Arachnoiditis

[Pain Applicant1]

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then you realize that many patients self-medicate while taking opioids including methadone....

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the lack of alternatives is a common limitation, but falling back on opioids is not the correct answer. your answer seems to suggest that someone who has failed everything is automatically a candidate for a narcotic.

these make up the vast majority of my referrals.

what I tell them is that the treatment is worse than the disease, and while chronic pain could cause quality of life concerns and functional limitations, opioids will cause both, and will lead to multiple iatrogenic effects. it is not in their best interest to be put on narcotics for the rest of their lives.


i tell them people can have good quality of lives while having chronic pain. pain is a subjective experience. that's what we need to focus on, and work on.

some times the best thing to do is "nothing". at least nothing medical or interventional.


funny thing, and I know you are thinking about this - but the vast majority of people come back for follow ups.

except for the addicts.

Let me clarify, I have about 3 patients on methadone. Opioids are far from a panacea and are not indicated for everyone who has failed more conservative measures but there's a time and there's a place.

I honestly hope that if I or any member of my family is suffering from chronic pain the way some of my patients are, I can find someone with a similar mindset to the one that I have. I am sure and I hope you feel the same way about yourself. Either way, it'll probably get annoying and boring to go back and forth so let's agree to disagree. You are welcome to have the last word if you'd like.

 

[epidural man]

The same reason to prescribe any opioid, because the more conservative options have been exhausted. There's a time and place for opioids.

Like I said earlier - I'll use methadone. I like it. My point is, I wouldn't fault anyone saying they will never use it - that is very reasonable.

BUT, I am much more in the camp that opioids for chronic pain should almost never be used. Certainly NEVER should be used for musculoskeletal problems like OA, failed back syndrome or other back pain issues, CRPS, etc.

The fact that there is no alternative isn't a reason to use a drug that doesn't work that causes harm. The problem lies with the fact that endogenous opioids DO NOT continually get the opioid receptor to work like we want them to. Not only has that been demonstrated in preclinical data, lab work, etc - there isn't a good study showing it works well in humans (and actually shows a lot of the harms I am alluding to). Maybe in PHN, there is some okay data for long-term opioid therapy.

Nonetheless, I don't buy this idea that there is no alternative.

Show me a chronic pain patient who has read 6 GOOD and useful books on chronic pain, including BACK IN CONTROL by David Hanscom, has read Full Catastrophe Living, has attended several chronic pain courses, studied the works of Lorimer Mosely (check out www.tamethebeast.org), does yoga daily, is getting restful sleep, has their depression and anxiety adequately treated, and has their spiritually needs met - show me that patient that requires opioids. My guess is, the count is zero.

 

[Ducttape]

for beginning patients, I recommend of Managing Pain Before It Manages You by Margaert Caudil.

for those with audiobook capability and really don't seem they will be an active participant in what they are reading, You Are Not Your Pain by Vidyamala Burch is a nice listen that incorporates meditation.

 

[Ferrismonk]

The fact that there is no alternative isn't a reason to use a drug that doesn't work that causes harm.

This x 1000. We're not withholding opioids because of restrictive laws/regulations and thus a compassionate doctor should buck the system and give them to patients, we're withholding opioids because they don't work for chronic non-cancer pain and they cause harm.

Show me a chronic pain patient who has read 6 GOOD and useful books on chronic pain, including BACK IN CONTROL by David Hanscom, has read Full Catastrophe Living, has attended several chronic pain courses, studied the works of Lorimer Mosely (check out www.tamethebeast.org), does yoga daily, is getting restful sleep, has their depression and anxiety adequately treated, and has their spiritually needs met - show me that patient that requires opioids. My guess is, the count is zero.

Definitely going to read these. Do you have any more good/useful books for self-managing pain that is written at a patient level?

 

[Pain Applicant1]

Like I said earlier - I'll use methadone. I like it. My point is, I wouldn't fault anyone saying they will never use it - that is very reasonable.

BUT, I am much more in the camp that opioids for chronic pain should almost never be used. Certainly NEVER should be used for musculoskeletal problems like OA, failed back syndrome or other back pain issues, CRPS, etc.

The fact that there is no alternative isn't a reason to use a drug that doesn't work that causes harm. The problem lies with the fact that endogenous opioids DO NOT continually get the opioid receptor to work like we want them to. Not only has that been demonstrated in preclinical data, lab work, etc - there isn't a good study showing it works well in humans (and actually shows a lot of the harms I am alluding to). Maybe in PHN, there is some okay data for long-term opioid therapy.

Nonetheless, I don't buy this idea that there is no alternative.

Show me a chronic pain patient who has read 6 GOOD and useful books on chronic pain, including BACK IN CONTROL by David Hanscom, has read Full Catastrophe Living, has attended several chronic pain courses, studied the works of Lorimer Mosely (check out www.tamethebeast.org), does yoga daily, is getting restful sleep, has their depression and anxiety adequately treated, and has their spiritually needs met - show me that patient that requires opioids. My guess is, the count is zero.

I don't know what to tell you. My only point is that there is an indication for opioids at certain times. When those times are comes down to provider experience. It seems like some posters on here, maybe even you, allude to the perception that they, and only they, know the exact right timing for this.

I judge myself by my practice. I like my pts and my pts seem to like me. My community, which I completely feel a part of, seems happy with me. I'm well known here and seem to be well-liked. I'm here for about 10 years and still get a lot of referrals from doctors and pts so I must be doing something right. Since I started my practice, opioid-related deaths have decreased in my county. I know this because one of the investigators is my pt. I'm not claiming it was my doing because the nationwide trend decreased at that time but it's interesting to think about nonetheless. I also know my opioid scripts are lower than average because my PMP compares me to my same specialty colleagues.

Every treatment we provide has potential adverse consequences that need to be considered. This is by no means limited to opioids and I'm not really convinced that anything we provide works so great for the long-term.

Reading those books and attending courses are completely unrealistic for my pt population. My opioid pts tend to be older pts who still work manual labor jobs. I don't know if you live in a city but in my rural town, your recommendations are a far cry from reality. You're assuming my pts have the time, education, and money to participate in these options.

 

[Orin]

Why are we okay with using opioids for cancer then? Is it okay if they're dying faster or are older?

 

[Ducttape]

Why are we okay with using opioids for cancer then? Is it okay if they're dying faster or are older?

1. there is a good probability that they will die from their cancer, unlike chronic pain
2. chronic pain does not metastasize or invade other organs
3. for chronic pain, ofttimes the main issue are the emotional and psychological effects of the pain that opioids do not help
4. chronic long term opioid therapy has risks, that generally we don't see with cancer pain - they either unfortunately die or hopefully get better and pain goes away.

 

[epidural man]

It seems like some posters on here, maybe even you, allude to the perception that they, and only they, know the exact right timing for this.

HELL NO, not me. I'm horrible at it. None of my patients seem to benefit from long-term opioids. That is probably why I am sour on the idea. If you are better at getting the answer at the opioid receptor by patient selection, that is awesome.

Reading those books and attending courses are completely unrealistic for my pt population. My opioid pts tend to be older pts who still work manual labor jobs. I don't know if you live in a city but in my rural town, your recommendations are a far cry from reality. You're assuming my pts have the time, education, and money to participate in these options.

I totally hear you. None of my patients do any of that either. But, some, when they really want to get better and they are sick of modern medicine telling them the problem is external and that within the holy walls of the clinic or hospital lies a solution, then they might start to listen and start on a journey of recovery that THEY have to drive and participate in.

 

[Orin]

1. there is a good probability that they will die from their cancer, unlike chronic pain
2. chronic pain does not metastasize or invade other organs
3. for chronic pain, ofttimes the main issue are the emotional and psychological effects of the pain that opioids do not help
4. chronic long term opioid therapy has risks, that generally we don't see with cancer pain - they either unfortunately die or hopefully get better and pain goes away.

Reg 1, we're getting better at treating cancer.
Reg 2, the fact that chronic pain doesn't advance or change makes it seem at face value more amenable to chronic medication management, but I think the argument here is that it's not going to improve.
Reg 3, opioids are very good anxiolytics and help with dissociation from problems. This is part of their abuse potential. This is an argument actually in favor of systemic opioid utilization for cancer pain, as I haven't met many people going quietly into that good night.
Reg 4, circling back to 1, there are more survivors now days and we're then stuck detoxifying them from these agents.

I'm just saying the data for opioids for cancer pain are as bad if not worse than for chronic pain.

 

[Ducttape]

we are getting better at treating cancer, but it is still the 2nd leading cause of death in the US. obviously, not all cancers are the same, and yes, i have seen patients who demand opioid medication for precancerous lesions (and "lipomas, cause that's a cancer, right?")

my reply to your second statment adds context - chronic opioid management does "advance - i.e. tolerance and dependence and the fact that these complications are not static.

again, I need to add context to my prior statement - anxiolysis and dissociation from problems are not in my opinion beneficial for chronic pain management.

 

[MD87]

FYI my patient just finished his SCS trial for arachnoiditis. His symptoms were left leg pain (especially his hip/groin/anterior thigh) but also foot and less so the right leg. Also has saddle anesthesia. He was on lyrica, tramadol, APAP, NSAIDs with mediocre relief. We were able to improve all of the symptoms during the trial except for some of the saddle stuff. He wants to move forward with a perm. Hopefully the relief lasts. I used Abbot, FWIW.