Another flawed solution to this "opioid epidemic" is born out of good intentions, and it is the one at the top of the FDA's list of solutions to the problem. It involves making prescription opioids "unappealing" to those solely interested in the euphoric component and "getting high."
Naltrexone and naloxone are two medications that are used in addiction recovery. Both of these drugs work in the body to directly counteract the effects of opioids. These and other similar medications are now often being paired and manufactured with opioids. They can be formulated so that, when the opioids are taken "properly" they will pass through the individual and eventually be harmlessly purged through urination and perspiration. These are prescribed for those feeling pain and work just as effectively as the traditional opioid-only prescription medications. If, however, the medication is misused--like when a pill is crushed for snorting or for processing into an "injectable" form--the opioid-blocker part of the medication kicks in. Although manipulating the medication in this way would normally increase the speed at which the opioid is metabolized and increase the speed and intensity of the euphoria experienced by the user, the "partner" in this medication tandem prevents the opioid from working altogether, and can actually induce the unpleasantness of withdrawal effects.
The downside here is that the medication must be inappropriately manipulated in order for the opioid blocker to activate. There is nothing to stop someone from keeping the medication in tact and then still overdosing on the medication in its natural form. This idea is, however, being touted as the best solution to this opioid epidemic as though any attempt to abuse the medication will prevent it from working, but it must be misused in a very specific way for this solution to work. In short, it prevents misuse, but not abuse, of the medication.
The alternative would be to find a way to manufacture a drug that prevents abuse which is a far greater problem than the misuse I was just describing. "Antabuse" (not kidding, that's its name, but the generic drug is called Disulfiram) is a drug that has successfully been used to help alcoholics shake off any "desire" they might have to drinking. This medication creates the nauseating effects of binge drinking every single time a person drinks. The premise is simple, have the brain either associate something negative (like nausea, vomiting, and a headache) with the intake of certain substances. It is a very effective program, and certainly, something similar could be developed to pair with opioids, like ipecac that would make a person violently ill every time they took the opioid. However, the downside with this tandem is that you have to take it voluntarily and only a person who wants to avoid the euphoria and break their own desires for that "high." Obviously, it would have no appeal for those legitimately taking opioids for pain relief. It would only serve those who have made a conscious choice to associate the effects of opioids with something negative.
Neither of these options are good options in the sense that one (the first) operates completely on a principle of distrust and the other only works in an environment of total trust.
The net result of these approaches, and, to repeat, the first one is being touted by the FDA as the best solution to this current societal problem, is that it treats all opioid users, including the predominant users who are in genuine pain, as the criminals responsible for causing the problem. And yet, the worst of it is the reality is that anyone intent on abusing opioids can still freely do so.
Next post "Bad Solution #3: Just Deal with It," will be published on or about April 30, 2017.
Sunday, April 16, 2017
Sunday, April 2, 2017
Bad Solution #1: Association Theory
There are several ideas for how to best handle the "Opioid Epidemic." One of the approaches focus on demonizing the individuals who are "contributing" to the problem--those who are originally prescribed the medication. Some of these are people who were at some point in their lives experiencing a significant amount of pain and for whom, the usual methods of quelling that pain were insufficient. They did exactly what they should do in such circumstances: seek help from their local family doctor if they can get in quickly enough or the more likely case of seeing whichever doctor happened to be on-call at the local Urgent Care center.
These doctors, in response to the expectations and limitations of what insurance companies have deemed acceptable practice, gave these individuals the narcotic of the day. Why some doctors favor hydrocodone (Vicodin) over oxycodone (Percocet) over codeine (Tylenol #3 or #4) is anyone's guess since most general practice or family practice doctors know very little about the difference between those medications other than they are part of what has become standard issue. However, in whichever the case, doctors are allowed to prescribe up to a month of medication and since the likelihood of seeing that patient again is small, they have to gauge what is an appropriate amount to tide the patient over based on their assessment of the patient's pain level with a recommendation to seek assistance from their family doctor who will then be able to make a referral to a pain management doctor if they feel that is warranted and the pain continues to persist beyond the 30 days of script.
Of course, pain that does persist beyond 30 days of opioid relief would technically be considered chronic pain and require the intervention of a pain management doctor. However, getting in to see a pain management doctor will likely take a few additional months at a minimum and leave the regular non-specialist in charge of managing the patient's opioid scripts.
Well from the very first script administered, there is no telling how effective the original opioid will be. There are subtle differences between the different opioids out there (beyond potency) and those differences will mean that while some will work fantastically well for relieving an individual's pain, others will have almost no pain-relieving effects and still others will have direct effects or side effects that are unpleasant in the least and nearly fatal at most.
One of the most significant consequences of this, very typical, situation is that people end up with an abundance of prescribed opioids that they are adverse to taking, yet fearful enough of the pain to not want to simply dispose of them. Never having had the need to secure their medication in a locked encasement or at least hide it from anyone, most individuals new to taking opioids will treat them no differently than any other medications they have been taking at various times in their lives. Then, the local and national media puts out stories about how enticing these drugs are and rather than risking getting caught in some salacious drug deal, everyone from innocent and ignorant teenagers to genuinely malevolent drug seekers find that they suddenly have easy access to either easy money or an easy high or both.
Meanwhile, there is an important, but smaller subgroup of chronic pain survivors who are doing what they need to--safeguarding their opioid medications because without them, they are living in extreme and incessant pain, or as I refer to it: relentless agony. They are not responsible for the influx of opioids on the street and in the local schools. However, the reaction by legislators and the media is to lump everyone who picks up a script from their local pharmacy as someone who is responsible for the idiot kid "with the bright future, who never did drugs before this incident" dies from an overdose because he didn't seem to understand that a person who isn't in pain and hasn't been issued a prescription shouldn't take three times the daily maximum of that opioid at one sitting.
Sorry, but the real demons here are the ones committing the felony by selling and dealing the drugs, and the ones who are taking those drugs deliberately intent on getting high, and the idiot legislators and media reporters. Before society can understand what the best solution to this problem--this "opioid epidemic"--is, they need to understand that associating chronic pain survivors with drug dealers and drug addicts is unfair and, itself, contributing to the ongoing problem.
Apologies for getting this post out a week late. Beginning with this post, I will be back on a two-week schedule. Next post, "Bad Solution #2: Aversion Therapy," will be published on or about Sunday, April 16, 2017.
These doctors, in response to the expectations and limitations of what insurance companies have deemed acceptable practice, gave these individuals the narcotic of the day. Why some doctors favor hydrocodone (Vicodin) over oxycodone (Percocet) over codeine (Tylenol #3 or #4) is anyone's guess since most general practice or family practice doctors know very little about the difference between those medications other than they are part of what has become standard issue. However, in whichever the case, doctors are allowed to prescribe up to a month of medication and since the likelihood of seeing that patient again is small, they have to gauge what is an appropriate amount to tide the patient over based on their assessment of the patient's pain level with a recommendation to seek assistance from their family doctor who will then be able to make a referral to a pain management doctor if they feel that is warranted and the pain continues to persist beyond the 30 days of script.
Of course, pain that does persist beyond 30 days of opioid relief would technically be considered chronic pain and require the intervention of a pain management doctor. However, getting in to see a pain management doctor will likely take a few additional months at a minimum and leave the regular non-specialist in charge of managing the patient's opioid scripts.
Well from the very first script administered, there is no telling how effective the original opioid will be. There are subtle differences between the different opioids out there (beyond potency) and those differences will mean that while some will work fantastically well for relieving an individual's pain, others will have almost no pain-relieving effects and still others will have direct effects or side effects that are unpleasant in the least and nearly fatal at most.
One of the most significant consequences of this, very typical, situation is that people end up with an abundance of prescribed opioids that they are adverse to taking, yet fearful enough of the pain to not want to simply dispose of them. Never having had the need to secure their medication in a locked encasement or at least hide it from anyone, most individuals new to taking opioids will treat them no differently than any other medications they have been taking at various times in their lives. Then, the local and national media puts out stories about how enticing these drugs are and rather than risking getting caught in some salacious drug deal, everyone from innocent and ignorant teenagers to genuinely malevolent drug seekers find that they suddenly have easy access to either easy money or an easy high or both.
Meanwhile, there is an important, but smaller subgroup of chronic pain survivors who are doing what they need to--safeguarding their opioid medications because without them, they are living in extreme and incessant pain, or as I refer to it: relentless agony. They are not responsible for the influx of opioids on the street and in the local schools. However, the reaction by legislators and the media is to lump everyone who picks up a script from their local pharmacy as someone who is responsible for the idiot kid "with the bright future, who never did drugs before this incident" dies from an overdose because he didn't seem to understand that a person who isn't in pain and hasn't been issued a prescription shouldn't take three times the daily maximum of that opioid at one sitting.
Sorry, but the real demons here are the ones committing the felony by selling and dealing the drugs, and the ones who are taking those drugs deliberately intent on getting high, and the idiot legislators and media reporters. Before society can understand what the best solution to this problem--this "opioid epidemic"--is, they need to understand that associating chronic pain survivors with drug dealers and drug addicts is unfair and, itself, contributing to the ongoing problem.
Apologies for getting this post out a week late. Beginning with this post, I will be back on a two-week schedule. Next post, "Bad Solution #2: Aversion Therapy," will be published on or about Sunday, April 16, 2017.
Tuesday, March 14, 2017
The Facts on Addiction vs. Dependency, Part 2
So fundamentally, we now have two groups of individuals who "need" to take opioids: those who are dependent on opioids to relieve chronic pain and those who are addicted to opioids to get high. Doctors whose routine includes seeing patients on long-term opioid prescriptions, depending on the state in which they practice, usually must declare themselves as belonging to one or both of two specialty fields: pain management or addiction recovery. Both certifications come in handy when a person with a chronic pain condition develops an addiction, but few doctors are genuinely qualified for both, nor would want to be, since patients with either condition are going to share the characteristic of being emotionally exhausting to deal with. I can only imagine how compassionate you would need to be to have a full caseload of individuals living with that much stress.
So let's take a closer look at some important terminology because I believe that the media and political pundits either ignorantly or deliberately mislead the public on these points. "Dependency" can be either physical, psychological, or both, but it is both incorrect and unfortunate that the general public associates any of these conditions with a distinct phenomenon known as "addiction." I hope that I can adequately distinguish between them for you here.
Let's start with physical dependency. This is something that all living creatures have. Chemicals upon which we are all physically dependent include things like diatomic Oxygen and water, but there are hundreds more. There are also nutrients like vitamins and minerals. Physical dependency, then, is a need for something external to be taken and absorbed internally in order for the organism to survive. It is a fact that some, however, are genetically configured to need more or less of these things. People who have diabetes have a glucose deficiency and many are required to add a regimen of insulin injections to their daily routine in order to maintain optimal functioning of their liver. Those who have asthma do not have a deficiency, but rather a disorder that overproduces certain cells in the body called eosinophils. These cells in abundance actually end up attacking the cells in the lungs, causing them to inflame and making it difficult to take in Oxygen sufficiently. Corticosteroids, like Fluoxetine, inhibit the body's unnatural overproduction of those eosinophils. Insulin and corticosteroids are, for diabetics and asthmatics respectively, a physical dependency.
Psychological dependency is very similar to physical dependency. There are certain chemicals in the body, hormones and neurotransmitters, that are critical to the efficient and optimal operation of our nervous system including the brain. Psychological dependency is a subcategory of physical dependency then, but is focused on biological functions that specifically involve the brain. It could include mood-altering medications being given to those who are clinically depressed or even an individual drinking soda or coffee to intake the caffeine their need to help deter the onset of a migraine headache. It could also include administering L-DOPA to patients with Parkinson's Disease to help them stabilize their control over their shaking hands.
There are areas where dependency "crosses over" and includes facets that are both physical and psychological. This could include hormone treatments for women who have difficulty controlling their moods or body temperature during their menopausal years. I also do not believe that it is a stretch to include chronic pain patients taking properly-managed opioids. I think that I am, myself, a perfect individual example of this. Although there are always unavoidable side effects to medications, I think that my ability to take narcotics without "getting high" proves that the medication is only working within my body (and brain) to suppress pain without stimulating the "pleasure center" within my head.
With each type of dependency mentioned above, an individual is genetically predisposed to a certain disease or disorder that involves their body or brain overproducing or underproducing a chemical that is a natural part of living and functioning. That imbalance requires external intervention, and forces an individual to be dependent on that external intervention to maintain themselves in the way that those who are "healthy" do naturally.
This leads me to the final condition, addiction. The distinction between all types of dependency and addiction should already be obvious to you. Addiction involves the massive and often repetitive abuse of certain chemicals that leads to the body or brain to overproduce or underproduce certain chemicals. Sufficiently abused, a chemical essential to life can cease to be produced by the body at all. The distinguishing component between dependency and addiction, then is that the imbalance requiring external intervention is set off either involuntarily by an unlucky set of genes or voluntarily by a person acting stupidly.
All this is complicated by the fact that a person's genes might not specifically cause a disorder to develop, but they could make a person more susceptible to developing one. In do many ways, like my own genetic disorder, every one of us could be sitting on a time bomb. My own doctors have said that my condition could just have easily manifested itself moments after birth or not been triggered by anything over my entire lifetime. So a person might not realize that they have a vulnerability or a predisposition toward addiction, but let's be smart about this... a drug that has a side effect of creating a euphoric sensation is going to be something that both body and brain would like repeated. Only a rational mind can then reason over the more primal system, to cut ourselves off before we are willing to forsake the things that had previously meant something to us in order to obtain this new "high."
So let's take a closer look at some important terminology because I believe that the media and political pundits either ignorantly or deliberately mislead the public on these points. "Dependency" can be either physical, psychological, or both, but it is both incorrect and unfortunate that the general public associates any of these conditions with a distinct phenomenon known as "addiction." I hope that I can adequately distinguish between them for you here.
Let's start with physical dependency. This is something that all living creatures have. Chemicals upon which we are all physically dependent include things like diatomic Oxygen and water, but there are hundreds more. There are also nutrients like vitamins and minerals. Physical dependency, then, is a need for something external to be taken and absorbed internally in order for the organism to survive. It is a fact that some, however, are genetically configured to need more or less of these things. People who have diabetes have a glucose deficiency and many are required to add a regimen of insulin injections to their daily routine in order to maintain optimal functioning of their liver. Those who have asthma do not have a deficiency, but rather a disorder that overproduces certain cells in the body called eosinophils. These cells in abundance actually end up attacking the cells in the lungs, causing them to inflame and making it difficult to take in Oxygen sufficiently. Corticosteroids, like Fluoxetine, inhibit the body's unnatural overproduction of those eosinophils. Insulin and corticosteroids are, for diabetics and asthmatics respectively, a physical dependency.
Psychological dependency is very similar to physical dependency. There are certain chemicals in the body, hormones and neurotransmitters, that are critical to the efficient and optimal operation of our nervous system including the brain. Psychological dependency is a subcategory of physical dependency then, but is focused on biological functions that specifically involve the brain. It could include mood-altering medications being given to those who are clinically depressed or even an individual drinking soda or coffee to intake the caffeine their need to help deter the onset of a migraine headache. It could also include administering L-DOPA to patients with Parkinson's Disease to help them stabilize their control over their shaking hands.
There are areas where dependency "crosses over" and includes facets that are both physical and psychological. This could include hormone treatments for women who have difficulty controlling their moods or body temperature during their menopausal years. I also do not believe that it is a stretch to include chronic pain patients taking properly-managed opioids. I think that I am, myself, a perfect individual example of this. Although there are always unavoidable side effects to medications, I think that my ability to take narcotics without "getting high" proves that the medication is only working within my body (and brain) to suppress pain without stimulating the "pleasure center" within my head.
With each type of dependency mentioned above, an individual is genetically predisposed to a certain disease or disorder that involves their body or brain overproducing or underproducing a chemical that is a natural part of living and functioning. That imbalance requires external intervention, and forces an individual to be dependent on that external intervention to maintain themselves in the way that those who are "healthy" do naturally.
This leads me to the final condition, addiction. The distinction between all types of dependency and addiction should already be obvious to you. Addiction involves the massive and often repetitive abuse of certain chemicals that leads to the body or brain to overproduce or underproduce certain chemicals. Sufficiently abused, a chemical essential to life can cease to be produced by the body at all. The distinguishing component between dependency and addiction, then is that the imbalance requiring external intervention is set off either involuntarily by an unlucky set of genes or voluntarily by a person acting stupidly.
All this is complicated by the fact that a person's genes might not specifically cause a disorder to develop, but they could make a person more susceptible to developing one. In do many ways, like my own genetic disorder, every one of us could be sitting on a time bomb. My own doctors have said that my condition could just have easily manifested itself moments after birth or not been triggered by anything over my entire lifetime. So a person might not realize that they have a vulnerability or a predisposition toward addiction, but let's be smart about this... a drug that has a side effect of creating a euphoric sensation is going to be something that both body and brain would like repeated. Only a rational mind can then reason over the more primal system, to cut ourselves off before we are willing to forsake the things that had previously meant something to us in order to obtain this new "high."
Unfortunately, there is a very fine line between seeking relief from pain and seeking pleasure and this is the very idea that is being misrepresented by the media. A person who is willing to do almost anything to get a reprieve from pain (including the option of suicide) might not outwardly appear any less desperate than the person who is seeking to relieve their symptoms of withdrawal by getting high again. However, and this is my entire point of focus, "the physical dependence on medication" and "an addiction to drugs" are very different and the general public needs to know and understand that difference.
Please make a point of emphasizing this difference at every opportunity that you can, and take a moment right now to invite at least two people you know to visit this site and subscribe for themselves.
Please make a point of emphasizing this difference at every opportunity that you can, and take a moment right now to invite at least two people you know to visit this site and subscribe for themselves.
The next step, of course, is trying to actually figure out how to solve this problem. I do have some thoughts about that, but first, let me explain why the current so-called solutions are not working.
Next blog: "Bad Solution #1: Association Theory" (on or about Sunday, March 26)
Next blog: "Bad Solution #1: Association Theory" (on or about Sunday, March 26)
Sunday, February 26, 2017
The Facts on Addiction vs. Dependency, Part 1
Pain management is generally a subspecialty in medicine. There are some neurologists who take up this specialty, but most often, pain management doctors first studied anesthesiology. They are not, however, simple anesthetists. An anesthetist works in an operating room and administers anesthetic medication to sedate a patient during a surgical procedure. They focus on making decisions about how much anesthesia to administer during a surgical procedure that will suppress pain while not unnecessarily suppressing other functions like heart rate and breathing. They are like trade electricians who you would hire to connect the wiring in your home.
They are distinct from anesthesiologists, who may spend some time working as anesthetists, but are more like an electrical engineer who knows the theory behind electricity (and usually the closely-related theory behind magnetism, and the combined theory of electromagnetism) and could work as professors in a university. Anesthesiologists understand the neuropsychological mechanisms explaining how your nervous system works and not just how to use your height, weight, and general health to decide how much sedative to administer to keep you asleep during surgery. Anesthesiologists (and some neurologists) are among those who might decide to further specialize in pain management.
Although laws are changing, right now, even primary-care doctors can write prescriptions for pain-relieving medications, and they often will opt for opioids because, as I mentioned in my previous blog, they are generally the best. Whenever possible, primary-care doctors should refer these pain patients to pain management doctors. However, pain management doctors are few and far-between and really good, pain management doctors are ever rarer.
Let me apologize for not doing more research on this enough to provide you with actual numbers and statistics here, but I choose not to do so because I do not trust the organizations who publish these kinds of statistics (as evidenced by how the mainstream media chooses to use them), and because it detracts from the point I'm trying to make here. For now, it suffices to point out that those who are most knowledgeable about pain and pain medicine could work every minute of every day seeing patients and would only get through a small percentage of those who could benefit from their services. [See digression #1 below.]
A primary care doctor may prescribe an opioid hoping that it will only take one script to get a patient through the healing process. Unfortunately, patients will rarely fit perfectly into this scheme. Some patients will need more than one month because they are chronic pain victims and some will need much less because they heal more quickly. Those who need more time might "graduate" and be referred to a pain management specialist. Within that discipline, services vary extensively by state and by sponsoring medical organization. Although I was extremely fortunate that the main doctor I saw was one of the best in the world, I saw others along the way constrained by laws and regulations for how to best treat me and my condition despite lengthy and careful documentation that showed what worked best for me. That is why, even after having moved from Wisconsin in 2012, I continued to go back to Milwaukee travelling upwards of 18 hours to see my main doctor there.
Still, there were time over the years when I tried seeing other doctors who were much more local. They ultimately failed to fully take over my case because they worked within a state that would not allow them to write the prescription that works best for my condition. Others worked for a hospital or medical group that required such a heavy press of patients that they could not take the time
my unique condition requires. [See "digression #2 below.]
There is an important point to make here. Although my pain condition is extremely rare and unusual, as is my intense desire to fight it so that I can continue to teach full-time and provide for my family, every pain patient is uniquely tormented by their experience. For at least a short time, everyone in pain suffers. When the pain signals persist beyond the time when the original pain stimulus exists, it is nearly impossible to not experience a psychological state akin to being tortured. Only a well-staffed pain management center with both medical doctors and psychologists--all of whom have specialized in pain management--is equipped to deal with individuals like that, but many patients will never even get a referral to such a place. For reasons almost as numerous and diverse as the patients themselves, unqualified or underqualified doctors will continue their own feeble attempts to treat these pain problems.
This is where the problems so grossly distorted by the media come into play. This is already a relatively small percentage of people, and now an even smaller percentage in that category will heal quickly enough that when they continue to take their opioids they will become addicted. Still smaller is a group who have healed and now their system becomes depressed by the opioids and they die. One final category of individuals in this very small group are those who stop taking their opioids after they have healed, but do not properly dispose of them and the medications fall into the wrong hands... healthy individuals who are simply looking to get high.
They are distinct from anesthesiologists, who may spend some time working as anesthetists, but are more like an electrical engineer who knows the theory behind electricity (and usually the closely-related theory behind magnetism, and the combined theory of electromagnetism) and could work as professors in a university. Anesthesiologists understand the neuropsychological mechanisms explaining how your nervous system works and not just how to use your height, weight, and general health to decide how much sedative to administer to keep you asleep during surgery. Anesthesiologists (and some neurologists) are among those who might decide to further specialize in pain management.
Although laws are changing, right now, even primary-care doctors can write prescriptions for pain-relieving medications, and they often will opt for opioids because, as I mentioned in my previous blog, they are generally the best. Whenever possible, primary-care doctors should refer these pain patients to pain management doctors. However, pain management doctors are few and far-between and really good, pain management doctors are ever rarer.
Let me apologize for not doing more research on this enough to provide you with actual numbers and statistics here, but I choose not to do so because I do not trust the organizations who publish these kinds of statistics (as evidenced by how the mainstream media chooses to use them), and because it detracts from the point I'm trying to make here. For now, it suffices to point out that those who are most knowledgeable about pain and pain medicine could work every minute of every day seeing patients and would only get through a small percentage of those who could benefit from their services. [See digression #1 below.]
A primary care doctor may prescribe an opioid hoping that it will only take one script to get a patient through the healing process. Unfortunately, patients will rarely fit perfectly into this scheme. Some patients will need more than one month because they are chronic pain victims and some will need much less because they heal more quickly. Those who need more time might "graduate" and be referred to a pain management specialist. Within that discipline, services vary extensively by state and by sponsoring medical organization. Although I was extremely fortunate that the main doctor I saw was one of the best in the world, I saw others along the way constrained by laws and regulations for how to best treat me and my condition despite lengthy and careful documentation that showed what worked best for me. That is why, even after having moved from Wisconsin in 2012, I continued to go back to Milwaukee travelling upwards of 18 hours to see my main doctor there.
Still, there were time over the years when I tried seeing other doctors who were much more local. They ultimately failed to fully take over my case because they worked within a state that would not allow them to write the prescription that works best for my condition. Others worked for a hospital or medical group that required such a heavy press of patients that they could not take the time
my unique condition requires. [See "digression #2 below.]
There is an important point to make here. Although my pain condition is extremely rare and unusual, as is my intense desire to fight it so that I can continue to teach full-time and provide for my family, every pain patient is uniquely tormented by their experience. For at least a short time, everyone in pain suffers. When the pain signals persist beyond the time when the original pain stimulus exists, it is nearly impossible to not experience a psychological state akin to being tortured. Only a well-staffed pain management center with both medical doctors and psychologists--all of whom have specialized in pain management--is equipped to deal with individuals like that, but many patients will never even get a referral to such a place. For reasons almost as numerous and diverse as the patients themselves, unqualified or underqualified doctors will continue their own feeble attempts to treat these pain problems.
This is where the problems so grossly distorted by the media come into play. This is already a relatively small percentage of people, and now an even smaller percentage in that category will heal quickly enough that when they continue to take their opioids they will become addicted. Still smaller is a group who have healed and now their system becomes depressed by the opioids and they die. One final category of individuals in this very small group are those who stop taking their opioids after they have healed, but do not properly dispose of them and the medications fall into the wrong hands... healthy individuals who are simply looking to get high.
Next blog: "The Facts on Addiction vs. Dependency, Part 2" (on or about Sunday, March 12)
Digression #1: Although the first indications of my pain condition began to manifest themselves in October 2003, I did not see a pain management specialist until July 2004. At that time, I had been enduring what most would consider severe pain for about five months. Within another six months, I would be internally transferred from seeing "a" doctor at the Pain Management Center within Froedtert Hospital to seeing "the" doctor. From late 2004 until February 2016, I was both blessed and privileged to be treated by Dr. Stephen Abram. He was among a small group of 12 doctors back in 1970 to be the first to officially receive certification in pain management by the governing board of the American Medical Association. Working into his early 70s, Dr. Abram was an incredible individual and humanitarian who always made me feel important and respected me both as a patient in pain as well as an educator that had studied neuropsychology, providing me with explanations for things using vocabulary he knew that I would understand given my background. I believe that being referred to him as early into the progression of my condition was providential as it was for me to find the doctor whom I am currently seeing where I now live in Georgia since Dr. Abram finally retired last year. Although the doctors at Froedtert are still good, and I would like to continue seeing them, Georgia law forbids me receiving prescriptions for opioids written by an out-of-state doctor (which is stupid considering the DEA issues the licenses to write those prescriptions). It is more than luck that I found a doctors here so quickly who was so willing to even take my case, let alone continue treating me using the methods proven by Dr. Abram.
Digression #2: One doctor, with whom I grew quite close during his fellowship and residency at the Medical College of Wisconsin (Froedtert Hospital), was put in charge of the pain management center at a hospital closer to my home, so I tried exclusively seeing him for a short time. As a resident working under my main pain doctor, he could spend an hour talking with me during my appointment and then additional hours researching cutting-edge methods and medications to try and help me. As the head of his clinic under his new employer (who I will not identify here), however, he was forced to limit our visits to 15 minutes and his research time was limited to what he had to voluntarily sacrifice away from his family. In fact, his employer told him outright that their statistics showed that nearly a third of the pain patients they had treated in previous years often canceled their appointments at the last minute. To avoid the prospect of paying his salary for just "sitting around," they required him to schedule six patients every hour banking that on average only four would show up, and of course, there were days when very few canceled. He referred me back to my previous doctor when he realized he could not dedicate himself to my case as he once did. Worse, he left pain management just a few years later and went back to exclusively working in anesthesiology because he felt so ineffectual under his employer's constraints. Last I had heard, his personal life had also suffered because of the long hours and immense stress he had to endure. Pain patients are not the only ones hurt by the flaws in the current system.
Sunday, February 19, 2017
How to Relieve Pain, Part 2
Part 2: Actually Relieving the Pain
The most complete way to relieve pain comes ultimately from healing and of course, "time heals all wounds." The phrase has endured because when it comes to pain from damaged tissue, when the tissue heals, the pain impulse ceases to exist. For nerve pain, it typically takes more time.
Until enough time has passed to allow for healing, the cheapest and least risky way to relieve pain is with pain medication: anti-inflammatory meds, opioids, and analgesics.* Now, because of the way the media has portrayed the matter, they would have the general public believe that there is a better way... medications that don't have any side effects or at least not any that are so dangerous as the ones that lead to the "epidemic of overdose deaths" that have been occurring. However, at the present time, only medication can relieve pain by reducing or dulling the pain signal, and opioids do that "best." By best, I mean the combination of magnitude and duration.
Opioids work primarily on the brain and are also versatile, coming in both short-acting and long-duration formulations. Natural or synthetic, opioids have been further perfected beyond what the earth naturally provides. Unfortunately, two of the key side effects of opioid use is to depress/repress vital functions and nearly all stimulate the pleasure centers of the brain along with reducing the pain. Some medications--analgesics--will completely desensitize nerves, but need to be applied directly to the nerves either at the source of pain or between the source and the brain before perception occurs. Unfortunately, while fantastic for the magnitude of relief that they provide, analgesics are very short acting. Anti-inflammatory medication is the least versatile of the three types because it works mainly to limit the reaction of the swelling of soft tissue that has been damaged, and thereby minimize the pain signal at its source.
To repeat and emphasize the main point, let me say again, taking medication is the cheapest and least risky way to relieve pain. Other methods vary based on the area of the body in pain and what is causing it, but most are very invasive because they involve surgery--removing something from the body or implanting something into the body... or both. Some, like implanting a neurostimulator and connecting to the spinal cord can work like an analgesic creating what's called parasthesia and replacing the pain signal with a sort of tingly-numbing sensation. The advantage is that such procedures will reduce or eliminate the need for medication, but are obviously incredibly invasive and may have permanent consequences.
Personally, I was on the operating table for nearly four hours with only a local anesthetic while parts of my vertebrae were chipped away and a network of wires was laid down and sealed in. The risk for infection is high and even with the most advanced technology in play, the implants still need to be replaced periodically (every 3-9 years) and need recharging every one to two weeks. Thankfully, only the actual neurostimulator unit needs replacing; my wires are "permanent" and my implant replacement surgeries have only been hour-long procedures with just 2-3 days' recovery. I'm on my third implant in nearly 11 years now and should be good until 2025. Another disadvantage to neurostimulation is that it is not always perfectly precise; I feel extra jolts of electricity in my legs (particularly my left leg) which impacts my ability to walk or run normally, but an acceptable trade-off for the increased relief I get from the parasthesia.
Other than combinations of the above (implanting a drug pump that delivers analgesics and opioids directly to the spinal cord) or the radical surgeries involving amputation, organ removal, or nerve extraction, there is nothing more than this that can be done to relieve pain in any significant way. So doctors, and more importantly those enduring pain, are quite limited on ways to relieve pain. This situation is further complicated by cases where even after the damaged area has healed, there is a malfunction that keeps the pain impulse active. This is the disorder that qualifies a person for the designation of "chronic pain victim" and it is a lot more prevalent than is portrayed by the media. Its prevalence, so grossly understated, means that primary care doctors are overwhelmed with complaints of pain and a lack of genuinely-qualified, pain-management doctors to whom to refer these individuals.
Next blog: The Facts on Addiction vs. Dependency (on or around February 26, 2017)
*Note that I did not distinguish between non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids, which are also considered anti-inflammatory, but use a slightly different mechanism within the body. I also did not include the pain relieving effects which can be had with muscle relaxers, antidepressants, anti-anxiety drugs, anticonvulsant drugs, and a few others--which have been known to help relieve pain, but are usually more individualized in that they do not consistently work as anti-inflammatory meds, opioids, and analgesics do.
The most complete way to relieve pain comes ultimately from healing and of course, "time heals all wounds." The phrase has endured because when it comes to pain from damaged tissue, when the tissue heals, the pain impulse ceases to exist. For nerve pain, it typically takes more time.
Until enough time has passed to allow for healing, the cheapest and least risky way to relieve pain is with pain medication: anti-inflammatory meds, opioids, and analgesics.* Now, because of the way the media has portrayed the matter, they would have the general public believe that there is a better way... medications that don't have any side effects or at least not any that are so dangerous as the ones that lead to the "epidemic of overdose deaths" that have been occurring. However, at the present time, only medication can relieve pain by reducing or dulling the pain signal, and opioids do that "best." By best, I mean the combination of magnitude and duration.
Opioids work primarily on the brain and are also versatile, coming in both short-acting and long-duration formulations. Natural or synthetic, opioids have been further perfected beyond what the earth naturally provides. Unfortunately, two of the key side effects of opioid use is to depress/repress vital functions and nearly all stimulate the pleasure centers of the brain along with reducing the pain. Some medications--analgesics--will completely desensitize nerves, but need to be applied directly to the nerves either at the source of pain or between the source and the brain before perception occurs. Unfortunately, while fantastic for the magnitude of relief that they provide, analgesics are very short acting. Anti-inflammatory medication is the least versatile of the three types because it works mainly to limit the reaction of the swelling of soft tissue that has been damaged, and thereby minimize the pain signal at its source.
To repeat and emphasize the main point, let me say again, taking medication is the cheapest and least risky way to relieve pain. Other methods vary based on the area of the body in pain and what is causing it, but most are very invasive because they involve surgery--removing something from the body or implanting something into the body... or both. Some, like implanting a neurostimulator and connecting to the spinal cord can work like an analgesic creating what's called parasthesia and replacing the pain signal with a sort of tingly-numbing sensation. The advantage is that such procedures will reduce or eliminate the need for medication, but are obviously incredibly invasive and may have permanent consequences.
Personally, I was on the operating table for nearly four hours with only a local anesthetic while parts of my vertebrae were chipped away and a network of wires was laid down and sealed in. The risk for infection is high and even with the most advanced technology in play, the implants still need to be replaced periodically (every 3-9 years) and need recharging every one to two weeks. Thankfully, only the actual neurostimulator unit needs replacing; my wires are "permanent" and my implant replacement surgeries have only been hour-long procedures with just 2-3 days' recovery. I'm on my third implant in nearly 11 years now and should be good until 2025. Another disadvantage to neurostimulation is that it is not always perfectly precise; I feel extra jolts of electricity in my legs (particularly my left leg) which impacts my ability to walk or run normally, but an acceptable trade-off for the increased relief I get from the parasthesia.
Other than combinations of the above (implanting a drug pump that delivers analgesics and opioids directly to the spinal cord) or the radical surgeries involving amputation, organ removal, or nerve extraction, there is nothing more than this that can be done to relieve pain in any significant way. So doctors, and more importantly those enduring pain, are quite limited on ways to relieve pain. This situation is further complicated by cases where even after the damaged area has healed, there is a malfunction that keeps the pain impulse active. This is the disorder that qualifies a person for the designation of "chronic pain victim" and it is a lot more prevalent than is portrayed by the media. Its prevalence, so grossly understated, means that primary care doctors are overwhelmed with complaints of pain and a lack of genuinely-qualified, pain-management doctors to whom to refer these individuals.
Next blog: The Facts on Addiction vs. Dependency (on or around February 26, 2017)
*Note that I did not distinguish between non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids, which are also considered anti-inflammatory, but use a slightly different mechanism within the body. I also did not include the pain relieving effects which can be had with muscle relaxers, antidepressants, anti-anxiety drugs, anticonvulsant drugs, and a few others--which have been known to help relieve pain, but are usually more individualized in that they do not consistently work as anti-inflammatory meds, opioids, and analgesics do.
Sunday, January 29, 2017
How to Relieve Pain, Part 1
Part 1: Feeling Pain.
Pain relief is a fairly simple process--that is, it can only be generally done in one of two ways. You can either reduce (or eliminate) the nerve impulse that is "causing" the pain, or you can increase a competing nerve impulse. Unlike other senses like vision or hearing, touch is almost 100% singular in its channeling. In other words, even amidst a flurry of conversations, we can often hear our name when mentioned in a distant conversation without even being explicitly directed towards us. Peripheral vision is perhaps an even more obvious example of being able to sense things beyond our direct focus.
Pain, however, is a purely survival sense. The principle is that you are in pain because some part of your body is in imminent danger of destruction. Pain is supposed to be the signal that causes you to retreat from the source that is causing it.
Interestingly, the automated portion of our brain that deals with pain sense places priority on the area that it believes in the greatest amount of danger based on what we think "hurts most." More interesting, from a scientific perspective, is that beyond the thing that hurts most, our brain barely registers any other pain that might be occurring. It functions kind like that almost clinically-obsessive person who cannot leave his current task unfinished while moving onto another. Pain is not a great juggler. In most cases, this is a great asset.
In my case, for example, I have a tremendously heightened tolerance for "normal" aches and pains. Things that would probably bother me much more are hardly noticeable. OK, the trade-off is that I am in constant pain (aka "relentless agony"), but this actually works to my advantage to let me function somewhat normally. Because the pain from my disorder come from the same area in my body (my chest/upper-abdomen) and is always the worst pain I am feeling, it made it easier for doctors to treat it.
This brings me back to the original focus: how do you relieve pain?
Of course, the answer will depend on what is causing the pain and which part of the body is affected. Although nerves transmit the pain signals, it is rarely the nerves themselves that are the affected area. Damaged tissue is the most common cause... a laceration on the skin or a blunt trauma that breaks a bone or a tear of a ligament... which then triggers a pain signal to race to the brain along a peripheral nerve to the spinal cord and then up to the sensory cortex of the brain. It is rarer, but sometimes, a nerve cell can also be damaged and then trigger the impulse directly. It is commonly believed that nerve pain is the "worst" pain to experience. This phenomenon may be akin to the idea of you getting hurt and then telling a friend to relay your pain to you doctor versus telling the doctor yourself. It also may be that nerve pain tends to take longer to heal.
Next blog: "How to Relieve Pain, Part 2" (On or about Sunday, February 12th)
Pain relief is a fairly simple process--that is, it can only be generally done in one of two ways. You can either reduce (or eliminate) the nerve impulse that is "causing" the pain, or you can increase a competing nerve impulse. Unlike other senses like vision or hearing, touch is almost 100% singular in its channeling. In other words, even amidst a flurry of conversations, we can often hear our name when mentioned in a distant conversation without even being explicitly directed towards us. Peripheral vision is perhaps an even more obvious example of being able to sense things beyond our direct focus.
Pain, however, is a purely survival sense. The principle is that you are in pain because some part of your body is in imminent danger of destruction. Pain is supposed to be the signal that causes you to retreat from the source that is causing it.
Interestingly, the automated portion of our brain that deals with pain sense places priority on the area that it believes in the greatest amount of danger based on what we think "hurts most." More interesting, from a scientific perspective, is that beyond the thing that hurts most, our brain barely registers any other pain that might be occurring. It functions kind like that almost clinically-obsessive person who cannot leave his current task unfinished while moving onto another. Pain is not a great juggler. In most cases, this is a great asset.
In my case, for example, I have a tremendously heightened tolerance for "normal" aches and pains. Things that would probably bother me much more are hardly noticeable. OK, the trade-off is that I am in constant pain (aka "relentless agony"), but this actually works to my advantage to let me function somewhat normally. Because the pain from my disorder come from the same area in my body (my chest/upper-abdomen) and is always the worst pain I am feeling, it made it easier for doctors to treat it.
This brings me back to the original focus: how do you relieve pain?
Of course, the answer will depend on what is causing the pain and which part of the body is affected. Although nerves transmit the pain signals, it is rarely the nerves themselves that are the affected area. Damaged tissue is the most common cause... a laceration on the skin or a blunt trauma that breaks a bone or a tear of a ligament... which then triggers a pain signal to race to the brain along a peripheral nerve to the spinal cord and then up to the sensory cortex of the brain. It is rarer, but sometimes, a nerve cell can also be damaged and then trigger the impulse directly. It is commonly believed that nerve pain is the "worst" pain to experience. This phenomenon may be akin to the idea of you getting hurt and then telling a friend to relay your pain to you doctor versus telling the doctor yourself. It also may be that nerve pain tends to take longer to heal.
Next blog: "How to Relieve Pain, Part 2" (On or about Sunday, February 12th)
Saturday, January 14, 2017
Neurocogntive Psychology 101
There are several different types of nerve cells in your body. Some cells are exclusively suited for communication, like telephone wires of olden days. Some specialize in sensation of specific things like reacting to light or sound, and within those specialties there is even more distinction, like retinal nerves that only activate with red light or taste buds that only activate with salty things.
The majority, of course, are actually in your brain and--truth be told--whenever you think you are sensing something like cold or bright or loud, those sensations are almost meaningless out of the context that your brain places them. As is typical in science, the greatest leaps in understanding occur when something goes wrong. The notion of contextual sensation is poignantly obvious with what we call "phantom limb syndrome." Even with an amputated limb, individuals report "feeling" things (often pain) in a limb that is no longer connected to the body. This is particularly difficult to treat since most often, it is the removal of the painful stimulus that results in the greatest relief.
So goes the saying that "it's all in your head." While that is certainly an oversimplification, it is true that the nerve cells in the brain are ultimately slightly more important than the nerves out "in the field" of the body's periphery. If you touch a hot stove, while it is the finger that gets damaged, another nerve delivers that carry that signal to the spinal cord and it's not until the signal reaches the brain that an impulse is generated that goes back to that hand to pull it back from the stove. Of course, all that happens in an instant, but you get the point. So all nerve impulse go through a sensation-perception-reaction process series. Depending on the individual and intensity of the stimulus, voluntary control can be seized before a reaction occurs, like a person who can hold their hand over a flame for a longer-than-normal interval of time.
So how do you help a person in pain, particularly when the source of the painful sensation is idiopathic and/or no longer physically present? The two conditions most baffling to pain management specialists are allodynia and hyperalgesia. The first is a malfunction "somewhere" in the sensation-perception process that causes a non-painful stimulus to be interpreted as pain. The second is a malfunction where a "mild" sensation of pain is perceived as "severe" to "excruciating" pain. Many individuals who need medical treatment for pain have one or both of these conditions.
Next Blog: How to Relieve Pain (to be posted on or about January 29, 2017)
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