The Killers of Pain

While tweeting on Twitter with fellow RD patients, advocates, and others who were interested a week or so ago, the issue of opioids and the U.S. Food and Drug Administration’s (FDA’s) recent decision to make hydrocodone a Schedule II drug came up. During the discussion one of the participants mentioned that doctors “need to consider alternative treatments for pain.”

My teeth started growing. I get so weary of being told to just find my happy place when my rheumatoid disease (arthritis) flares. “You go meditate while a butter knife is jammed between your joints and flexed, up and down, back and forth, for hours and hours, then tell me how that works for your pain,” I wanted to tweet back to her, in angry caps. “Then we can get serious and discuss alternatives to opioids.”

I didn’t tweet those words because they were a hot, frustrated response to this person’s sincere and uncontroversial opinion. She didn’t deserve to be the target of my anger. She’s a doctor who cares deeply about her patients and their pain. She’s wary of prescribing opioids for a variety of reasons, not least of which is that they can be addictive and are, sadly, frequently abused. And she’s not alone. These problems are the reason that the FDA has made them more difficult to access.

But this well-meaning doctor likely hasn’t experienced chronic RD pain. Such bland assertions--that doctors need to consider alternative treatments for pain--are fighting words to those of us who cope--and function--with frequent severe pain.

I’ve taken hydrocodone (and other opioids) for RD pain off and on for years. For the last two or so, it’s been more “on” than “off” as my disease-modifying medications have slowly lost their efficacy, allowing my pain to grow. And I won’t deny that I’m dependent on this drug. After months and years of use, dependence is almost impossible to avoid. But being dependent on an opioid painkiller doesn’t make me an addict.

Pain is the body’s distress signal. It tells you, instantly, that you’re ill or injured and that you need to take action. If you touch the hot rack in your oven with a bare finger, its pain that makes you yank your hand away. Opioids work by altering the way your brain perceives those pain signals. The drugs have no effect on whatever is causing the pain. For instance, when my rheumatoid disease makes the synovial tissue between the bones in my knee thicken and become painfully inflamed, hydrocodone won’t have any effect at all on the inflammation or my RD. Instead, it alters how my brain reacts to the pain stimulus.

For me, the pain doesn’t actually go away when I take hydrocodone. I still feel it; I still know my knee is under painful attack. With the drug, though, the pain gently fades into the background of my mind like soft elevator music. I can get on with living my life, doing things that I just wouldn’t be able to do without the drug.

Lots of people also experience a pleasant--sometimes very pleasant--euphoria from these drugs. Others, as the pain takes a back seat in their minds, feel overwhelmingly sleepy. Both effects can pretty much kill an afternoon--or longer.

So except for maybe sleeping the day away, what’s not to like about opioid drugs? They are potentially addictive, and abuse is far more widespread than it once was.

I think it’s vitally important to draw a clear line between “dependence” and “addiction.” Dependence, in this context, refers to how the body may react and adapt to the drug, something that happens with many types of prescription medications. Stopping the drug suddenly may cause physical or mental withdrawal symptoms, which can be severe. In addition, dependence can cause tolerance, meaning that the body learns over time to tolerate the drug’s effects so that it no longer works as well. To make it efficient again the patient must increase the dose.

Addiction is different. A person who’s addicted to a drug is, yes, usually dependent and tolerant. If they stop it suddenly, they’ll experience withdrawal. But--and this is key--they take the drug compulsively to experience the euphoria it can cause. Their brains crave the drug, and they can’t stop using it even when it disrupts their families, their friends, their work, and their lives. They’ll find ways to get it outside of legal means, and they may continue using despite any harm they might be doing to themselves or to others.

The trouble can begin early on, when the brain learns to work against the opioid. In time, the pain signals will get louder again. At the same time, the brain limits or stops the characteristic euphoria the drug causes, and/or its ability to induce sleep. To achieve relief again, we increase the dose. (Some people increase it to regain the euphoria.) For a while the drug is effective again. When it loses that efficacy, we increase the dosage again.

And this is where the drug becomes dangerous. In higher doses opioids may suppress the body’s breathing reflex. The higher the dose, the stronger the suppression can become. An overdose can cause you to stop breathing entirely--and you die.

It’s this danger that prompted the FDA to reclassify opioid pain relievers like hydrocodone as Schedule II drugs, lumping them in with heroin, LSD and cocaine.

Obviously, the vast majority of people who take opioid painkillers are not and will not become addicts. Physicians prescribe their drugs. They take them responsibly so they can live, to the best of their ability, normal and productive lives. They don’t take them for the euphoria--they take them to control their pain. And while alternative treatments/a> for pain - meditation, exercise, adequate sleep, biofeedback, distraction, TENS unit, etc.--may help relieve pain over time, they don’t work as quickly or as efficiently as opioid drugs.

The argument over opioid painkillers continues, as does the search for safer, non-addictive drugs that will work as efficiently and well as they do against chronic pain. Medical marijuana holds a lot of promise. So does research into the painkilling qualities of some snake and spider venoms. In the meantime, we need to be careful how we label each other. I can be dependent on opioids for pain relief without being an addict.

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