UCLA Pain Clinic/SM

[ans]

Went here today and liked being checked by a nice resident and efficient doctor who suspect that I might have S/I joint problems that could account for intense (illogical re: dermatome theory, not that I've had a recent discogram). hip/quad/lower leg pain and w/do injections. They put me on Avinza which is a "rara avis" rx (people drive from 50 miles away to the hospital pharmacy to get it filled) and provided a coupon whereby I hardly paid anything for this rx that my BC would deny. Thus, recommended. Of course I freaked at hearing that I'd take morphine sulphate (closet conservative I am) but he explained the logic: no highs/low, better to prevent respiratory depression. Hopefully w/Celebrex I can continue my career journey w/o being flattened and being cognitively impaired - always a concern when inherently "slow".

Recommended.

http://www.uclapainmanagement.com/aboutus.nxg

[Jack]

I don't know you age or how long you have struggled with chronic pain. My view is that narcotics for the young or young at heart should not be considered a cure but used to get you through the time period it takes to find a permanent or at least a point where pain is not the dominate factor in a persons life and you can make it without narcotics.

Please don't take my remarks as one who is looking in a condescending manor. Yes, I take pain meds myself. It makes for a very bumpy life. Use your pain meds as an interim patch. Look for a different job, or quit work for a while to get stuff under control, if possible.

[2cool4U]

I feel I must counter that opinion. Opioids are no longer taboo when used for pain management. Viewing them as only a short-term necessary evil is an attitude in need of an update. It reflects the viewpoint of medical professionals trained more than 10 years ago, and it is often an impediment to getting appropriate treatment for pain.

According to recent literature, less than 1% of people who use them for legitimate pain become addicted to them. There are certainly complications of use, which anyone can look up on the internet. For many patients, however, they are an integral part of pain treatment and are necessary to allow the patient to function at an appropriate level. Indeed, many don't have a "permanent" solution available to them. Advising them against opioids may not be in their best interest. I am not qualified to give complete advice to patients regarding the use of opioids, but the risks of low daily doses is much less than the risk of taking high doses of NSAIDs every day, especially when those NSAIDs don't give relief. When short-acting opioids are not effective, longer acting medications can be given. After a short acclimation period, most patients do not get drowsiness, decreased mentation, etc. Of course, physical dependence occurs and doses must be tapered gradually when stopping. Tolerance occurs, and doses may gradually increase if pain control is not achieved. These things occur to some degree in every patient, but they should not be viewed as reasons to avoid the medications and suffer from pain.

If others would like more information, I'd suggest checking out the following resources:

www.painfoundation.org American Pain Foundation

"The War on Pain" by Scott Fishman and Lisa Berger (published 2001, BTW)

There are, indeed, many others. These two I'm reciting from memory. Maybe others can chime in with helpful resources.

Respectfully,

-tc-

[scduggan]

Dear TC,
Thank you so much for your post. It is a little eerie as I plan on calling my OS for a referral to a pain management doctor tomorrow. It has taken me such a long time to get to this. I have been prideful thinking that pain management is good for others but not for me. I feel myself physical condition getting worse each day as I wait for ADR surgery. I even called TBI last week for information on the Freedom Lumbar trial. I don't know jack cheese about the Freedom disc. I certainly do not need to rush to be in a trial....just feel like I have to do something even if it is wrong. I will always say it is not the pain...pain smain! It is the way it wreaks havoc on one's life. It is such an energy drain. I realize I know NOTHING about pain management. All I know is I hear forum members write about "staying ahead of the pain". I don't think I have had one minute ahead of the pain. My OS is old school and gives me Lortab 7.5. I might be running along BESIDE the pain for about two hours after taking my meds. So, (sorry for the rambling) I will wade through uncharted waters and try pain management. Especially after all the things you stated regarding the potential benefits. My masterpiece insurance appeal letter will be mailed tomorrow. I have United Healthcare so...tough beans for me. I will remain hopeful. Miracles happen. Thank you TC, for your insight, and for giving me a new outlook......and some much needed courage. One last thing, am I assuming correctly I will need a referral from my surgeon?
CD

[2cool4U]

I found this after a brief search. This links to a specific page on the website "stoppain.org." Of specific relevance here are the paragraphs on the mu agonist opioids, the most prescribed drugs. This reference specifically states "Sleepiness, fatigue, dizziness and mental clouding. These are common at the start of therapy and usually pass after a short while." It is a very common misconception that one cannot properly function while taking pain medication.


CD, glad the info helped. Be sure to be your own advocate when you see your new doc. Make sure you're on board with the treatment plan, and be sure to speak up if something isn't working. Yes, you probably will need a referral letter from your primary physician or a specialist, and the pain doc will need info from them about your current prescriptions. You will likely only be able to get medication from the pain doc once they start your treatment plan. Getting meds from more than one doc is a big red flag, so be sure you're happy with your choice.

Hope this info helps.

http://www.stoppain.org/pain_medicin...on/opioids.asp

[ans]

Thank you so much TC for your information. I take no offense; I had to change careers from an active one to a more sedentary on as I'm 56 and lived an OK life. This is all new to me but it sure beats the highs/lows of taking Vicodin, etc. and my pain doc/an interventional anethesiologist so far is aggressive in trying to figure out why I have new/excruciating pain patterns that a respected ortho surgeon in Century City couldn't imagine.

I already got to taking some of the time-released beads out of the lowest dose Avinex and could think today. It makes me very hopeful to think that I can be productive, live at level 2-3 pain (as the pain doc wants), and not be cognitively impaired. I was in lotsa despair before I saw this guy and now I'm more hopeful as I'm not the best fusion candidate (lotsa DDD) nor ADR (facets) and osteoporosis.

Again, appreciate your time/info.

ans

[ans]

Sorry for over-posting; I couldn't delete this.

One more point: there's a beauty to a 24-hour timed medication in that the sleep cycle isn't disrupted by taking a med, waiting 1/2 an hour, then taking more, etc. Then, the next day, you're lucky if you can see straight from sleep-deprivation that is physiologically unhealthy too.

[Jack]

Originally Posted by tconner94

I feel I must counter that opinion. Opioids are no longer taboo when used for pain management. Viewing them as only a short-term necessary evil is an attitude in need of an update. It reflects the viewpoint of medical professionals trained more than 10 years ago, and it is often an impediment to getting appropriate treatment for pain.

According to recent literature, less than 1% of people who use them for legitimate pain become addicted to them. There are certainly complications of use, which anyone can look up on the internet. For many patients, however, they are an integral part of pain treatment and are necessary to allow the patient to function at an appropriate level. Indeed, many don't have a "permanent" solution available to them. Advising them against opioids may not be in their best interest. I am not qualified to give complete advice to patients regarding the use of opioids, but the risks of low daily doses is much less than the risk of taking high doses of NSAIDs every day, especially when those NSAIDs don't give relief. When short-acting opioids are not effective, longer acting medications can be given. After a short acclimation period, most patients do not get drowsiness, decreased mentation, etc. Of course, physical dependence occurs and doses must be tapered gradually when stopping. Tolerance occurs, and doses may gradually increase if pain control is not achieved. These things occur to some degree in every patient, but they should not be viewed as reasons to avoid the medications and suffer from pain.

If others would like more information, I'd suggest checking out the following resources:

www.painfoundation.org American Pain Foundation

"The War on Pain" by Scott Fishman and Lisa Berger (published 2001, BTW)

There are, indeed, many others. These two I'm reciting from memory. Maybe others can chime in with helpful resources.

Respectfully,

-tc-

Sounds like I need to clarify my position (maybe I could be a politician). I’m not against whatever legal meds it takes to make a person’s life as rewarding as possible for themselves and their families. What I do think is that they don’t work well as a cure. If a person continues on narcotics without exhausting all reasonable alternatives to get pain under control, they will most likely regret their decision.

There is psychological addiction and physiological tolerance. Above all else, I want to be pain free and off narcotics. But my body reacts to the lack of narcotics the same way a street addict does.

I have been up and down both sides of this curve over the last three years. Narcotics are safe in a purist view with their effect on the body. There really is not an upper limit based on toxicity. You can OD but that is a different issue. An online friend with history of head injury and chronic opioid use has to go to the ER from time to time and get bolus doses of 200mg IV morphine. Needless to say his tolerance was very high.

The downside of chronic opioid use has a lot of worts. For one, expect to be in withdrawal at least on occasion. As tolerance develops, the dose has to be increased. Once a person hits the limit of what the pain management doc is comfortable with, they rotate the patient to a different narcotic to try and regain pain control without further increasing the drug they were on. There is a 4 to 7 fold difference in plasma levels of a given narcotic in person to person. As a result, when the narcotic is changed, the patient is put on a dose less than needed to control pain and withdrawals. The patient is worked their way up to the dose needed to control pain and withdrawal. If you were on high doses of narcotics like I was, expect vomiting, diarrhea, chills body aches etc., until your dose gets adjusted upwards. These drugs are schedule II so don’t expect to get something called in if it is a weekend. I can advise you on the pitfalls if you want to send me a message. Expect some sort of problem with libido. Men have to get some sort of testosterone supplement. It is difficult to keep your GI system in sync without constipation. Diaphoresis (sweating) is a problem as dose increases. I was changing clothes 4-5 times a day even in winter. Two years ago, I spent 3 days in ICU on a vent due to encephalitis. Luckily, neurologists treat most everything with IV morphine as it can be easily reversed with Narcan or similar drug. When I came off the ventilator, I had a hard time sleeping in the step down unit. They wouldn’t give Ambien or a similar sleep med but used IV morphine. This incident made me think about being hospitalized and being on narcotics. I told my wife to make sure my med history is not just blown off if I’m brought into the ER for an accident or whatever.

The LD50 (what it takes to kill 50% of those who take a given dose) varies considerably with narcotics irrespective of tolerance. Methadone and Darvon (propoxyphene) are two of the worst. The power or strength (bad choice of words I know) of the drug has little effect on its lethality. Tinkering with your dose without consulting your provider is not wise.

No one needs to know what meds you are taking as the street value for narcotics is staggering. Break-ins are a concern.

Narcotics do serve to give all chronic pain sufferers hope, relief and a crutch to lean on while seeking a better solution. If not for my meds, I’m sure I would have spent the last three years trying to recover from one back surgery after another with “failed back surgery syndrome” or found a worse solution. With fusion, I was give a 20% chance of being pain free, A 50% chance of being worse, and an 80% chance of still being on narcotics after surgery.

Age is a factor as well. Anyone in their 20s or 30s facing chronic pain would especially have my sympathy. The chances of finding a solution without narcotics are a lot more favorable than someone like me at 60. Youth helps our bodies heal.

Ultimately we all have to make tough decisions. I too may have to go back on higher doses of narcotics other than my 4 Percocets a day. I hope not but at least I take solace in knowing it is an option. Right now, I can't work and spend a goodly part of the day in protect my back mode. I could go back up on my narcotics and do more but really want something better.

My point is don't give up on trying to get relief other than narcotics. Keep your dose as low as you can. I pray for all in this predicament.

[2cool4U]

Jack,

Good post with lots of good info that needs to be considered. I'm sorry you've had such a rough time. It really sucks to go through that.

There is a common saying that statistics only apply to groups, not individuals. Of course it's easy for me to say that opioids are a valid option when needed based on the literature, but it's another thing to have had the complications you've experienced. However, based on the published literature, I think what you've suffered through is the exception rather than the rule. I don't want to dismiss it; you provide an important example to others of the downside of pain meds. It does fall into the anecdotal type of evidence, however, and all that pain patients can really rely on are the studies on large groups of patients. Although it doesn't help if you become one of the exceptions, the initial decision-making process should include a review of the evidence-based studies. Either the patient can sift through these on the internet, or their doctor can summarize the benefits and risks for them.

I think this thread will be valuable reading for pain sufferers for some time to come. I hope the take home message here is that you can safely try opioids while under close supervision by an experienced pain doctor if other options are not workable or have failed. Remember, not everyone will have other options for relief or a permanent treatment, or they may have exhausted all of those options. While it is important to keep in mind that opioid use is not to be taken lightly, one should also not unnecessarily fear them or avoid them if suffering from acute or chronic moderate to severe pain. Life-altering pain can be controlled with their judicious use, possibly returning many pain sufferers to a lifestyle they thought impossible.

The stigma associated with pain medication use needs to disappear, and I believe those in the medical field need to be better educated about the advantages of their use when indicated. There is a growing concern in medicine that chronic pain is being under-treated, and there is preliminary research showing that early and adequate treatment prevents the brain from being re-wired to be more sensitive to pain. I hope the posts on this section of the board encourage pain sufferers to seek that early treatment rather than avoiding the medication option due to the stigma. They may possibly save themselves from a lifetime of debilitating pain.

As I always say, hope this info helps.

-tc-

[Jack]

TC,

I agree some of what I wrote was anecdotal. Most needs to be seriously considered and prepared for in a person taking narcotics as I get a lot of info from a Phd Psychologist specializing in help people with chronic pain cope. This is another good resource for someone taking narcotics for chronic pain if they can find one in their 'hood.

There is nothing morally wrong with taking narcotics and one should not feel guilty. Just realize it is not a free ride. Knowledge, is key.

As I'm sure you know, the best studies are double-blind cross-over studies to eliminate bias. This is not always possible but is the ideal. That is the problem, the person doing the study is try to prove a point and let's their bias get in the way. A study needs to be able to be reproduced by others with a similar outcome. Any retrospective study that uses statistics to derive an outcome is almost worthless except to make the study newsworthy. I read every piece of literature with a grain of salt so to speak until it is verified.

Something else I have learned. I proposed a "what if" to a friend of mine who is a district judge. I ask him about taking narcotics and having an accident that was my fault. NC law states that if you have a ligit script and are not overdosing yourself, You can't be found guilty because of the narcotic anymore than say benadryl. Your insurance company can't use it as a claim to deny coverage. You can always still be sued. You can't use your script as a defense obviously, but it is no better or worse than any other drug. Anyone on narcotics might need to check with their state law a prepare accordingly.

Just because someone calls themselves a pain doc doesn't make them one. Ask them if they are board certified in pain management. Most should have a history in anesthesiology as well. Also even some of the anesthesiologist are kind of aggressive with the procedures they do ($$), especially epidurals. You should not have more than three a year, sometimes in a series close together. Odds are if one series doesn't help, there is not much need to get more later.

Some of the current Hollywood shows just perpetuate the myths and misconceptions about the use of pain meds. Now there is a bunch I wish I could sue.