but seek the care of a trusted, experienced medical practioner.

Be aware that 'What F' is our enemy. Don't give him more attention than he deserves.

[Jack-of-all-trades]

I need to do a better job of proofreading. It should be "WHAT IF". It is hard enough for us to deal with the knowns without dealing with the what ifs. I needed to tell myself the same thing. This post help to do that.

You are right about who finances studies. Some are little more than fictitious drama. It is surprising how hard it is to set up a study, especially based on opinionated multiple chose questions.

[muddywaters]

Ahh, if only I could get away from wondering the "What-If's". I can't! It's my neurotic nature that no med except anesthesia can control.

Be well. - m

[muddy]

Now I think I"m screwed. After taking about 11 Norco's per day, I saw at UCLA a PM specialist/interventionist. He put me on 30 mg/Avinza and I thought OMG, I feel round-the-clock relief. Then about a month later, I needed 45 mg. Now, months later, I am up to 240 mg of morphine sulfate and I saw an ENT who would not fix a deviated septum due to my high Rx. I am inoperable I think and it's freaking me out e.g. if I get appendicitis. Or maybe I'm over-reacting and I need the right anesthesiologist but most definitely will be treated as an addict in recovery and be under medicated post-surgery.

So: Can I suffer and taper? I don't think so. Or move to Suboxone? What if I need surgery on Suboxone? Oy vey! A drug that neutralizes other drugs?

I am very confused and bummed now. I need answers and think it will take a while. I fell into the TRAP.

I am open to advice. If I was an addict (I have zero psychological craving), it would be easier to detox b/c I wouldn't have back pain.

I wonder if I have hyperalgesia or if this is a mere boogeyman.

Lost.

A former Alpha Male, now whimpering ~ ans