The American Inquisition: Chronic
By Dan Schweitzer
First, let me add a couple of definitions here:
An addict is someone who has a psychological problem that causes him to continue to seek and use a drug, even though that drug is obviously causing him harm. His tolerance rises and continues to rise, and he gets more and more harm and less and less benefit. Without help, his use of the drug will destroy his life, sometimes literally.
The behavior of people who need narcotics for pain control is, at the moment, called "pseudo-addiction", because much of the behavior is the same as for an addict, but in this case it exists for good reason. Like a diabetic seeking insulin, a CPP (chronic pain patient) will seek narcotics because they do indeed control the pain, often when nothing else will, which makes this behavior perfectly reasonable. Exactly opposite to an addict, a CPP gains his life back from use of opiates. Once the proper dose is found, tolerance generally does not rise. If doses increase, it is always because the condition causing the pain has gotten worse.
Medically (as opposed to legally and in popular usage) a narcotic is the same thing as an opiate. The drugs in this class of drugs are all either derivatives of opium, or they are synthetics that are chemically similar to components of opium or it's derivatives and are still called narcotics.
Myths About Chronic Pain and
"You can learn to live with it." Not true. The route of chronic pain in it's transmission through the system takes it through the emotional centers, among other things. The body treats pain as a survival priority message; in other words the body is saying, "Do something about this or die!" The pain will keep you awake as long as possible; treatments that work once or twice will stop working; you will become massively depressed (this is physiological - you can't help it). Pain signals will be rerouted, altered, anything necessary to keep the pain foremost in your mind. For real, physical reasons, you cannot learn to live with it.
"Nothing shows on any tests that we can do, so you can't be in pain." Not true. Damaged disks don't show on x-rays; also, if the proper tests are not done, damage that one could reasonably expect to cause pain will not show. This is a real problem due to the prevalence of "cost saving measures" of HMO's and insurance companies. Perhaps the main problem is simply that there IS NO OBJECTIVE TEST THAT WILL MEASURE PAIN. Medical science does not know everything there is to know about the human body. Just because something doesn't show up on tests does NOT mean that nothing is wrong. Twenty years ago, rheumatoid arthritis was thought to be a psychological problem because there were no tests to show that it really existed. Now, of course, we know better. Fibromyalgia is a disease whose sufferers are in that position now.
"No one dies from pain." Not directly, perhaps, but thousands, perhaps tens of thousands of people take their own lives every year because of uncontrolled pain.
"Give it time and it will fade." Not only is this not true, it is exactly opposite to the truth. Research has shown that pain-transmitting nerves actually proliferate if pain is left uncontrolled, and these nerves are damaged such that even if the physical reason for the pain heals, these nerves still transmit and magnify pain signals. The longer pain is uncontrolled, the more likely this is to happen. There are also some indications that fibromyalgia may be triggered by long periods of uncontrolled pain, as well as by sudden trauma, especially when the pain is not treated. Another consequence of chronic pain appears to be rapid aging, which has long been known to be a result of unremitting stress.
"Anyone who takes narcotics for too long or in too high a dose becomes an addict." Not true. This is a vicious piece of propaganda that has destroyed many lives (and advanced many political careers), and is still causing even people who are terminal to refuse to take medication for their pain. Sadly, it also causes doctors to refuse to prescribe them even when they are the only tools in medicine that can help. Doctors are human, and are as vulnerable to propaganda as any of us.
People who take narcotics for pain find that they have far fewer and milder side effects than "recreational users." People who use what they need and no more of the medication that works best for them get no "high" or "buzz". Patients have said for years that it is as though the pain and the drug cancel each other; the pain seems to eat the drug up. For decades, this statement has been interpreted (along with every other reason given by patients for opiate use) as the rationalization of an addict. Current research shows, however, that this is an excellent explanation in layman's term for what actually does happen.
"Any opiate will work just as well as any other opiate." Not true. People are very much individuals, and this includes the size, shape and number of endorphin receptor sites - the places in the nervous system that opiates attach to in order to block or mitigate pain. Because of this, it is often necessary to try several medications. While oxycodone may work well for some people, codeine works better for others and hydrocodone may work best for someone else.
"The recommended dose will work the same for everyone." Also, "A doctor can decide from the injury and the patient's weight and other physiological factors the right amount of medication to control pain." Both are untrue. Even for two people with the same injury, who are the same size and weight, the same age, relative fitness and so on, different medications and different doses will most likely be needed. Only the patient can tell if a certain dose of a medication is working, and how well it's working.
I'd like to add here that, like everything else in medicine, we are dealing with AVERAGES. This means that approximately two thirds of the population will be closer to one end of the spectrum or the other than they will be to the average. Keep in mind too that a few people will be at the extreme ends; where, say five milligrams of morphine will be an adequate dose for one person, another may need forty or more to achieve the same effect. Doctors: NEVER ASSUME - FIND OUT!
"Narcotics will work for every painful condition." Not true. There are some conditions that require other treatments; sadly, there are also a few that appear to respond to no treatment. Any course of pain management must be multi-disciplinary. Around 80% (per Dr. Nelson Hendler of the Mensana Clinic, Stevenson, Maryland) of all pain patients have organic, undiagnosed conditions that can be treated with surgery or some other modality that will mitigate or entirely relieve the pain. Again, it's a matter of doing the right tests.
"Narcotics are a cure." They are not. Narcotics raise pain tolerance and effectively block pain. The underlying cause remains.
"Detox must be a part of any pain management program." Not true. If the pain remains, it must be treated. A patient should be treated with narcotics if no other modality works. Taking a patient off of pain medication when he is still in pain is not only cruel, it is now medical malpractice.
"You should wait until you can't stand the pain anymore before you take a pain pill." Not true. This causes a see-saw reaction in the body that actually makes the pain worse. No other medical condition is treated like this: if a condition exists all the time, it is treated all the time. Pain should be no different.
"Narcotics are bad drugs." This is like saying that hammers are bad tools. You can use a hammer to build a home for your family and yourself, or you can use it to bash someone's head in. Narcotics, used properly, are the most effective tools now in medicine's arsenal for the treatment of pain.
"Long term use of narcotics will destroy the liver and rot the brain, causing memory loss." Not true. Opiates have been in use for at LEAST five thousand years; they are the most well known, well understood medications we have. There are NO long term damages that we know of. NSAIDS (Non Steroidal Anti-Inflammatory Drugs) however, like ibuprofen and aspirin, are responsible for a great many deaths every year due to gastric and intestinal damage. Long term use has been known to cause kidney damage, and overdose causes terrible liver damage.
There are many more myths about pain and it's treatment. This bears repeating: doctors are no less susceptible than patients to propaganda, societal conditioning and prejudice. Something else most people are unaware of is that medicine is changing very quickly as we learn more and more. Even specialists have a difficult if not impossible time keeping up with new things in their fields. If generalists like family practitioners attempted to keep up with every new discovery, they would do nothing but read; they'd have no time for seeing patients. That is a part of my reason for doing these articles: somehow they must be exposed to this information. More than 90% of all patients come in to see a doctor because of pain.
The next article will deal with why doctors are reluctant
to prescribe narcotics, and why patients are reluctant to take them.
by Dan Schweitzer