Thursday, February 18, 2010

Relapsing with narcotic pain meds - Dr P Coleman

This last week I have had the pleasure of training Dr Joe Koernigsmark from Indiana. He is the Medical Director in our new office in Indiana. He is a fabulous doctor and I am very excited to be working with him.

During our training, I was amazed at how many patients we saw who had relapsed because they had to take opiates for legitimate medical pain. We saw at least four patients who had relapsed in this way. They had all taken the narcotics as prescribed but then found themselves physically dependent and quickly needing the medicines just to avoid withdrawal. Eventually their use developed to the point of causing problems and needing detox and more treatment. I have changed the details of these patients for confidentiality reasons.

We saw a health care professional who had over 5 years of clean time. She had been going to NA and really working a good program. Unfortunately she developed foot pain and required surgery. She warned her doctors that she was a recovering addict. The post-operative pain was quite severe and she needed strong narcotics for quite a long time and became physically dependent. Over time she felt guilty and made some bad choices, fearing what would happen if she told people what was happening. She started taking Suboxone to avoid using street drugs and has now become very dependent on that. We are trying to wean her down off the Suboxone but she is having a very difficult time. Now she has lost her license, feels terrible, trapped and very depressed.

We saw another health care professional who quit alcohol about 15 years ago and was doing beautifully. Unfortunately he injured his back on the job and has had chronic pain for over 5 years now. He has seen many doctors and had numerous surgeries but none of these have provided good pain relief. Through all of this he became very dependent on opiate painkillers and started having severe withdrawal whenever he didn’t take his medicines. He also was having a lot of side effects from the medicines. He had sleep problems, low energy, felt depressed, mental fogginess, and many other symptoms. In addition to this, he was still in a lot of pain. So we detoxed him over 5 days with our Accelerated Detoxification. The detoxification went beautifully and he has done well. He is now off all opiates for about 3 months. His side effects have all gone away, but he has still having considerable pain and may require more surgery.

Last week we finished a detox on a lovely young lady. We had detoxed her about 5 years ago and she used Naltrexone implants. She did beautifully but unfortunately developed some complications after her last baby. She had severe abdominal pain and needed narcotics. Fortunately she is now back on track again.

These patients, and others like them, have become dependent on opiates because of legitimate and real medical problems. It is not their fault. These patients teach us a number of very important things. They teach us just how powerful this disease is. Re-exposure to mood altering drugs can very quickly reactivate the disease. They reaffirm for us that people who have this disease of Chemical Dependency really are vulnerable to relapse when they take any mood altering substance, even when they take it as prescribed.

We believe that Chemical dependence is a disease characterized by a genetic vulnerability. The genetic vulnerability seems to have two components. There is an initial increase in pleasure effect when addictive substances are taken – a dopamine effect. This high pleasure that addicts feel seems to make them more likely to repeat the experience, and be more willing to keep doing it even when there are negative consequences. This is, of course, the hallmark of addiction – continuing to use even when there are negative consequences form the using. The second genetic component in people with a vulnerability to addiction seems to be that these people have a more difficult time stopping, and more painful withdrawal symptoms. This is what happens to someone who is in a healthy recovery but gets re- exposed to addictive medicines. Their withdrawal symptoms are worse and they have a very difficult time stopping. There are animal models of this phenomenon. Scientists are able to breed rats which have much more difficult withdrawal symptoms. These tendencies are passed down genetically.

So what can recovering people do if they need narcotics?

Here at the Coleman Institute we frequently help patients get through these situations. When patients call us asking for assistance, we almost never have problems with them becoming re-addicted. There are a number of key things patients can do when they have to take addictive medicines:

1. Plan ahead – if you know you will need surgery or need narcotics then enlist help from people who can help you. This includes your physician, your spouse or family member, or someone from your support network. (I personally already have an AA member who has agreed to monitor medicines for me if I ever need to take them.) If it is an emergency situation like an accident or kidney stone, then enlist help as soon as possible.

2. Have your doctor use non- addictive medicines whenever possible – it is amazing how much Ibuprofen helps pain when people are not looking for a narcotic effect. There are now many other non-addictive medicines to help with pain.

3. Use non-drug techniques to help with pain as much as possible – ice, splints , rest, TENS, epidural steroids, acupuncture, etc

4. If you do need narcotics, use the lowest dose for the shortest time.

5. Be honest and open – with your doctor, your family and support people. Tell them how much pain you are in and how many pain meds you are actually taking.

6. Have a family member or a friend hold the medicines so you have to ask someone to get them – not to be cruel, just to have another check and balance.

7. Follow up with our office or your doctor within 1 -2 days after surgery. The specific goal for this follow up visit is to evaluate how much pain there really is and how many narcotics really need to be taken.

8. Continue close follow up visits, usually once or twice weekly, until the narcotics are no longer needed.

In our experience, when patients have followed these guidelines they have never gotten re-addicted unless the pain condition went on a very long time. And in these situations they can be detoxed again fairly easily.

Remember, we are available any time to help with these situations. We do it all the time, and we are delighted when people reach out to us for help.

Peter Coleman MD

3 comments:

  1. Chronic pain. My spouse is prescribed narcotics for severe and degenerative back disease. There was some talk of using methadone. I am a bit anti methadone due to it's difficult detox. I prefer he stay on his meds and stay on minamal dose he is not an addict and dose not abuse his meds. Are there new bennifits to methadone? Its lck of convience and stigmatism is poor. He goes to pain clinic does shots accupuncture physical therapy. Responce? KT

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  2. Thanks for the comment. This is a difficult and complex topic and situtation.

    In general Methadone is a powerful and long lasting narcotic. As such, its strengths are that it has fewer ups and downs and supplies more consistent pain relief. It may be less abuseable because there are less ups and downs. The negative is that it takes a lot longer to detox off of - if you have to detox - which is another complex decision.

    Our experience with chronic pain is that most people do better off all narcotics because then their brain endorphin system goes back to normal - they still have some pain but they can handle it and they stop having narcotic pain medicine side effects.

    I am more than happy for you to call me at our office to discuss the issues involved - 804.353.1230

    Dr Coleman

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  3. I am soooooo happy to here of the office in louisville ky!!! I first found you on the web needing despretly to get off pain killers becase i to had terrable back and leg pain. I had been going to my dr to take pain meds for the pain and he did give them to me for about 8 to 10 years!I had a sergery and boom i new i must get off those pills i had to have so much i couldnt believe it. I had taken all of it in the first 3 days.I started buying them from people at work!!!Long story short i found a dr with suboxone great med but now cant get off that. will be contacting your office in louisville thank you thank you thank you!!!!

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