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Re: Getting Doctors to prescribe opiates

Posted by Deus_Abscondis on September 2, 2007, at 1:29:14

In reply to Getting Doctors to prescribe opiates Quintal, posted by FredPotter on August 14, 2007, at 15:30:08

This thread is quite topical for me especially at the moment.

I'm going to make a long contribution (some may say rant) and make no apologies for this. It is an opportunity to put down some of my ideas and to perhaps connect with other sufferers.

Without delusions of grandeur I've read quite widely (for a lay person) on opioid use for "non-cancer pain" analgesia. I haven't yet read the Elle article but will after this post.

One question I haven't answered for myself is what harm occurs if you accidentally (short term memory problem) take 4 tablets of 500mg paracetamol and then 2 tablets every 4 hours thereafter? Would anyone like to comment?

There are a few questions I'd like to raise on this board - one of which I will start in a new thread - it relates to the stimulant properties of Oxycodone.

Anyway, to go back to the initial indication - pain due to ingrown toe nail. I'm a little surprised that this couldn't be dealt with without permanent removal of the nail perhaps with orthotic/biomechanical investigation - but I will take it at face value that it is the only remedy for some. Back to opioids.

The use of opioids in medicine is restricted primarily for political reasons rather than for rational scientific/medical reasons. The historical development of "opiophobia" in medicine would be worthy of a Phd topic, book or long research article.

The main driving force against rational opioid use today is lead by the USA and the zeal with which 'anti-opioidists' pursue their 'cause' is mixed up with the irrational, ineffectual manufactured 'war on drugs' and in the pandemic of religious fundamentalism that dominates US culture. The anti opioid medical lobby has manufactured misinformation on the role of opioids. The US is not entirely to blame as the British used opium to devastating economic effect as a weapon against the Chinese after which medical opinion started to change and certainly after soldiers started to use morphine in the first and second world wars. The impact of substances on a culture requires more than just analysis of the bio-chemical/physiological/psychological basis of action.

Unfortunately, Australia is a client state of the US but in some ways we here are more conservative. The consideration of appropriate use of opioids is in the Dark Ages.

The upshot of all of this is that there are vast numbers of people who suffer needlessly. Many chronic pain conditions can be successfully managed with little risk through the rational use of opioids in a broad pain management plan. I'm being generous here to pain management 'holistic' folks as I believe that most pain can be managed by opioids and opioid agonists and antagonists. There are other positive health benefits that come out of multidisciplinary approaches to pain management but it is surreptitious to leverage these benefits on the basis of pain management. I'd even be prepared to go as far as to include so called 'psychic' pain in rational opioid use. It is all a matter of rational, educated management.

I recently was offered and attended a four day (eight half days over two months) pain education program at taxpayers expense because the physician believed that while I may have been in the category of those with chronic pain who might benefit from opioid use I also might not, so rather than finding out and trialing an opioid first I went through the pain education program - the real cost of which was probably well over A$5,000.

Many if not most local physicians (we call them General Practitioners - GPs - here in Australia) don't know the difference between addiction, pseudo-addiction, tolerance and dependency. Rather than learning how to manage their patients pain patients are sent of to pain management centres (PMCs) some of which are set up as commercial operations. While there is good evidence that some people benefit from multidisciplinary pain management approaches and many people benefit to some degree it is irrational to exclude opioid use.

One reason opioids don't get used here is that it requires the doctor to register their use - they are monitored once their use exceeds a certain amount. There are different requirements in different states in Australia. Part of the reasons for restriction is that some doctors were self administering opioids, some (were talking of a handful over many decades) were also diverting them. Doctors hate being monitored. There is little justification for them to fear that their appropriate substantive use would lead to questioning let alone any disciplinary action. All is required is that they phone a number and register the use (diagnosis, dose, duration) - they receive a code that is used by the pharmacist to validate the script to help prevent forgeries. There were attempts to enforce doctors to obtain a second opinion whenever they wished to use opioids. This was ludicrous and on this I am sympathetic with doctors - this level of interference by bureaucracy is unjustified.

Some of the promotion of PMCs is ludicrous. In one "news" story recently (in fact a covert ad for a PMC) a patient sitting behind her work desk advocated the PMC she stated - "I once suffered from migraines - now I just don't think about them - I still get them - I just don't think about them, I get on with my job". Clearly whatever this woman experienced as a migraine is not what I experience - in absence of other indictations I think the trail of vomit and diarrhoea across the office floor might give the game away that there was more going on for me than just a headache. While I know there are means to lessen the incidence of migraine I have yet not been offered (except Cafergot with one GP) any drug treatment options beyond paracetamol.

Two doctors I visited had extreme views about opioids.

Listen to this story. It didn't occur to me when I was experiencing protracted dry vomiting due to a stomach bug why one particular doctor stated when I asked for the antiemetic Stematil "I probably shouldn't be giving you this". I don't think it was due to possible side effects. Years latter I approached this doctor for an opioid. I was armed with information. I suggested Oxycontin (Oxycodone slow release - I had the opportunity to try a limited quantity and found it effective). His response was dramatic and in an agitated manner he stated waving his finger "Do you use narcotics?" I replied "no just paracetamol, even paractemol/codiene doesn't work well for me...." then he stated "I don't turn my patients into addicts - I don't prescribe narcotics to any of my patients - If I prescribed you a narcotic and you told someone my waiting room would be full of drug addicts". I asked what alternatives there were to paracetamol and non steroidal anti-inflamatories and he suggested I go to a PMC. Then it clicked as to why years earlier he made the statement about Stematil - he was thinking that I could be using it to offset opioid nausea/emises. Wow - this doctor was mad with suspicion. In yet another visit when he refused Zyban (bupiopion) as a quit smoking aid - after initially mis-classifying the drug and looking it up on screen he said one of the side effects was a risk of seizure - he had never prescribed it.

Another doctor refused to see me again after I asked for opioid pain relief(without telling me at the time - on a subsequent visit the administrator at the counter said she - the Dr - "didn't want to see me and I should go elsewhere). I visited my regular doctor (in another state whilst on holidays - I had moved) who was more amenable - he had entrusted me with Rohypnol (Flunitrazepam) on one occasion. His response was that he only used opioids with his cancer patents and wrote my request into his records.

These experiences have happened over the course of years. I am now about to consult a Dr who is an expert in addiction and dependency and specialises in the treatment of 'street' addicts. First indications is that he says he may not be able to help in pain management outside of his limited field. It is ironic that if I was 'hooked' on street heroin I would probably receive better health care than I do as a well informed middle class patient with a chronic pain condition. I have come close to trying to procure illicit opioids. The risk of apprehension is too great, I have a dependent whom I'm responsible for - such is my luck I expect that my attempted first deal would be with a under cover law enforcement officer. I don't fancy my chances trying to explain to a magistrate the reasoning behind my actions. In any case I can't afford to purchase illicitly.

All in all the state of rational use of opioids in "non-cancer" pain in Australia is PATHETIC. There are a few champions in the literature but I have yet to meet them let alone get access to opioids through them.

That a painful degenerative condition that is not life terminating should be distinguished on the basis of terminating with death verses ongoing life debilitating is irrational.

From an economic viewpoint billions are lost through non productivity. During the one 4-6 week period I had access to Endone (5mg) and Oxycontin (10mg) I was able to return to paid employment - albeit in a friends business. Untreated I am a liability - I wouldn't employ me! The prospect of lying to an employer doesn't sit well with me - I have a hard enough time dealing with my anxiety of workplaces.

Chronic pain has been shown to impact on hippocampal structure and function - evidence of dendritic retraction and cell death has been presented. This could account or contribute to my recent diagnosis of adult ADHD (inattentive type) verified independently with QEEG (for what it is worth - I have little knowledge of the efficacy of QEEG although my psychiatrist believes she can see evidence of ADHD on EEG traces). While I haven't had my memory tested yet my subjective opinion is that it is poor. Some putative models of ADHD put working memory at the core of the condition. This makes a lot of sense to me. I am now a registered user of dexamphetamine - any doctor (an perhaps other agencies) in the country can find this out about me. Dex helps considerably with attention and also helps with the profound fatigue I experience - it's not a perfect treatment. In Australia there is a statutory limit to 30mg a day - I'm on 15mg and would like to trial a larger dose but my psych is against it.

There should be but is not a right to pain mitigation. Opiophobia in chronic pain is unjustifiable and not evidence based. This is a non technical forum but I would be prepared to go head to head with anyone in terms of a literature review/analysis who would be prepared to argue that opioids have no place in chronic pain management.

It has been argued by one doctor as part of my pain education program that opioids lose their effectiveness if used continuously (tolerance) and are not effective against neuropathic pain. This doctor knew well that my condition was nociceptive and to possibly a lesser extent 'neuropathic', he just wanted to obfuscate and avoid my questions. The distinction in pain management terms is questioned by some experts. It may well be the case that I do develop tolerance at the levels I am comfortable taking (I have reasons to think not and that an effective maintenance dose for me is quite small and this only contributes to doctors suspicion). There may be a level where the cognitive effects are problematic - I suspect so. Other side effects may limit opioid use - nausea, constipation. My experience is that codeine is far more constipating for me than Oxycodone. I get a daily headache with codeine/paracetamol compound - indeed two doses (20mg Codeine/500mg Paracetamol at 4 hour interval) will give me a rebound like headache particularly if I take it in the evening - I can guarantee waking with a headache.

So I take 4 grams of paracetamol every four waking hours. Am I dependent on paracetamol - by some criteria yes. It is some but limited help, I know if I stop taking it pain will increase. I do wish to avoid pain - pain avoidance is a conditioned response. Do I get irritable and seek out my paracetamol - sometimes yes - especially if I go out and forget to take a supply or run out and search my house for misplaced supply. Sometimes I'm not timely with taking it, sometimes I forget if I've taken it - it is so ineffective you don't know if you've taken it or not. I've asked about the risk and harm of accidental double dosing paracetamol - there is no risk with the levels of opioid I expect I need. Respiratory depression would require a much larger dose.

Has having done the pain education program helped? Yes, I have restarted doing meditation - it has thrown up some other psychological issues that I'm dealing with - for the hour I do it, provided I am seated properly or lying down I experience less pain. Does meditation have ongoing pain reduction effects? - I think not. Does exercise help? - yes but not as much as is suggested. I have been 'super fit' before - provided I have extensive periods to rest afterwards I can exercise hard. Do I get a lasting endorphin effect - probably not. I cramp up regardless of whether I do exercise. I need to do yoga stretching regardless of aerobics. I also find hard exercise precipitates the frequency and depth of migraines, I am advised the more exercise I can do the better but find moderate gentle exercise and rest helps more. Do I think appropriate analgesia and all of the other stuff together works better than either alone? - yes but I'm not afforded 'appropriate' analgesia. Would you exercise more with better analgesia? - probably.

Addiction leading to abuse is a real phenomenon although I would probably characterise it differently than the mainstream. Paradoxically attempting to with hold addictive substances can increase the depth of substance seeking and interfere more with the quality of the persons life and the community around them than if they were allowed supervised access. That there are some who are addicted or have the potential to become addicted to opioids is no justification to with hold analgesia. Those in chronic pain are less able than most addicts at achieving access to analgesia. There is scant unreliable evidence that opioid use by chronic pain sufferers leads to addiction.

My experience with Endone/Oxycontin was profound not only from a pain perspective but also from a cognitive and mood perspective. I will however post this up in another thread "Oxycodones stimulant effects and ADHD".

That's all





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