I received a letter today– a person discussing the use of opiates by a family member with chronic pain.  I was not sure if the letter was asking questions about my opinions, or was instead arguing that my ideas were off-base.  In either case it is worth publishing, as several topics are discussed.  As per usual, the names were blocked to keep things confidential.
Here it is, with my answers:
Why is it wrong to take pain medications for pain?  Especially if you have INTRACTABLE CHRONIC PAIN.
Medications for pain are not ‘evil’—the only way I approach the issue is from a quality of life position.  There are many problems with pain meds as they are now.  At some point I expect we will find a way to avoid tolerance to opiates—that will truly revolutionize pain treatment.  But as things are now, tolerance is the basis for the problems with chronic use of narcotics for pain.  Any person taking narcotics, either for pain or for ‘fun’ (although there is nothing fun about opiate dependence after the first few weeks), will become tolerant to the effects.  The medication will become less and less effective, requiring increases in dose to get the same pain relief.  The dose cannot be increased forever—eventually the patient would be chewing on pills every minute of the day—and so the doc must limit the pills.
If I give enough medication to satisfy a person who is 40 yrs old, what will I do when the person is 42 years old?  Tolerance develops very quickly—this leads to tension between doctor and patient, and eventually the patient takes too many and asks for early refills.  This annoys, angers, or frightens the doc, who therefore eventually stops the narcotics or quits seeing the patient.  The patient, meanwhile, thinks he is being deprived, and gets mad at the doc, mad at all docs, and mad at the world.  Finally, pain meds get inside the head of everyone who takes them, whether they are being taken legitimately or not.  The patient becomes more and more focused on the meds, getting the meds, the pain, and the withdrawal.  Relationships suffer.  Depression develops.  The patient eventually becomes a one-dimensional shadow of who they once were, where the biggest relationship in the patient’s life is the relationship with the pain pills.
I have seen this all happen many, many times, with every patient who takes narcotics.  I do treat with opiates, but I do tell the patient all of this, so they understand what they are taking on.  This is why opiates are always the last resort.  Any good pain doc will tell you that they have seen patients who complain of terrible back pain, who ask for narcotics repeatedly and think they need them…  who get detoxed for some reason and after getting past the withdrawal are surprised to find that the pain is gone, or very small.   I have seen it many times, and I cannot explain it, other than the body trying to trick the person into thinking he needs pain pills as part of an addictive process.
For cancer pain, by the way, none of this is relevant—with a limited life span the doc should just give what is needed to control pain.  But for non-malignant chronic pain, I have never seen opiates improve a person’s quality of life in the long term.  And I have seen many lives destroyed.  The patient may not see it—he may insist things are great on the pain pills, even as his marriage falls apart and his kids disappear.
Why would you want to withdraw, if the pain was being controlled and it lowered your blood pressure?
We have plenty of ways to lower blood pressure—narcotics should never be used for that purpose, except in the case of acute myocardial infarction, when morphine has a number of helpful effects including lowering blood pressure.
What if the patient was limited, and could not do alot of physical therapy to get the benefits of endorphins to work for them.
Patients can do much more than they think with physical therapy.  They need to be taught patience, and they need to work at it every day at home—not only at the therapy center.  Physical therapy is so valuable—but patients generally look for short term solutions.  That is unfortunate.  As far as endorphins go, I caution people against getting wrapped up in thinking about what their brain chemicals are doing.  It is much more complicated than magazines suggest–  endorphins, for example, do many things besides pain control—including things that have nothing to do with pain.  Yes, they have been shown to be released by exercise, but… so what?  We don’t know if that release actually does anything helpful for people.
Like you said, there is a difference between dependency and addiction.  My family members suffer from chronic pain due to chronic pain conditions, that we were either born with or developed.
There is a difference early on, but over time the differences go away.  A person who I see for a congenital pain condition who takes loads of narcotics has very few differences with a person who started pain pills ‘for fun’ and who takes tons of narcotics.  If anything, the addiction is worse in the pain patient, because they are convinced they need the pills, and cannot see the destruction they are causing.  A person who starts ‘recreationally’ is more likely to truly hate the pills, and is often willing to go to greater lengths to get off of them.  That person hates the pills, where the pain patient thinks he loves them.
So, intervention should come, if I am just lying around getting HIGH in a chair, like the rubbish I have been reading
I don’t know what you mean by this sentence.  If you are referring to addicts as ‘rubbish’, you are off base.  Yes, some addicts have bad characters, just as some non-addicts have bad characters.  It sounds like you see a difference between ‘good people’ on pain pills and ‘bad people’ on pain pills.  That difference does not exist.  Over time, any person on pain pills becomes a slave to them, and desperately wants to be free from them.  For some people, it takes longer to seek freedom; some people never seek it.   I can assure you, though, that opiate addicts are not sitting around enjoying themselves—not after they have been doing it for a few months.  They are scrambling for money to get something to avoid being sick—stealing, prostituting, whatever.
OR should it be, I take the pain meds, and I can walk around in the house, function a little better than suffering in pain.
That is your decision.  But it is more complicated than you would like to believe.

I wish you the best, and hope things work out.



Alex · June 24, 2017 at 6:18 am

A friend of mine starred taking subooxone about a yr ago to get off opiates. She was taking 15 to 20 oxycodone 30s a day.
She has suffered from migraines since she was 24 and she’s now 41 and her migraines have mutated into cluster headaches and she is in severe pain.
She started buying roxy 30s about 6 months ago and now she’s taking 4 or 5 roxy’s a day after she takes her 8mg subooxone.
She says she doesn’t get high off the pain meds that it just helps stop her pain.
My question is if the sub blocks the opiates and she doesn’t get high from the oxy how cld the oxy help with pain? Isn’t that how narcotics ease pain by giving a euphoric feeling so the person doesn’t feel the pain?
I guess I’m asking cld the oxy really be helping with her pain or is she just wasting the oxy and sub?

    Jeffrey Junig MD PhD · June 27, 2017 at 6:04 am

    I’ll first say that I certainly don’t recommend doing what she is doing without the help of a doctor. Opioids are dangerous medications, and must be used under the direction of a doctor who knows their properties well.
    First though, the euphoric feeling is a side effect of opioid action. Opioids act at the site usually activated by endorphins, and they actually turn off the firing of pain nerve fibers. Some people get euphoria as a side effect; some instead get dysphoria and nausea.
    I have blog posts about combining buprenorphine and agonists (use the search function and search for ‘pain relief without tolerance’ and you will find those posts). When I wrote them I was not aware that others have written about the same combinations a number of years ago. The mechanism for the effect is not clear, but people describe pain relief, without any other subjective effects. Moreover people maintained on the combination long-term do not appear to develop an increase in tolerance.
    I believe that the combination could represent a novel approach to pain treatment. There are naysayers out there who will see the combination from a superficial perspective and say it is a placebo effect, but I know that is not the case, as I’ve used the combination to get patients through some of the most painful operations, including shoulder reconstruction, knee replacement, and chest surgeries.
    Again, anyone on the combination needs to be under the care of a physician.

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