The number of patients that I see who are prescribed chronic narcotic medications is astronomically high. Of course, there are many people who have pain worthy of taking narcotics on a daily basis---for cancer-related pain, post-surgical pain, etc---yet so many people abdicate their pain management all too easily to the drugs that will cause them physical dependence, constipation, and somnolence with no end in sight. As a person with chronic pain with an unknown etiology, I fully understand that strong drive to eradicate pain from one's life. Pain overtakes one's psyche, pushes other concerns out of the way, and leaves one desperate for relief.
While it is well-documented that pain is woefully and poorly managed throughout the United States, leaving countless patients suffering unnecessarily, I still find myself having mixed feelings about the ease with which so many providers seem to write those scripts for Oxycontin, morphine, and Percocet. At our local ER, it seems like there's a gum-ball machine near the revolving door, and patients simply have to say they're in pain and a prescription is produced in a knee-jerk reaction of instant gratification.
One of the questions we ask ourselves and each other about these patients on chronic narcotics is how long they will be on these meds? For the patients with failed back surgeries and other serious conditions, we consider that they may very well be on narcotics for life, and that is often the lesser of many evils. For others whose pain has no visible or discernible cause, we often question the intelligence of long-term narcotic use, understanding that tolerance will increase with time, and dependence only continue to deepen, both physically and psychologically. Now, often that dependence (which is different than addiction, mind you) is wholly warranted and acceptable, yet I feel that there is sometimes a lack of judiciousness on the part of the prescribers as they acquiesce to the pressure to write those scripts for controlled substances.
I do not question that narcotics are often needed for patients whose pain is not touched by non-steroidal anti-inflammatories and other non-pharmacological interventions, but sometimes I feel that those prescriptions move just a little too freely, especially when one considers that diversion (the selling of such medications to others for profit) happens on downtown street corners on a daily basis. Word has it, I hear, that our clinic is considered a great place to score some narcotics to sell at the bus station. A nice reputation to have.
Perhaps I feel uncomfortable with the amount of narcotics that fly off the shelves these days because a significant portion of my job these last few years has been fielding calls from my patients who are on chronic narcotics as they seek a new refill of their meds. Since many of my patients are former substance abusers and our level of trust in them is relatively low, some of them need to come to the office every seven days for a one-week supply of morphine or Percocet. While having to come in to see me weekly is inconvenient for them, it is equally a hassle for me in terms of printing up scripts, hunting down docs for signatures, and having all of this ready in a timely manner for frequently impatient patients. As I ready to leave my job of seven years, I quietly revel in the notion that I will soon enough finally escape from this narcotic merry-go-round.
Percocet, anyone?
5 comments:
Where do you stand on narcotics for someone getting one or more migraines a day?
I'm struggling with juggling a lifetime of this sort of pain and how much it limits my life, versus the hideous idea of gradually working my way through until there's nowhere to go to for pain relief.
I did manage to spend months without pain relief of any kind, and didn't actually die from it, but I didn't actually do anything useful for those months either and it never got easier, so apparently I need something, and nothing but opiates ever hits the pain. As you say, the side effects are problematic.
I'm not asking for treatment advice - I have a pain clinic I will go to in February and my GP/PCP meanwhile for that - but the question of juggling potential dependency on pain relief with actually living is one I am trying to work out in my head.
Hmmm. Narcotics and migraines? In my experience, not usually a good mix. With migraines, there's always such a risk of rebound headaches from most treatments, even triptans like Imitrex and compound meds like Fioricet.
Most treatment seems to center around something like Imitrex or Zomig, with perhaps Fioricet or a similar med for occasional use. But the overall concern is to figure out the triggers and eliminate them from the diet.
Keith, this is very insightful. As someone juggling long-term migraine with painful nerve damage (result of surgery, not disease), this classic catch-22 really sucks. Years ago I eliminated as many triggers as possible and stopped using antihistimines and NSAIDS on a regular basis. Even so, I still get 2-3 per month due to weather and hormonal fluctuation. Daily preventitives caused an increased in migraine frequency and were discontinued. Maltrex has been an effective treatment but the expense and risk of rebound curtail use when migraines more frequent.
With the nerve pain, although severe and certainly as debilitaing as any migraine, I avoid using narcotics until forced to do so out of sheer desperation and limit use to perhaps 8 doses a month. Partly because I'm one of those freaks who get very little relief from narcotics/opiates and because the side effect of maddening itching and next-day headache aren't worth it.
I get lectures that the reason the narc doesn't work well is because it must be used to keep pain under control, not as last-resort effort to dent severe pain. I understand that! But just 2 consecutive doses brings on a 3+ day migraine that even the Maxalt can't lessen. Because effective CHRONIC treatment for either condition doesn't exist, all I can do is avoid as much as possible the things that worsen and/or trigger both migraine and nerve pain. The bright side is that I need not worry about tolerance or dependence issues.
Rx, even in this age of medical miracles, is not the answer for every malady. Too many chronic pain patients and doctors don't understand even effective pain medications create other problems and/or the necessity of making lifestyle changes in conjunction WITH appropriate drug therapy. Doctors and patients are both guilty of relying on medications to do it all, while at the other end of the spectrum are the doctors who refuse to prescribe necessary pain relief even when it is an appropriate short-term therapy.
It's a delicate balance that needs to be determined on a case-by-case basis.
These points to an interesting article in findrxonline where they talk about this subject it is necessary to inform the community.
It is ultimately the patient's responsibility to use narcotics responsibly.
A few years ago, narcotics were only prescribed after surgery, severe trauma, or for terminal cancer because of a concern over the possibility of addiction. Recently, they have been cautiously prescribed to treat moderate to severe non-malignant chronic pain in conjunction with other modalities such as physical therapy, cortisone and trigger point injections, muscle stretching, meditation, or aqua therapy. Unfortunately, the upsurge of narcotics as medical treatment also increased associated cases of abuse and addiction.
Derived from either opium (made from poppy plants) or similar synthetic compounds, narcotics not only block pain signals and reduce pain, but they affect other neurotransmitters, which can cause addiction. When taken for short periods, only minor side effects such as nausea, constipation, sedation and unclear thinking are noted.
However, when narcotics are taken for several weeks to months, these side effects can become more challenging: loss of effectiveness due to built-up tolerance, possible addiction, or overuse for a temporary "high," not for pain. Because of the potential for addiction, whether physical (anxiety, irritability, nausea, vomiting, abdominal cramps and insomnia) or psychological (compulsive use, craving the drug and needing it to "feel good," narcotics are considered controlled substances findrxonline indicated in their medical articles, which means that the FDA and DEA govern their distribution, prescription, and use and classify them into different schedules as per the Controlled Substances Act of 1970.
While weak narcotics such as Tramadol (Ultram) and Schedule IV opioids analgesics such as Darvon or Darvocet N 100 have a low risk for physical dependency and addiction with mild side effects such as dizziness, sedation, headache, nausea and constipation, Schedule III opioids analgesics such as Lortab, Tylenol #3, Vicodin and Vicoprofen have a low to moderate potential of physical or psychological dependence. Demerol, Dilaudid, Duragesic, Oxycontin and Percocet, which cannot be automatically refilled, fall under Schedule II because of their high abuse potential, and possible severe physical or psychological dependency.
In view of the fact that narcotics can be addictive, they should only be prescribed when no other alternative is available and should only be taken as directed by your doctor. Most often, patients are required to consent to adhere to certain rules regarding the use of their prescription listed in a "Narcotic Agreement" between the patient and physician. Often, violation of this contract, especially selling, sharing, or trading the medication, attempting to obtain duplicate pain medication prescriptions from different physicians, and attempting to have the medication refilled early, at night, or on the weekend, to mention a few, would result in the patient's discharge from the practice.
So, take responsibility for your actions and know all your treatment options. Narcotics are rarely your sole savior.
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