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Name: Dr. JOHN RAYMOND BAKER,BSc,DC on Jul 2, 2009Comments: Vicodin is far more helpful and enables far better functioning for people in chronic or acute pain than most meds. For people with tooth extractions or after a motor vehicle accident, or chronic injury pain, Vicodin helps folks greatly and banning is crazy!Flag
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Name: L.Lynn Studdard on Jul 2, 2009Comments: this is stupid, for every person that abuses these or any other legal drug, there are a thousand people that need them.Flag
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Name: David Gomez on Jul 7, 2009Comments: Why would they want to ban Vicodin! I take these pills for my severe pain I have in my head and eye due to crappy surgerys! plus my mom has chronic back pain for years now! if it wasnt for these pain killers, we would go crazy and be violent! We will go crazy. The world is going to go nutts.Flag
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Name: Brenda Diaz on Jul 8, 2009Comments: I know so many people who are in pain because of Doctors lack of responsiblity. At least let these people who need to take something to at least ease the pain take what they can, Why do you ban such medicationsFlag
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Name: Kathleen Ann Fifer on Aug 15, 2009Comments: This decision is crazy, hydrocodone is needed by chronic pain suffers, just reduce the acetaminophen in it and make it less expensive.Flag
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Name: William Doyle, Ph.D. on Sep 13, 2009Comments: This is a thinly disguised attempt to drastically eliminate patient access to narcotic pain medications. Hydrocodone without any secondary ingredient is currently a CII medication, for which prescribing standards are much more stringent, as opposed to the old CIII designation. This is a horrible idea.Flag
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Name: Chris Lague on Oct 6, 2009Comments: Refusing people the choice of sound treatment whereby the doctor and patient can discuss and weigh the risks and make their own decisions is unacceptable.Flag
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Name: Wesley Shea Vines on Jan 11, 2010Comments: I am 30 years old and have been having severe migraine headaches since I was 22 years old! I happen to inherit them from my mother's side of the family and the only thing that works is Hydrocodone that I have been taking for 8 years now. I really don't think it's a good idea at all if your going to try to ban this! Sure there are a lot of folks out there that abuse the drug but don't punish the ones like me or anyone else for someone else's drug problem. I'm really getting sick of this government! You want to ban our sports supplements,ban our pain medication that gets us through the day but I still have not yet seen the government ban tobacco or alcohol which people are dying from them too but oh I forgot,the government would'nt make no money off of that if they banned tobacco and alcohol sales. The U.S. government needs to think about other issues like getting our soldiers out of war and getting the economy back to where it use to be! That's all I got to say!Flag
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Name: Kathy Quigley on Feb 7, 2010Comments: I have chronic myofascial pain syndrome and Vicodin has allowed me to live my life. Please do not take this drug off the market. Alcohol is also responsible for liver damage, should we ban that as well.Flag
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Name: Kenneth Nicklowicz on Feb 14, 2010Comments: I'm 26, disabled, and rely on vicodin to keep pain down! My doctor has addressed the issue of too much acetaminophen with hp, and has put me on Norco which has less tylonol! I Never abused my medicine, and herefore sign this petetion to say that this medicine changes my life for the better and I dont want to be forced to take that darn oxycotten!!!Flag
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Name: Anne Nelson on Feb 16, 2010Comments: Have you people no heart or soul? Have you never been or had a loved one in constant pain? Do you understand at all the misery you are going to bring with this proposed ban?Flag
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Name: Jane M Hardwick on May 15, 2010Comments: I know what my life would be like if I had to endure another day of total pain. I wouldn't want to live that life. With the pain medication I am now taking, I can live a rather normal life, not always completely pain free, but I function very well. Please consider all of the pain sufferers that rely on their pain medications, and not those that misuse these wonderful drugs that make our lives worth living.Flag
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Name: Gary Venig on Aug 29, 2010Comments: I injured my back about 9 years ago while working as a concrete laborer. I was prescribed vicodin in order to help me manage with my back pains. It took about a year for my back to heal to the point where I no longer needed the vicodin. If vicodin was not accessible to me at the time, instead of continuing to be a hard working tax payer, I would have had no choice but to not work for that approximate year and apply for disability, or workers comp, or simply live on credit cards that I would have no way to pay back. I do not believe in collecting free money without working for it, which is why I chose to take the vicodin to get me through a hard days work for that entire year. It was still hard, but the vicodin helped me get through it. I took the medicine as described, and never had any addiction problems. If this medicine gets banned, I can guarantee the the number of workers comp cases, disability claims, and number of sick days taken from people who have physically intense jobs, will all sky rocket. The government will be shooting themselves in the foot if they ban this medicine. Not to mention, there will be a lot of unnecessary pain and suffering from people who truely need this medicine. I now work in a hospital, and I see first hand on a daily basis people who get into accidents, have an injury at their job, who come into our ER and need something for their pain. To deprive innocent people the pain medicine that they obviously require is inhumaine.Flag
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Name: Anonymous on Sep 10, 2010Comments: Pain medication is not for divertion,nor for getting high.I have been disabled for 11 years because of being struck in the face by a 40 lb. coil spring with a force of 4000 psi.without some type of instant release medication I can not even get out of bed in the morning.this seem be Inhumane to take away the only releive some people have to fuction a little.Maybe if all the people fighing to take away pain med's could be in our shoes they my think twice about there desision. Living this way is not life,it is just exisiting.Flag
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Name: Anonymous on Sep 10, 2010Comments: Pain medication is not for divertion,nor for getting high.I have been disabled for 11 years because of being struck in the face by a 40 lb. coil spring with a force of 4000 psi.without some type of instant release medication I can not even get out of bed in the morning.this seem be Inhumane to take away the only releive some people have to fuction a little.Maybe if all the people fighing to take away pain med's could be in our shoes they my think twice about there desision. Living this way is not life,it is just exisiting.Flag
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Name: Anonymous on Sep 10, 2010Comments: Pain medication is not for divertion,nor for getting high.I have been disabled for 11 years because of being struck in the face by a 40 lb. coil spring with a force of 4000 psi.without some type of instant release medication I can not even get out of bed in the morning.this seem be Inhumane to take away the only releive some people have to fuction a little.Maybe if all the people fighing to take away pain med's could be in our shoes they my think twice about there desision. Living this way is not life,it is just exisiting.Flag
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Name: Dawn Tenorio on Oct 2, 2010Comments: I have been living with severe chronic pain for decades. My medication in no way makes me high. It does not even take all of my pain away, it only buffers it. I cannot get out of bed without taking my medication. My fear is that many of us will choose suicide to living with this kind of pain and the blood will be on our governments hands. It is not fair that those of us who need this type of medication will be punished by people who are in no pain at all and using this medication illegally to get high! It is infuriating to me that I am someone who has never broken a law, never even smoked a cigarette and you are going to treat us like criminals for needing pain relief! You will be murderers! Mark my words! I promise you this will happen since those of us in this much pain have no energy to go out and get it illegally. We are very sick, and I have never been high in my life! Enraged is a mild description for those making this decision for us!Flag
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Name: Anonymous on Oct 26, 2010Comments: The idea of banning these drugs is outragous, Instead of going after those that abuse them for fun, you take them away from those who are in chronic pain such as myself. I have fibromyalgia, lupus, degenerative disc disease, spinal stenosis and take all my medications as prescribed by my doctor. By banning them you are not taking it away from abusers, you are taking it away from those who need it to have any kind of life. The abusers are getting it on the streets and will continue to do so. Dont punish us that are actually in pain because of those that use it for fun. If you were in our shoes for just one week this would not even be a consideration.Flag
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Name: John Cutrell on Nov 14, 2010Comments: NORTH CAROLINA North Carolina Board of Medical Examiners Source: Forum, num. 4, December, 1996 Adopted: September 13, 1996 Amended: July 2005 North Carolina Medical Board Position Statement Policy for the Use of Controlled Substances for the Treatment of Pain North Carolina Medical Board Position Statement Policy for the Use of Controlled Substances for the Treatment of PainAppropriate treatment of chronic pain may include both pharmacologic and non-pharmacologic modalities. The Board realizes that controlled substances, including opioid analgesics, may be an essential part of the treatment regimen. All prescribing of controlled substances must comply with applicable state and federal law. Appropriate treatment of chronic pain may include both pharmacologic and non-pharmacologic modalities. The Board realizes that controlled substances, including opioid analgesics, may be an essential part of the treatment regimen. All prescribing of controlled substances must comply with applicable state and federal law. Guidelines for treatment include: (a) complete patient evaluation, (b) establishment of a treatment plan (contract), (c) informed consent, (d) periodic review, and (e) consultation with specialists in various treatment modalities as appropriate. Deviation from these guidelines will be considered on an individual basis for appropriateness. Section I: Preamble The North Carolina Medical Board recognizes that principles of quality medical practice dictate that the people of the State of North Carolina have access to appropriate and effective pain relief. The appropriate application of up-to-date knowledge and treatment modalities can serve to improve the quality of life for those patients who suffer from pain as well as reduce the morbidity and costs associated with untreated or inappropriately treated pain. For the purposes of this policy, the inappropriate treatment of pain includes nontreatment, undertreatment, overtreatment, and the continued use of ineffective treatments. The diagnosis and treatment of pain is integral to the practice of medicine. The Board encourages physicians to view pain management as a part of quality medical practice for all patients with pain, acute or chronic, and it is especially urgent for patients who experience pain as a result of terminal illness. All physicians should become knowledgeable about assessing patients' pain and effective methods of pain treatment, as well as statutory requirements for prescribing controlled substances. Accordingly, this policy have been developed to clarify the Board's position on pain control, particularly as related to the use of controlled substances, to alleviate physician uncertainty and to encourage better pain management. Inappropriate pain treatment may result from physicians' lack of knowledge about pain management. Fears of investigation or sanction by federal, state and local agencies may also result in inappropriate treatment of pain. Appropriate pain management is the treating physician's responsibility. As such, the Board will consider the inappropriate treatment of pain to be a departure from standards of practice and will investigate such allegations, recognizing that some types of pain cannot be completely relieved, and taking into account whether the treatment is appropriate for the diagnosis. The Board recognizes that controlled substances including opioid analgesics may be essential in the treatment of acute pain due to trauma or surgery and chronic pain, whether due to cancer or non-cancer origins. The Board will refer to current clinical practice guidelines and expert review in approaching cases involving management of pain. The medical management of pain should consider current clinical knowledge and scientific research and the use of pharmacologic and non-pharmacologic modalities according to the judgment of the physician. Pain should be assessed and treated promptly, and the quantity and frequency of doses should be adjusted according to the intensity, duration of the pain, and treatment outcomes. Physicians should recognize that tolerance and physical dependence are normal consequences of sustained use of opioid analgesics and are not the same as addiction. The North Carolina Medical Board is obligated under the laws of the State of North Carolina to protect the public health and safety. The Board recognizes that the use of opioid analgesics for other than legitimate medical purposes pose a threat to the individual and society and that the inappropriate prescribing of controlled substances, including opioid analgesics, may lead to drug diversion and abuse by individuals who seek them for other than legitimate medical use. Accordingly, the Board expects that physicians incorporate safeguards into their practices to minimize the potential for the abuse and diversion of controlled substances. Physicians should not fear disciplinary action from the Board for ordering, prescribing, dispensing or administering controlled substances, including opioid analgesics, for a legitimate medical purpose and in the course of professional practice. The Board will consider prescribing, ordering, dispensing or administering controlled substances for pain to be for a legitimate medical purpose if based on sound clinical judgment. All such prescribing must be based on clear documentation of unrelieved pain. To be within the usual course of professional practice, a physician-patient relationship must exist and the prescribing should be based on a diagnosis and documentation of unrelieved pain. Compliance with applicable state or federal law is required. The Board will judge the validity of the physician's treatment of the patient based on available documentation, rather than solely on the quantity and duration of medication administration. The goal is to control the patient's pain while effectively addressing other aspects of the patient's functioning, including physical, psychological, social and work-related factors. Allegations of inappropriate pain management will be evaluated on an individual basis. The Board will not take disciplinary action against a physician for deviating from this policy when contemporaneous medical records document reasonable cause for deviation. The physician's conduct will be evaluated to a great extent by the outcome of pain treatment, recognizing that some types of pain cannot be completely relieved, and by taking into account whether the drug used is appropriate for the diagnosis, as well as improvement in patient functioning and/or quality of life. Section II: Guidelines The Board has adopted the following criteria when evaluating the physician's treatment of pain, including the use of controlled substances: Evaluation of the Patient —A medical history and physical examination must be obtained, evaluated, and documented in the medical record. The medical record should document the nature and intensity of the pain, current and past treatments for pain, underlying or coexisting diseases or conditions, the effect of the pain on physical and psychological function, and history of substance abuse. The medical record also should document the presence of one or more recognized medical indications for the use of a controlled substance. Treatment Plan —The written treatment plan should state objectives that will be used to determine treatment success, such as pain relief and improved physical and psychosocial function, and should indicate if any further diagnostic evaluations or other treatments are planned. After treatment begins, the physician should adjust drug therapy to the individual medical needs of each patient. Other treatment modalities or a rehabilitation program may be necessary depending on the etiology of the pain and the extent to which the pain is associated with physical and psychosocial impairment. Informed Consent and Agreement for Treatment —The physician should discuss the risks and benefits of the use of controlled substances with the patient, persons designated by the patient or with the patient's surrogate or guardian if the patient is without medical decision-making capacity. The patient should receive prescriptions from one physician and one pharmacy whenever possible. If the patient is at high risk for medication abuse or has a history of substance abuse, the physician should consider the use of a written agreement between physician and patient outlining patient responsibilities, including urine/serum medication levels screening when requested; number and frequency of all prescription refills; and reasons for which drug therapy may be discontinued (e.g., violation of agreement). Periodic Review —The physician should periodically review the course of pain treatment and any new information about the etiology of the pain or the patient's state of health. Continuation or modification of controlled substances for pain management therapy depends on the physician's evaluation of progress toward treatment objectives. Satisfactory response to treatment may be indicated by the patient's decreased pain, increased level of function, or improved quality of life. Objective evidence of improved or diminished function should be monitored and information from family members or other caregivers should be considered in determining the patient's response to treatment. If the patient's progress is unsatisfactory, the physician should assess the appropriateness of continued use of the current treatment plan and consider the use of other therapeutic modalities. Consultation —The physician should be willing to refer the patient as necessary for additional evaluation and treatment in order to achieve treatment objectives. Special attention should be given to those patients with pain who are at risk for medication misuse, abuse or diversion. The management of pain in patients with a history of substance abuse or with a comorbid psychiatric disorder may require extra care, monitoring, documentation and consultation with or referral to an expert in the management of such patients. Medical Records —The physician should keep accurate and complete records to include the medical history and physical examination, diagnostic, therapeutic and laboratory results, evaluations and consultations, treatment objectives, discussion of risks and benefits, informed consent, treatments, medications (including date, type, dosage and quantity prescribed), instructions and agreements and periodic reviews. Records should remain current and be maintained in an accessible manner and readily available for review. Compliance With Controlled Substances Laws and Regulations —To prescribe, dispense or administer controlled substances, the physician must be licensed in the state and comply with applicable federal and state regulations. Physicians are referred to the Physicians Manual of the U.S. Drug Enforcement Administration and any relevant documents issued by the state of North Carolina for specific rules governing controlled substances as well as applicable state regulations. Section III: Definitions For the purposes of these guidelines, the following terms are defined as follows: Acute Pain —Acute pain is the normal, predicted physiological response to a noxious chemical, thermal or mechanical stimulus and typically is associated with invasive procedures, trauma and disease. It is generally time-limited. Addiction —Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include the following: impaired control over drug use, craving, compulsive use, and continued use despite harm. Physical dependence and tolerance are normal physiological consequences of extended opioid therapy for pain and are not the same as addiction. Chronic Pain —Chronic pain is a state in which pain persists beyond the usual course of an acute disease or healing of an injury, or that may or may not be associated with an acute or chronic pathologic process that causes continuous or intermittent pain over months or years. Pain —An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Physical Dependence —Physical dependence is a state of adaptation that is manifested by drug class-specific signs and symptoms that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. Physical dependence, by itself, does not equate with addiction. Pseudoaddiction —The iatrogenic syndrome resulting from the misinterpretation of relief seeking behaviors as though they are drug-seeking behaviors that are commonly seen with addiction. The relief seeking behaviors resolve upon institution of effective analgesic therapy. Substance Abuse —Substance abuse is the use of any substance(s) for non-therapeutic purposes or use of medication for purposes other than those for which it is prescribed. Tolerance —Tolerance is a physiologic state resulting from regular use of a drug in which an increased dosage is needed to produce a specific effect, or a reduced effect is observed with a constant dose over time. Tolerance may or may not be evident during opioid treatment and does not equate with addiction. (Adopted September 1996 as “Management of Chronic Non-Malignant Pain.”) (Redone July 2005 based on the Federation of State Medical Board's “Model Policy for the Use of Controlled Substances for the Treatment of Pain,” as amended by the FSMB in 2004.) -------------------------------------------------------------------------------- Do Doctors Undertreat Pain? or, The Prayer of Maimonides “Freud thought that medicine attracts people with relatively strong sadistic impulses …. of course, to the extent that sadism is about power over weaker, dependent people, sadists have the simpler device of stinting on the pain-killers they control.” (Bioethics 11:3/4 Oxford/Boston: Blackwell Publishers) “Thanks to new guidelines, large conferences, and publicity, physicians are beginning to see how much ‘information’ about morphine and opioid toxicity, tolerance, addiction, and depression of vital functions is myth. Likewise, they are learning that lower doses are needed when patients are allowed to administer their own analgesics at will, especially before the onset of pain. Moreover, research is beginning to show that unrelieved pain has itself deleterious effects on vital functions, for example, on the immune system and hence on healing.” (Id.) ======= Do Doctors Undertreat Pain?[1], by William Ruddick, Bioethics Oxford/Boston: Blackwell Publishers At graduation, some North American medical students repeat the Prayer of Maimonides “never to forget that the patient is a fellow creature in pain, not a mere vessel of disease.” [2] How could a physician ever forget that a patient is in pain? Don’t physicians confront constant reminders such as moans, groans, winces, and other obvious manifestations of pain? …. Physicians and nurses have various familiar ways to forestall or discount patients’ pain reports and requests for more pain relief. In advance of a painful procedure, they minimize the pain that a patient may experience. (‘This may sting a bit,’ ‘You may have some headache for a short time after the lumbar puncture.’) Their clinical rationale is to reduce a patient’s fear and resistance, as well as the pain both may enhance. But these understatements also teach patients the acceptable linguistic parameters for their subsequent complaints. In general, when patients try to speak of pain, physicians and nurses routinely translate their reports into talk of discomfort and distress or even tenderness, the mere possibility of “distress.” Given clinicians’ control of language and general authority, patients may begin to question their own pain-reports. They may begin to wonder, “Am I really in as much pain as I think?”-a seeming exception to what philosophers call the “incorrigibility” of pain, that is, the impossibility of being wrong about the existence or severity of one’s own pain. Whatever the effects of clinician understatement on patients, this linguistic discounting helps clinicians forget how much or how often their patients are suffering, and thereby it helps clinicians distance themselves from the pain they continually encounter and often produce in the course of diagnosis and therapy.[3] For such self-protective distancing to succeed, however, there must be clinical rationales that disguise this functionand they abound. Most common are such routine saws as i) Patients with a history of drug abuse are exaggerating their pain in the hope of getting enough drugs for a hospital high; ii) Patients identified by their ethnic affiliations are engaging in “typical Italian histrionics” or “the usual Jewish kvetching;” and, more sweepingly, iii) All patients tend to be “cry babies,” regressing toward childhood under the strain of illness and hospital routine. Such generalizatons and stereotypes may be based on little evidence, or none at all in the case of particular patients. But given their value for rationalizing clinicians’ self-protective underdescription of patient pain, evidence is not at issue. …. From the outset students are trained to regard pain relief as a secondary concern. They are taught to regard pain as useful symptom for diagnosing disease and, accordingly, to respond not by relieving but by observing and exploring the pain, even if that involves enhancing it through palpation of soft tissues and manipulation of joints.[4] Likewise, students learn how helpful pain can be in following the course of a disease, stages of healing, or the efficacy of drug therapy. More seriously, they learn the many ways in which analgesics, especially morphine and opioids, complicate therapeutic protocols. …. Critics charge that the risk and severity of these side-effects are greatly exaggerated, in our Puritanical, anti-drug culture. In short, from the outset physicians learn to think of pain relief as a complication or hindrance to their diagnostic and therapeutic efforts, not as an integral part of therapy. They early adopt the policy First diagnose and treat; then relieve within limits. There are, however, exceptions to this implicit policy-most notably in the case of patients who are terminally ill or in chronic pain with no discoverable organic causes. But these are “exceptions that prove the rule”-the very patients of whom physicians say or think: “I’m afraid there is nothing more we can do for you.” There is, of course, something more they could do, namely, to provide palliative care. But, significantly, once they are certain of these diagnoses or prognoses, physicians often relegate that task to hypnotists, acupuncturists, biofeedback specialists, hospice nurses, or other non-physicians. The modern physician’s proper work is curing or at least arresting disease, not providing comfort. Not all physicians, however, transfer patients once they are judged to be terminally ill or suffering from pain without a discoverable organic cause. Some are willing to shift from curative efforts to pain relief, including opioids in high and increasing dosages as needed for full relief. In so doing, however, these physicians often provoke their colleagues’ charges that they are overdosing or, even, engaging in unprofessional conduct bordering on homicide. In their self-defense, physicians so charged may invoke one of several familiar ethical principlesfor example, the Principle of Double Effect (“Even if we foresee that death may result, it is relief of pain not death that we intend”), the Principle of Patient Autonomy (“I providing the care that my patient has competently and freely chosen”), or the Principle of Humane Aid (“I am relieving intolerable pain”). But these replies will not persuade critics whose standards of pain relief derive from a conception of Medicine as essentially curative and life-preserving. For them, knowingly to cause, or even risk the death of a patient for the sake of patient comfort is to forsake the defining goals of modern Medicine. By so doing, physicians forfeit the right to call themselves “doctor,” not unlike Jack Kevorkian. I’ll come back shortly to such heated claims about “the Goals of Medicine.” There is, I think, an underlying, more subtle issue, namely, the appropriate concept of pain. What, I suggest, physicians’ training produces is a new, clinical concept of pain that tends to replace their prior lay concept of pain. As a result, what physicians in their training and practice come to forget is this prior, ordinary concept that most of their patients continue to hold. … it is this forgetting of patients’ concept of pain that sets physicians apart from their “fellow creatures in pain.” Concepts of pain: private, privatized, and social I think that the difference between physician and lay concept of pain is more than degrees of precision and sophisticated inference. And it lies not in physicians’ better inferences but in their peculiar trained responses to a patient’s pain. Normally we do not infer someone’s pain from their behavior, rather, we respond to people’s pain the pain manifest in their facial, vocal, and bodily expressions.[5] Pain is indeed a sensation but a sensation that is expressed in these various ways, subject to our respondents. In infants, pain manifestations are initially nonvoluntary. Crying is as natural as the suckling that relieves hunger, and so, too, within a culture, are parental responses.[6] With time, a child’s pain-manifestations become more selective. Even before speech, infants modulate their crying, accentuating or suppressing it in the light of the appearance or absence of recognizable relief-givers (and pain-causers).[7] We early learn who will and will not respond, and the circumstances in which no one will respond, and cry accordingly. Our crying becomes largely limited to those situations in which relief is expectable including, of course, the relief of crying in private. In extreme cases, suppression may become virtually total and habitual as with the “warehoused” infants who live in cage-like cribs without responsive attendants. Just so, patients may learn to privatize their painto “suffer in silence,” to “keep their complaints to themselves,” to “put on a good face” or a “good act.” This may be prompted by clinicians’ routine verbal discounting of pain-reports mentioned above, or by their routine pseudo-inquiries, “How are we feeling today?”-a perfunctory greeting, not a request for information. Or patients, like good soldiers, may not want to trouble their superiors. Or they may wish to avoid further painful investigations that honest revelation of pain would provoke. But, clearly, even such “privatized” pain is response-relative: patients suppress manifestations of pain in order to prevent impatient, or dismissive, or investigative responses of their caretakers. ....in learning to substitute one kind of response for another to patients’ manifestations of pain, physicians are acquiring a different concept of pain. In the presence of physicians who exhibit and subtly impart their learned clinical concept of pain, some patients may themselves come in time to take the same distanced curiosity in their pain that their physicians show, coming to regard their own groans and winces, not as demands for immediate relief, but as symptoms for assessment. To that extent, they will have themselves taken on the physicians’ clinical concept of pain, even in the midst of their own pain. But the majority of patients are not so acculturated: their expressions of pain continue in hope of sympathetic efforts at relief. Hence, they see doctors and nurses who fail to respond appropriately, according to this ordinary concept of pain, as insensitive or worse. [11] Sadism and Callousness To patients who have not become medically acculturated, their physicians and nurses may seem sadistic or callous. Freud thought that medicine attracts people with relatively strong sadistic impulses, but not as a way of acting on these impulses, but as a way of suppressing them through “reaction formation.” Admittedly, our advance rescue techniques (CPR, ventilators, open heart surgery, toxic chemotherapies) may provide “undefended” sadists with more opportunities than the physicians of Freud’s day enjoyed. And, of course, to the extent that sadism is about power over weaker, dependent people, sadists have the simpler device of stinting on the pain-killers they control. ….Callousness is a far more serious worry. If, as I suggest, physicians learn to forget their patients’ concept of pain, they will find it easy to ignore their patients’ expectations of pain relief. What counter-measures might be taken? Vivid films[13] or stories[14] about patient suffering and physician callousness may help; so, too, physician-patients accounts of their own suffering at the hands of other physicians.[15] Another corrective for callousness might be to require graduating medical students to spend some time as hospital patients. Claiming to have vague symptoms, they would at least undergo some of the painful diagnostic tests that they will routinely impose on their own patients, as well as the hospital delays and indignities that increase patient suffering.[16] But if I am right about the causes of physicians’ “forgetting that their patients are fellow creatures in pain,” then the underlying therapy/palliation contrast must be challenged directly. Indeed, a variety of just such scientific and social challenges are underway. Thanks to new guidelines,[17] large conferences, and publicity, physicians are beginning to see how much “information” about morphine and opioid toxicity, tolerance, addiction, and depression of vital functions is myth.[18] Likewise, they are learning that lower doses are needed when patients are allowed to administer their own analgesics at will, especially before the onset of pain. Moreover, research is beginning to show that unrelieved pain has itself deleterious effects on vital functions, for example, on the immune system and hence on healing. ….Moreover, even when there is “something more” physicians can do to try to cure, or at least arrest a debilitating or degenerative disease, patients or their insurers increasingly are unwilling to “fight to the end.” In such cases, palliation or “comfort care” becomes a therapeutic option, or even “the treatment of choice”-not an admission of clinical failure or fatigue. ….It remains to be seen whether these social changes, along with more precise knowledge of pain’s harms and analgesia’s manageable side effects, will give pain-relief greater status in clinical training and practice. …. But there is reason to believe that the current contrast I have drawn between physicians’ concept of pain and patients’ concept of pain will shrink. If so, then the Prayer of Maimonides may become more than ceremonial and physicians will more easily remember that their patients are “fellow creatures in pain, not just vessels of disease”. …. Were physicians to remember their patients’ concept of pain as demanding relief and act accordingly, then, of course, they would reduce the amount of pain they would need to “forget” by self-protective misdescription and dismissive stereotypes. Notes 1. A revised version of a paper read at the panel, “Mismanaging Pain,” III World Congress of Bioethics, San Francisco, California, on November 24, 1996. 2. Attributed to the 12th century physician-philosopher Maimonides (Rabbi Moses ben Maimon, or RamBam) but possibly of 18th century origin. 3. Other self-protective euphemisms: surgeons “lose” patients, oncologists detect “growths,” infants are born “with problems.” Even acronyms and eponyms may play a euphemistic role: ‘ALS’ and ‘Lou Gehrig’s disease’ seem less dire than the fully descriptive ‘amyotrophic lateral sclerosis.’ 4. This diagnostic response to pain is caught by the old medical school joke: Q. “What are the five classical signs of infection?” A. “Rubor, calor, tumor, dolor — and clamor.” Pain (dolor) and its expression (clamor) are assimilated to redness, heat, and swelling-all signs or symptoms useful for diagnosis of their pathological causes. 5. Ludwig Wittgenstein:”….(Pity, one may say, is a form of conviction that someone else is in pain.)” Philosophical Investigations I, para.287. Readers of Wittgenstein will appreciate that my remarks are variations on his general attack on the view that psychological terms are to be thought of as names for private sensations, rather than as tools whose meaning is given by uses in what he called “forms of life,” “the stream of life.” 6. For us, parental comforting of a crying baby seems as natural, or spontaneous as the crying itself. Parents, especially mothers, who do not so respond are thought to be abnormally depressed, exhausted, or otherwise distracted. Observers of other cultures-and honest reporters of our “deviant” responses-show how culturally defined the interaction of sufferer and respondent may be. 7. Wittgenstein: “A child discovers that when he is in pain for instance, he will get treated kindly if he screams; then he screams, so as to get treated that way. This is not pretense. Merely one root of pretense.” Last Writings, Volume I, para.867 (Blackwell 1982). ….11. The conflict between the relief-response concept of pain and the clinician-response concept is especially acute in neonatal matters, partly because the relations between causes, manifestations, and effective relief of pain are too tenuous and variable for clear definition. Hence, the counter-charges between “heartless” surgeons and “sentimental” lay critics. See Nancy Cunningham Butler, “Infants, pain and what health care professionals should want to know — an issue of epistemology and ethics,” and Dr. Neil Campbell’s response in Bioethics 3:3, 1989, 181-210. ….13. For example, “Dax’s Case,” a film about a severely burned patient treated over months against his will. During his excruciatingly painful tubbings and debridements the paramedics keep their radio blaring. In commenting on his case, his physicians can seem almost as unhearing. Also, The Right to Die?: The Dax Cowart Case New York: Routledge CD ROM 1996. 14. In Ernest Hemingway’s “Indian Camp,” a physician tells his young son that he does not hear the screams of the Indian woman on whom he performs a Caesarian section without anesthesia. Nor does he hear the empathetic cries of the woman’s husband in the bunk above her-a suicide by the end of the ordeal. 15. In a Leg to Stand On, Oliver Sachs recounts his often callous treatment for a painful leg injury (New York: Harper & Row 1984). 16. See the film, “The Doctor” (dir. Randy Haines 1991) about a physician (William Hurt) who required hospitalization as part of his medical students training after the humiliations of hospital treatment he himself had recently suffered. 17. E.g. U.S. Department of Health and Human Services, Acute Pain Guidelines Panel. Acute Pain Management: Operative or Medical Procedures and Trauma. Rockville, MD, 1992. 18. Cf. David Joranson, et al. “Opioids for chronic Cancer and Non-Cancer Pain: A Survey of State Medical Board Members. Bulletin of the Federation of State Medical Boards of the United States, June 1992: 15-49. Related articles by Zemanta Katharine Whitehorn on assisted suicides in Oregon National Pain Awareness Month -------------------------------------------------------------------------------- Pain Control: Dispelling the Myths by Dr. Joel Potash, MD. Hospice strongly advocates good pain control for terminally ill patients, even to the point of using narcotic drugs (we call them opiates) such as morphine as they are needed. With all the concern about drug abuse, patients and their families and friends sometimes question this use of narcotics. Are we pushing “dope”? Or are we practicing good medicine? Let’s explore some of the myths about the use of narcotics for pain control. Myth #1: Morphine is offered to patients only when death is imminent. It is not the stage of a terminal illness, but the degree of pain that dictates which medicine to use. We start with the mildest medicine and if it works, stop there. If it doesn’t we move on, to morphine when it’s appropriate. Some people never need morphine, while others will require it for quite a while. You can live for a long time on morphine. Myth #2: People who take morphine will become addicted. Drug addicts are people who are driven by their needs for narcotics; they may commit crimes or harm others to get their needs met. Hospice patients usually don’t have drug-seeking behavior. When their pain is in good control, they don’t desire more opiates. Sometimes we can even decrease the dosage. If patients take morphine for a while, their body does become used to it and it should not be suddenly stopped, because side effects could occur. However, hospice patients on morphine are not considered to be addicts. Myth #3: People who take morphine will become so sedated (sleepy) that they can’t function. When patients start to take drugs like morphine, they often feel drowsy for a few days. But their bodies usually will very quickly build up a resistance to the sedating effects. Most patients whose pain is well controlled on morphine are not bothered by unusual sleepiness. Some people, however, notice a difference in their alertness and might choose somewhat less than perfect pain control as a tradeoff. Myth #4: People who take morphine die sooner because morphine causes them to stop breathing. Fortunately, patients quickly adjust to any effect that morphine may have on their breathing. We prescribe a small initial dose, gradually increasing it if needed. So rarely do breathing problems occur, they are usually not even listed as side effects. In fact morphine is a drug of choice for breathing distress in people with end-stage heart or lung disease: it makes their breathing more comfortable. Myth #5: I’m allergic to morphine: once I had a shot of morphine after an operation and I felt very strange. Of course you can be allergic to morphine just like any other medicine. But feeling strange is not a sign of morphine allergy usually. Some people may have unpleasant mental sensations temporarily when they start to take morphine. But that is not an allergy; and it might never recur. There are other opiates available for those people who are truly allergic to morphine. Myth #6: Morphine must be given by injection. We used to think that opiates were not effective unless administered by injection. But Hospice has been a leader in demonstrating the effectiveness of morphine and other opiates taken orally. Even people who required injections of morphine in the hospital (the most common way of giving morphine there) will probably be able to be well controlled on oral morphine at home. There are also long-acting preparations of morphine which can be given every twelve hours, or opiate skin patches which can be applied every 72 hours, to simplify the routine of pain control. Myth #7: People should wait until their pain is bad to take morphine so it will be effective when it’s really needed. There is no upper dose limit to the use of morphine or other opiates. If pain increases we can increase the dose; this is true of very few other medications. Using it when it’s needed early in the course of a terminal illness does not mean that it won’t continue to work later in the disease. Morphine, one of the oldest drugs in existence, has found a well-deserved place in the new field of palliative care: the relief of pain and other symptoms. We recommend opiates for pain control only if they are needed. When they are needed, they are often successful in controlling the pain and suffering of terminal illness. Prescription Pain Relievers What Are the Different Kinds of Prescription Pain Relievers? For many years, the most widely used prescription pain relievers have been narcotics. Narcotics are drugs that relieve pain. Historically, these drugs came from the opium poppy. They are also called opioids or opiates. Today, many narcotics are synthetic, that is, they are chemicals manufactured by drug companies. Frequently used opioid pain relievers include the following: codeine hydromorphone (Dilaudid) levorphanol (Levo-Dromoran) methadone (Dolophine) morphine oxycodone (in Percodan) oxymorphone (Numorphan) How Do I Decide Which Pain Medications To Use? This is not something you should decide alone. Discuss this with your doctor, nurse, or pharmacist before you use any drugs for pain. Medications that worked for you in the past or that helped a friend or relative may not be right for you at this time. Never take someone else’s medicine! Only one doctor should prescribe your pain medicine. If a consulting doctor changes your medicine, be sure the two doctors discuss your treatment. Otherwise, you may take too much or too little. Let your doctor or nurse know whether your pain medication gives you relief. Work together to find the medication or pain-relief program that is best for you. Remember, your need for pain medicine may change as your cancer treatment changes. It is important to record the name and amount of pain medication you take. You can then give precise information to the doctor or nurse about its effect on your pain. Will I Become Addicted if I Use Narcotics for Pain Relief? No. Narcotic addiction is defined as dependence on the regular use of narcotics to satisfy physical, emotional, and psychological needs rather than for medical reasons. Pain relief is a medical reason for taking narcotics. Therefore, if you take narcotics to relieve your pain, you are not an “addict,” no matter how much or how often you take narcotic medicines. If you and your doctor decide that narcotics are a proper choice for your pain relief, use them as directed. Addiction is a very common fear of people who take narcotics for pain relief. Narcotic addiction is an emotionally charged subject. You may hear people use the term “addiction” very loosely without understanding exactly what it means - the compulsive use of habit-forming drugs for their pleasurable effects. Drug addiction in cancer patients is rare. Generally, when narcotics are used under proper medical supervision the chance of addiction is very small. Most patients who take narcotics for pain relief can stop taking these drugs if their pain can be controlled by other means. It is important to remember that if narcotics are the only effective way to relieve pain, the patient’s comfort is more important than any possibility of addiction. If you take narcotics for several weeks or more, be prepared for someone to express a concern about addiction. Most people with prolonged pain who take narcotics have faced this problem. Remind yourself that other people’s concerns about addiction are often due to lack of information. If you have concerns about addiction, share them with those who are caring for you. These fears should not prevent you from using narcotics to effectively relieve your pain. What Is Drug Tolerance? When certain drugs are taken regularly for a length of time, the body doesn’t respond to them as well as it once did, and the drugs at a fixed dose become less effective. Larger or more frequent doses must be taken to obtain the effect that was achieved with the original dose. People who take narcotics for pain control sometimes find that over time they will need to take larger doses. This either may be due to an increase in the pain or the development of drug tolerance. Increasing the doses of narcotics to relieve increasing pain or to overcome drug tolerance is not addiction. What if the Medicine That Has Been Recommended Doesn’t Relieve My Pain? Tell your doctor or nurse as soon as you can if you are not getting effective pain relief. Don’t wait for your next appointment! They need to know: How much, if any, pain relief you get. How long the pain is relieved. Any side effects that occur or do not occur, especially drowsiness. How pain interferes with your normal activities such as sleep, work, eating, or sex. With your doctor’s help, you can usually get good pain relief. When the medicine does not give you enough pain relief, the doctor may increase the dose or the frequency or prescribe a different drug. Some narcotics are stronger than others, and you may need a stronger one to control your pain. If your pain relief is not lasting long enough, ask your doctor about long acting forms of medicine. Morphine is now available in a tablet form that releases it over a long period of time (MS Contin or Roxanol SR). You may have developed drug tolerance if you have taken narcotics for a long time. As a result, doses that may have been too large for you a few weeks before may be safe now. The desired effect is pain relief with as few side effects as possible, regardless of the size of the dose. Some doctors are reluctant to prescribe large enough doses or stronger narcotics for pain control. However, with careful medical observation, the doses of strong narcotics (by mouth or injection) can be safely raised enough to ease severe pain. Do not increase the dose of your pain medicine on your own. Remember, you are the best judge of whether your pain is relieved. If you still have pain and your doctor does not seem to be aware of other alternatives, ask to see a specialist in cancer pain management. http://www.hospicenet.org/html/prescription.html -------------------------------------------------------------------------------- Common Myths About Using Opiates to Treat Pain Addiction to opiates is very common and occurs easily. Many people think that addiction is common because they mistakenly believe that persons who go through withdrawal if their drug is stopped are addicted. In fact, a person who experiences withdrawal is physically dependent; physical dependence is a normal response to sustained opiate therapy and is not important to a patient as long as the drug is not stopped suddenly. Pain medication can and should only be prescribed to a patient when pain occurs. A patient with continuous or frequently recurring pain should be given pain medication around the clock, preferably a long-acting drug. It is far easier to prevent pain than to deal with it after it occurs. "As needed" dosing should only be considered in some patients. For example, patients with repeated episodes of acute pain may be given a drug to take just when the pain occurs and some patients who are given a pain medication around the clock are also given a short acting drug that can be taken when an acute pain (a so-called "breakthrough pain") occurs. Uncontrolled pain is an unavoidable part of many serious illnesses like cancer. Pain does not need to be an inevitable part of most serious illnesses. Cancer pain and pain associated with other serious illnesses usually can be controlled with medications and other therapies. The side effects of opiates prevent a person from functioning and can cause more suffering than the pain. The truth is that if the dose of the medication is carefully adjusted, and the side effects are treated, most patients have a much better quality of life. The overall effect of treatment with these drugs is very favorable in most cases. As a patient's pain increases, the illness must be getting worse and death must be near. Although it is true that pain can be a signal of disease, and the doctor should assess new pains or pains that are worsening, it is also true that pain comes and goes for different reasons. Worsening pain doesn't necessarily mean advancing disease. If end of life is near, morphine or other opiates can't be increased without causing death. Many people make an unfortunate connection between the use of morphine and imminent death. Remember, physicians use morphine and other opiates to relieve pain. These drugs can be used safely when a patient has a serious medical illness, and even at the very end of life. It is a myth that the only way to stop the pain associated with cancer or other serious illness is to give the patient a lethal dose of these medicines. Almost always, doses can be increased with little risk of serious harm. The reason to increase the dose is to relieve worsening pain; pain relief is often the most important concern at the end of life. Enduring pain builds strength and character. Many patients think that if they "tough it out” this time it won't be as bad next time. That doesn't work. The opposite is true. Pain weakens a person. It weakens the immune system. It does not build character. Pain should be treated immediately and effectively. Doctors face a choice between treating a disease and treating the pain. Some people believe there is a choice between treating a disease and treating the pain caused by the disease. This is not true. Pain should be treated at all times, whether or not the disease can be treated. Some people mistakenly believe that if they're given a lot of pain medication, their doctors have "given up on them." The better way of thinking about it is this: If you treat the pain, the body doesn't have to concentrate on battling it. There is some evidence that treating pain relieves stress on the body, so the body heals faster. Patients need ever increasing doses of opiates because tolerance develops rapidly to these drugs. Tolerance means the loss of drug effect over time. Tolerance to opioid medications is a complex phenomenon. It usually does occur to side effects, such as nausea and sleepiness, and is a favorable occurrence. Tolerance to pain relief might become a problem, but does not appear to be an inevitable consequence of chronic opioid therapy. In fact, most patients stabilize on a dose for a long time. If more pain medication is needed, it usually is because the painful problem has worsened. In this case, pain control usually can be regained, the dose of drug can be increased or a patient can be switched to another opioid. Edited by Russell Portenoy, M.D., Chairman, Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, and June L. Dahl, Ph.D., Professor of Pharmacology at the University of Wisconsin-Madison, and Director of the Resource Center for the State Cancer Pain Initiatives. The myths document was prepared and edited on behalf of The Mayday Fund, a New York-based family foundation dedicated to alleviating the incidence, degree and consequence of human physical pain. -------------------------------------------------------------------------------- Review Shows Opioids Relieve Chronic Pain With Little Addiction Risk Karen Lee Richards Monday, January 25, 2010 http://www.healthcentral.com/chronic-pain/c/5949/101849/addiction A new review supports what those of us who have worked in the area of chronic pain have long known – people who take opioids for real chronic pain problems rarely become addicted to them. Meredith Noble, a senior research analyst at ECRI Institute, one of 14 evidence-based Practice Centers in the country under the U.S. Agency for Healthcare Research and Quality, and her colleagues reviewed the findings of 26 clinical studies comprising 4,893 participants. “There is a lack of consensus that opioids are safe and effective for people with chronic severe non-cancer pain,” Noble said. “We wanted to look at studies that treated people for six months or longer, given that chronic pain can go on for years. This review includes studies of individuals on opioids for as long as 48 months.” Patients in the studies had previously tried other treatments like non-opioid medications and physical therapy, but still had considerable pain. Clinicians prescribed opioids including oxycodone, morphine and methadone by pill, transdermal (skin) patch or intrathecal pump. Most of the patients in this review had chronic back pain following failed surgery, severe osteoarthritis, or pain related to nerve damage. Among studies reporting abuse or addiction, only seven of 2,613 participants reportedly took their medicine inappropriately or became addicted. That's only about one quarter of one percent. The findings indicate that carefully selected patients with no history of addiction and abuse, who take their medications as prescribed, can experience good amounts of pain relief with a very small risk of addition. Alex DeLuca, M.D., an independent consultant specializing in addiction and pain medicine, praised the thoroughness of this review and pointed out the very low rate of signs of addiction in treated pain patients. A take-home message for physicians reading this review is that all relevant studies find that long-term opioid therapy improves the life of non-cancer patients experiencing chronic pain and is both safe and effective, DeLuca said, and there is zero evidence to the contrary. A Personal Note I was so pleased to see this review. Unfortunately, when it comes to opioids, most people still don't understand that there is a big difference between physical dependence and addiction. (For more information read: Opioids: Addiction vs. Dependence) Hopefully this review will give us more ammunition in our fight for appropriate treatments for chronic pain patients. Sources: Noble M, et al. Long-term opioid management for chronic noncancer pain (Review). Cochrane Database of Systematic Reviews. Issue 1, 2010. McAdams, P. (2010, January 19). Used as Prescribed, opioids relieve chronic pain with little addiction risk. Health Behavior News Service. © 2010 MedPage Today, LLC. All Rights Reserved. -------------------------------------------------------------------------------- Pain Management Suffers Due to Fears of Prescription Drug Abuse Karen Lee Richards January 4, 2010 We're all too aware of the fact that chronic pain is being significantly under-treated because many physicians either have inadequate training, personal biases or are afraid of prescription drug abuse. Surveys show that at least 30 percent of patients with moderate chronic pain and more than 50 percent of those with severe chronic pain do not get adequate pain relief. Now someone is speaking out about the problem. Kathryn Hahn, a pharmaceutical expert in pain management, affiliate faculty member at Oregon State University and chair of the Oregon Pain Management Commission, says the issue is reaching crisis proportions. She outlined some of the problems in two publications, the Journal of Pain and Palliative Care Pharmacotherapy, and The Rx Consultant. “We have more sophisticated pain management techniques available now than ever before,” said Hahn, “But many doctors are not fully informed about all the options available, and also often turn patients away because they’re very concerned about the problems with prescription drug abuse. Because of this, many people suffer needlessly with pain that could be treated...” Adequate pain treatment has always been a concern, Hahn said, in part because it’s not a major part of most physician’s medical training. Even though they will often see a stream of patients with pain problems throughout their careers, they may only get a few hours of education on the use of opioids in medical school. In recent years, the problems have dramatically increased due to concerns about prescription drug abuse, in which drugs such as oxycodone are often stolen from homes or otherwise misused. Concerns about this within the medical profession are sufficiently high, Hahn said, that many doctors prefer not to even work with patients who have ongoing pain issues. “I see patients every week who have lost their doctors, don’t know what to do and these people are scared,” Hahn said. “It’s particularly bad with elderly and Medicare patients. Prescription drug abuse is a very real problem, we do have to take necessary steps to address it, but right now the pendulum has swung too far, and legitimate pain problems are not being managed.” Long-term solutions, Hahn said, will take education and responsibility by all parties involved, including consumers, physicians, nurses and pharmacists. Among the steps that may help: Doctors and nurses should accept that patients are the final arbiter of determining that something is painful, believe them and work with them on their concerns. Patients should cooperate with their health care providers on pain relief plans that may include a range of options, including prescription drugs but also alternative approaches such as chiropractic care, exercise, acupuncture, meditation, implantable devices, massage, or physical and occupational therapy. Even within the umbrella of medications, there are a huge range of opioids, over-the-counter pain relievers, antidepressants and other medications to carefully consider for specific problems. Consumers must acknowledge the seriousness of the prescription drug abuse issue and lock up their medications securely – literally in a home safe in some circumstances. The unlocked medicine cabinet is the foundation of a cottage industry of drug abuse in America today. All involved parties should understand that psychological addiction or physical dependence on drugs is rarely a major concern in a properly managed and prescribed pain management program. Individuals should try to work and communicate patiently with their health care providers, not switch doctors arbitrarily, educate themselves if necessary, but be persistent in having their pain concerns taken seriously. Physicians must stay up to date on the latest approaches and full spectrum of pain management options, and recognize than pain control and management is a key part of overall health care. Hahn noted that community pharmacists are often on the front lines of this issue and constantly see individuals with pain concerns and inadequate pain management by their health care providers. They can help serve as advocates, improve lines of communication between patients and their doctors, and help patients manage their prescribed drug therapies. She also believes that health insurers have an important role to play in reducing prescription drug abuse by helping to educate physicians on appropriate use, advocate for universal precautions in use of pain medicines, restrict off-label uses of readily diverted opioids, and pay for multidisciplinary pain management programs. ––––––––––––––– Sources: Hahn K. Chronic pain management Rx Consult. 2009;18(11):1-7. Hahn K, Colon Y. The roles of pharmacists in pain management. J Pain Pall Care Pharmacother. 2009;23(4):414-415. OSU (Oregon State University). Pain management failing as fears of prescription drug abuse rise [news release]. © 2010 MedPage Today, LLC. All Rights Reserved. -------------------------------------------------------------------------------- Genetic Variations Affect Opioid Response Karen Lee Richards Have you ever wondered why some people seem to get more pain relief with opioid medications than others? Scientists at the University of North Carolina at Chapel Hill's Center for Neurosensory Disorders may have discovered the answer. They have identified genetic variations that have given them insight into why individuals repsond differently to opioids like morphine. There's a wide range of differences in how patients respond to opioids. One patient may experience more than 10 times the amount of pain relief as another patient receiving the same dosage. And as many as one-third report significant side effects. Until now scientists have not known why there is such a drastic difference in response. This study, published in the March 15, 2009 issue of the journal Human Molecular Genetics may hold the key that unlocks the mystery. Researchers identified new variations in the gene that produces opioid receptors. Opioids work by binding to these receptors in the brain and spinal column, which then slows the rate at which a pain message can be transmitted. The genetic variations found in these receptors play a crucial role in determining how a patient will respond to opioid medication. Although this is just the first step on the journey, researchers are hopeful that these findings will lead to the development of: Genetic tests that will predict how an individual patient will respond to a particular pain medication. Medications (possibly a new class of opioids) that offer greater pain relief with fewer side effects. ___________________ Source: Shabalina, Svetlana A., et al (2009, March 15). Expansion of the human mu-opioid receptor gene architecture: novel functional variants. Human Molecular Genetics, Vol. 18, No. 6 http://www.healthcentral.com/chronic-pain/c/5949/69170/variations © 2010 MedPage Today, LLC. All Rights Reserved. -------------------------------------------------------------------------------- Opioids: Addiction vs Dependence Karen Lee Richards One of the greatest obstacles chronic pain patients face in their quest for adequate pain relief is the widespread misunderstanding of the difference between physical dependence on a drug and addiction. Many patients, the general public, and sadly even some physicians fear that anyone taking opioid medications on a long-term basis will become addicted. As a result, pain patients are often labeled as “drug seekers” and stigmatized for their use of opioid medications. Worst of all, their pain frequently remains under-treated. Understanding the Terminology Before we can adequately discuss this topic, it is important to clearly define the terms we will be using. Addiction is a neurobiological disease that has genetic, psychosocial, and environmental factors. It is characterized by one or more of the following behaviors: Poor control over drug use Compulsive drug use Continued use of a drug despite physical, mental and/or social harm A craving for the drug Physical dependence is the body's adaptation to a particular drug. In other words, the individual's body gets used to receiving regular doses of a certain medication. When the medication is abruptly stopped or the dosage is reduced too quickly, the person will experience withdrawal symptoms. Although we tend to think of opioids when we talk about physical dependence and withdrawal, a number of other drugs not associated with addiction can also result in physical dependence (i.e., antidepressants, beta blockers, corticosteroids, etc.) and can trigger unpleasant withdrawal symptoms if stopped abruptly. Tolerance is a condition that occurs when the body adapts or gets used to a particular medication, lessening its effectiveness. When that happens, it is necessary to either increase the dosage or switch to another type of medication in order to maintain pain relief. Pseudoaddiction is a term used to describe patient behaviors that may occur when their pain is not being treated adequately. Patients who are desperate for pain relief may watch the clock until time for their next medication dose and do other things that would normally be considered “drug seeking” behaviors, such as taking medications not prescribed to them, taking illegal drugs, or using deception to obtain medications. The difference between pseudoaddiction and true addiction is that the behaviors stop when the patient's pain is effectively treated. Can a chronic pain patient become addicted to opioid drugs? Although most chronic pain patients who take opioids on a long-term basis will become physically dependent on them, very few will ever become addicted to them. The rare few who do develop a problem are often highly susceptible to addiction due to a genetic predisposition. In a review of 24,000 patients who were medically prescribed opioids, only seven could be found who got into trouble with them. So a chronic pain patient becoming addicted to opioid medications is definitely the exception rather than the rule. Following are some of the key differences between addicts and pain patients: Addicts Pain Patients Addicts take drugs to get high and avoid life Pain patients take drugs to function normally and get on with life. Addicts isolate themselves and become lost to their families. When pain patients get adequate relief, they become active members of their families. Addicts are unable to interact appropriately with society. When pain patients get adequate relief, they interact with and make positive contributions to society. Addicts are eventually unable to hold down a job. When pain patients get adequate relief, they are often able to go back to work. The life on an addict is a continuous downward spiral. When a pain patient gets adequate relief, their life progresses in a positive, upward direction. _____________ Sources: The American Academy of Pain Medicine, The American Pain Society and the American Society of Addiction Medicine. (2001). Definitions related to the use of opioids for the treatment of pain. Retrieved December 1, 2008, from American Pain Society Web site: http://www.ampainsoc.org/advocacy/opioids2.htm The National Institute on Drug Abuse. Addiction vs Dependence. Retrieved December 1, 2008 from Our Chronic Pain Mission Web site: http://www.cpmission.com/main/addiction.html © 2010 MedPage Today, LLC. All Rights Reserved. -------------------------------------------------------------------------------- Chronic Pain - Underdosing, Not Overdosing, Is the Real Problem By: Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital Recently I've read several articles about how Gil Kerlikowske, Obama's drug czar, is shifting the drug law enforcement emphasis from marijuana to methamphetamine and prescription drug abuse. While I'm all for legalizing marijuana for medical use and I fully support putting an end to the use of meth, increasing the monitoring of prescription drug usage concerns me. Of course I'm opposed to abusing prescription drugs, but in trying to reduce abuse, too often the government throws out the proverbial baby with the bath water. Stopping the street sale of prescription drugs is one thing, but more stringent monitoring of physicians, pain clinics and even patients is quite another. Undertreatment of pain is already a huge problem. Making it riskier for doctors to prescribe needed pain medication will only worsen the problem. Every time a celebrity dies from an overdose of prescription drugs, the media stirs up discussions about doctors who over-prescribe opioid medications. Do some doctors overdose their patients? Sure. But their number is very small – and often it seems they are connected with celebrities. Perhaps the money and prestige of treating a celebrity is too great a temptation. Whatever the reason, those doctors are certainly not typical. In my opinion, underdosing chronic pain patients is a far greater problem than overdosing them. Check out this video I came across on Reason.tv – When Cops Play Doctor – How the drug war punishes pain patients.Flag
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Name: Michael Smith on Nov 29, 2010Comments: There are people who truly need this medication and should not be denied its effects because some people have the potential to abuse it. The FDA needs to stop over stepping their bounds and regulating everything we put in our bodies in the name of our safety. We should be left with non bias information and left to decided on whether or not it would be appropriate for us personally to use it. The FDA should be a source of information we can trust, instead of playing the role of big brother.Flag
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Name: John A. Vehill on Nov 29, 2010Comments: I wrote my district rep about this. William Blake once said: "better that ten guilty persons escape than that one innocent suffer" and this holds true for our argument. It should be preferred that 10 addicts draw harm from this medicine than one legitimately sick patient be denied it's indisputable benefits.Flag
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Name: Ken Bucklin on Feb 5, 2011Comments: i would not go on living with the backpain, without the relief i get from percoset. let the abusers do their thing but some of us need the relief, i'm 61. kenFlag
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