I don't want to panic people, but I read something about this in another post, so I went and did some googling. I could be wrong, but I found a lot of recent documents/sites about limiting/reducing opioid use by chronic pain patients. I'm writing about it here because if this IS happening, we all need to be aware of it and be ready to talk to people (particularly doctors) about it.
One document (an Oxford University Hospitals document entitled, "Guidance for opioid reduction in primary care" (dated 12/2017)) seemed to summarise what a lot of the others were saying:
Opioids Aware five headline points
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1.
Opioids are very good analgesics for acute pain and for pain at the end
of life but there is little evidence that they are helpful for long
term pain.
Some patients (hi *waves*) have lived experience that they're good for long-term pain. Are we not evidence? Other sources estimate that about 20% of chronic pain patients find opioids helpful. That's a lot of people!
2.
A small proportion of people may obtain good pain relief with opioids
in the long term if the dose can be kept low and especially if their use
is intermittent (however it is difficult to identify these people at
the point of opioid initiation).
I wouldn't know about
doses, but I assume that if people have really severe pain, higher doses
might be required? Just an assumption - I'm not medically-qualified or a chemist. Comments, anyone?
It seems to make sense that intermittent use is
probably more likely to stay effective (I occasionally stop my tramadol for days), but
again, that's just my opinion. The fact that it's difficult to identify the people
who do benefit at the point of initiation of opioid treatment is an issue, but that doesn't mean that they shouldn't have the choice to use them. What if they need them and nothing else helps enough
3. The risk of harm increases
substantially at doses above an oral morphine equivalent of 120mg/day,
but there is no increased benefit.
Safety at lower doses makes sense, but I'd like to see the studies that say that increased doses don't result in an increased benefit.
4.
If a patient is using opioids but is still in pain, the opioids are not
effective and should be discontinued, even if no other treatment is
available.
UH?!?!?! What?! This goes against everything
I've read and been taught about chronic pain . The "magical treatment/med that completely stops the pain" is one of
those myths that pain clinicians spend a lot of time fighting. It may exist for some people (although it's very very rare), but for most of us, we need to accept that the magical cure doesn't actually exist (yet) before we can begin to move forward WITH our pain.
However, the lack of a magical, complete cure doesn't mean that a partially effective treatment isn't useful! Why would we continue to
use TENS, injections, stretching, pacing, and meds with nasty side-effects if that were the
case? In my experience, nothing completely gets rid of my pain (if it does for some of you, congrats!), but a lot of things help. When I have 8/10 pain I'm bed-bound, have trouble standing
without help, my body gets twisted into odd shapes by muscle spasms, and I'm in absolute agony. If I take the appropriate doses of opioids and benzos, my pain generally goes down to ~4/10, which is
a pain level I can handle. At that point I can stretch, and perhaps do other things that reduce the pain further. I can pay attention to a TV program, or go to sleep. I can get to
the loo by myself, or grab something to eat. I'm much more able at 4/10 than I am at 8/10. No, I'm not pain-free - I haven't been for a decade - but my pain
(and other symptoms) are far easier to handle on opioids+benzos. They WORK.
5.
Chronic pain is very complex and if patients have refractory and
disabling symptoms, particularly if they are on high opioid doses, a
very detailed assessment of the many emotional influences on their pain
experience is essential.
I imagine that almost all
chronic pain patients have experienced the "It's all in your head" thing
(from both medical and non-medical people). We're often judged to be
nuts/malingering/making it up. The pain we feel is real, and often it's
due to dysfunction in the peripheral and/or central nervous system(s).
However, emotions do have a large effect on how much pain we feel. The
brain releases certain chemicals to create pain in the body. It releases
similar chemicals to signal emotions. Some of those chemicals are the
same, and some affect each other. Happiness *chemically* reduces the
amount of pain we feel, while sadness chemically increases it. Mental
health problems such as depression and anxiety cause more pain, while
love and touching a loved-one really do reduce pain. This isn't us being
*crazy*; it's how the nervous system works.
As
a result, if we're really down on ourselves, our lives, the people
around us, etc., our pain will feel worse. If that's the case, we might
benefit from some psychological treatment, some support to change our
life circumstances (or an actual functioning benefits system which
doesn't torture us and leave us in destitution!). If we're too scared to
do anything physical because we think that we'll make things worse, and
if that isn't true, then we could benefit from education and support to
understand that, and to become more active (in the particular case of
ME and the Pace study, ignore this completely!).
We
might also benefit from some support to adjust to our new lives, if
we've become disabled. I went from extremely fit, high-paid, in a career
I loved, with lots of savings, and a partner I had a future with, to
unable to get up off the floor, destitute and bankrupt, no career, no
job, and dumped by my partner in 3 months. That was damned difficult to
deal with! My mental health went haywire for years. I would really have
liked some expert help to deal with the whole situation (I could still
use some help, to be honest!).
Obviously, all the above are individual for each patient.
However, intimating that
refractory and disabling symptoms while taking high opioid doses means
that somehow these patients' chronic pain is more psychological in
character is .... *$&#(# I've run out of words.
Tired. Hope this made sense.
