- Is your pain totally or mostly relieved, or at least significantly better?
- Is your function maintained or improved?
- Are the side effects (constipation, fatigue, mental clouding, respiratory depression, nausea, sedation, euphoria or dysphoria, and itching) tolerable?
|Actiq||Oral transmucosal fentanyl citrate|
|MS Contin||Morphine sulfate|
|Suboxone||Buprenorphine hydrochloride + naloxone|
|Stadol NS||Butorphanol tartrate|
|Type||Brand Name||Generic Name|
|Hypnotics (for sleep)||Ambien||Zolpidem titrate|
Mel Pohl MD, 2008. A Day Without Pain, Central Recovery Press, Las Vegas NV.Indications of Problematic Opioid Use 1.Taking more medication, more often than was prescribed by the physician 2.“Doctor shopping”, or attempting to get prescriptions from multiple doctors.Also, repeated episodes of “lost” prescriptions 3.Aggressively complaining about the need for higher doses or requesting specific drugs.An overwhelming focus on opiates during doctor visits that impede progress with other issues regarding pain management 4.Hoarding or saving drugs during periods of reduced symptoms 5.Taking pain medication to deal with other problems such as stress 6.Stealing or borrowing medications from other patients 7.Engaging in concurrent abuse of related illicit (illegal) drugs or alcohol 8.Family members or others expressing concern about a person’s use of pain medication Is opiate addiction the same as opiate dependence? Yes and no.Opiate dependence and opiate addiction both result in withdrawal symptoms upon discontinuation of use.For this reason, both are initially treated the same way.Treatment involves education as to why chronic opioids are likely to maintain pain, detoxification, treatment of pain with non-opioid analgesics and other complimentary and alternative medicine, psychological support, coordination of care, and promotion of healthful behaviors. Detoxification alone is rarely sufficient. The psychology of drug dependence is powerful and must be taken into account. For the opiate addict, additional addiction treatment is necessary to avoid future relapse with the drug.The risk of addiction needs to be understood and built in to all treatment using potentially addictive drugs. Opiate Addiction Risk factors for addiction can be considered in three categories: 1.Psychosocial factors 2.Drug-related factors 3.Genetic factors The highest risk for addiction arises when risk factors in each category arise together. Pain patients with no genetic predisposition, no psychosocial factors, and taking stable doses of opioid for the treatment of severe pain in a controlled setting are unlikely to develop addiction. On the other hand, patients with a personal or family history of substance abuse, displaying one or several psychosocial factors, are at risk of developing addiction.
Ballantyne, J.,LaForge, S.(2007). Opioid dependence and addiction during opioidtreatment of chronic pain.Pain 129 (2007) 235–255Signs of Addictive Use 1.Continued use despite harmful consequences 2.Withdrawal from family, friends, or other social activities 3.Ignoring responsibilities such as work, school, family 4.Increasing dose, number of doses, extending use without doctor approval 5.Becoming defensive when confronted 6.Being overly sensitive to normally sensitive situations 7.Personality changes; energy & mood suddenly change 8.Doctor shopping; visiting numerous doctors and ER’s to get prescriptions 9.Forgetfulness 10.Ignoring appearance/personal hygiene & changing eating and sleeping habits Complimentary & Alternative Medicine (CAM) Treatment CAM’s do work, there are volumes of experiences and research to support them.The reason they are not more popular is that they take time and effort to work.Sustained effort is required to maintain sustained change.The pill is reliable, although imperfect, in it’s effect;it only lasts a few minutes to a few hours.Medication has been the therapy of choice in treating pain for one reason – it is easier for the patient and the doctor.It requires no work on the part of the doctor to write the prescription or on the part of the patient to take the pill.However, in light of the rising epidemic of opiate induced problems, CAM’s are increasingly being used by doctors and their patients for relief from pain, return to functioning, and increased life satisfaction. CAM’s work well when used along with non-opiod medications.These non-opiod medications, some originally used for other conditions, are helpful in managing pain.
Non Opiod Medications
Mel Pohl MD, 2008. A Day Without Pain, Central Recovery Press, Las Vegas NV.For many pain patients, their pain becomes part of them.It defines them.It consumes their identity.In other words, they become their pain.But their pain is not who they are – it is simply the pain they feel.Chronic pain does not go away.But it can be diminished and controlled.The person can take control of their life back.Chronic pain does not have to mean chronic suffering.Many pain patients have learned to give up the opiates and manage their pain by using these techniques.When they do they report moments, days, even weeks, without pain.They report decreased levels of pain.They report increased ability to engage in joyful activities.They are able to live without the constant distraction of pain.They get control back from the helplessness of chronic pain, and so can you. Following is a list and brief description of some Complimentary and Alternative Medicine (CAM) treatments from Dr Mel Pohl’s book, A Day Without Pain.These techniques are used in chronic pain treatment programs.Consider this a smorgasbord of options to pick and choose from.They work best when several are used in conjunction with one another.For more information about these treatments please ask your health care provider.
- Exercise.When you are inactive your body becomes de-conditioned, which can add substantially to your pain.Exercise helps pain by decreasing weight and taking pressure off joints and vertebrae, increases flexibility which decreases stiffness and aches, builds strength to take pressure off joints and bones, increases serotonin levels which improve mood and blocks perception of pain in the brain, and strengthens the heart and circulatory system.Many chronic pain patients are resistant to begin an exercise program, fearing the movement will cause more pain.However, in reality - it is the lack of movement that causes more pain.
- Nutrition.Eating “junk foods” is easy to rationalize when you are not feeling well.But eating healthy foods like green leafy vegetables, lean fish & meats, fresh fruits, and whole grains leads to being and feeling healthy which helps fight pain sensations.
- Meditation & Imagery.When people meditate they can increase the amount of natural painkillers in their body and produce pleasurable brain chemicals.
- Chiropractic therapy.Many patients report a reduction in pain with the use of regular chiropractic manipulations.There are hundreds of different techniques and manipulations used by chiropractors.
- Physical therapy.Physical therapists use many different modalities to treat pain.They include manipulation, traction, therapeutic exercise, functional training, patient education and counseling about movement and body mechanics, ice & heat therapies, electrical currents, and other new techniques to remove adhesions.
- Stretching, Pilates, Yoga, & Tai Chi. All of these methods work to improve pain on many levels;body awareness, mindfulness, core strengthening and awareness, postural balance, increased range of motion, spinal stability, stress relief, improved circulation,weight reduction, and inner peace.
- Acupuncture.Acupuncture is thought to relieve pain by increasing release of endorphins (brain chemicals related to euphoria and happiness).Studies show that acupuncture is especially effective at relieving neck and low back pain.
- TENS (Transcutaneous Electrical Nerve Stimulation).TENS units are small battery operated devices that produce a signal to interrupt pain transmission to the brain.They can be worn externally or implanted by a surgeon.
- Massage & Aromatherapy.Massage relaxes tight muscles and tissues and improves oxygenation, circulation, and blood flow to painful areas.Aromatherapy claims to stimulate the brains limbic system awakening and strengthening the body’s self-healing chemicals.It works the same way as smelling freshly baked chocolate chip cookies makes you hungry!
- Cognitive restructuring and psychotherapeutic therapy.Thoughts profoundly affect mood and the perception of pain.Cognitive restructuring of negative thinking about pain improves a sense of power and control over the pain and reduces the perception of pain.It also decreases muscle tension associated with the emotions of pain.
- Hypnotherapy. Relaxation suggestion therapy can help change behaviors, like nail-biting and smoking.It is also helpful in treating depression, PTSD (post traumatic stress disorder), phobias, fears, anxiety, stress, and sleep disorders. It is helpful in treating pain by addressing the physical and mental aspects of pain.
- Biofeedback.People are taught to control some normally involuntary processes such as muscle tension, blood pressure, and the perception of pain with the use of electrodes from a measuring device.
- Support groups.People who experience chronic pain find that their pain is lessened when shared with other people who have the same experiences they do.When treating addictive opiate use, 12 step groups are the primary source for social and recovery support.For the non-addicted, chronic pain support groups are commonly held in hospitals and pain management centers.