The Killers of Pain

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 for pain–meditation, exercise, adequate sleep, biofeedback, distraction, TENs, 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.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The RheumatoidArthritis.net team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

Comments

View Comments (14)
  • Senior driver
    4 years ago

    Hello I’ve been reading this site for a few years now, but it seems most of the stories are from women. Not that there is anything wrong with that. I am a man who was diagnosed with RA 11 years ago. I have tried all the usual drugs all of which we effective for a time, but then they would quit working and the pain would return. One doctor’s remedy was to just give me pain killers and when that one quit working gave me stronger ones. After 2 years of that I was so confused I just quit taking them. Flash forward a few years. I am seeing an specialist. We try all sorts of things. About 5 years ago I started taking a biological. It works really well to control the RA. Now my flare ups are becoming worse and more frequently. I’ve even had a full body flare for the first time a few weeks ago. I guess I should be grateful it happened at night as I still work part time. Because of other disease’s I can now longer take the pain meds that really help thru these flare up’s. I should tell you I am 63 yrs. and had planned on working till I was 70 yrs. old. Because of RA ,Diabetes, COPD, and Atril fibulation I am on disability. I was a mechanic for 35 years, it was my passion and I was real good at it. I guess that’s really been the hardest part of having RA. I can now longer hold the tools in my hands, they just fall out. I have an occasional pity party ( I think I am allowed ) . Now having said all this I want to let you know I haven’t given up being a contributing member of society. I am currently working as a driver delivering hot meals to shut in seniors. I also do volunteer work with traumatized children in foster care as a Court Appointed Special Advocate. RA is something I have, it is not what defines me. I want to say thank you for this site, it has helped me just to know there are others that know what I am going thru. God Bless

  • Jenn Lebowitz
    4 years ago

    Hi Senior Driver,

    Thank you so much for your post, and for being part of the community! We are sorry to hear what you’re going through, and are glad you found us.

    You may be interested in articles from Dr. Andrew Lumpe, a male patient advocate with RA who contributes to this site. Here is is bio and a link to his articles, if you are interested: http://rheumatoidarthritis.net/community/experts/andrew-lumpe-phd/. Additionally, you may be interested in one of our sister sites on COPD, which can be accessed here: https://copd.net/.

    Please remember you can come here any time for support, to express your thoughts, or to share your story (if you’d like to share your story with the community, we welcome you to do so here: http://rheumatoidarthritis.net/stories/.) Thank you again for being here – we appreciate you!

    Best,
    Jenn (Community Manager, RheumatoidArthritis.net)

  • SofiaRA
    4 years ago

    Wren I think you are right on the mark here. Most of us with RA have tried “Alternative Treatments” to control pain, the narcotics are a last resort because we cannot function at times without them. There are times when one has an infection or after surgery when you cannot take immunosuppressant drugs to control the disease or like many people the disease never goes into remission despite trying all DMards and biologics possible. What are we to do when Rheumatologists decide to stop prescribing them pain medications when they are needed? Then you are labeled as doctor shopping if you need to change to find a Rheumatologist willing to prescribe what you need at the time for legitimate reasons, not because you are seeking pain medication due to an addiction. What quality of life are we left with when these medications are needed but withheld from patients in need of them?

  • Nancy McHugh
    4 years ago

    I didn’t comment on this blog when it was first submitted but seeing it again today, I feel I must. I have come to know way too much in the last 7+ months about opioids and addiction. My 24 year old daughter suffered a back injury about 3 years ago while in college and her doctor prescribed for pain Percocet and then Oxycontin. Shortly thereafter, my husband was laid off and we eventually lost our health insurance. Eventually, her part time job could not pay for her pain meds with her and she eventually turned to heroin which is considerably cheaper. She is 7+ months in recovery now, but I have learned that opioid pain meds are pretty much the same as heroin and both cross the brain barrier and can change your brain chemistry. Some crazy statistics in this country came out recently that more Americans die from overdoses than car accidents. This is an epidemic in this country and if precautions by healthcare providers are taken, I am all for it. My rheumatologist is constantly asking if I want a prescription for Hydrocodone for pain and I politely reply, “No, thanks. I will take aspirin if I need to.”

  • FAIRY CUPPLES FORD
    4 years ago

    I spend a lot of time reading these RA stories. I take the Rituxin treaments twice a month every 4 months, I also take Arava every night and Methyltrexate 4 tablets once a week. I live off of Aleve, Tylenol, Midol or whatever i can find to help with the pain because the rheumatologist that i see doesnt like giving pain meds. My question though is this: How do you make your friends and family understand what you are going thru? They all seem to think that if they can’t see it then it isn’t there. I love to spend time being active with my friends and family but when i am so exhausted that it takes every ounce of energy i can muster up just to move they don’t understand it. I know they are teasing but the remarks they make are hurtful because i cannot show them “my pain”…if I go to bed early when on vacation i have to hear about it all day the next day about being a party pooper etc. I just want a nice polite way to respond. Often times I respond and the words are not very nice and then I feel bad about it. I would love to have an “article” to print out and give them that people who are not doctors could understand. Any suggestions?

  • 1a964x3
    4 years ago

    Hydrocodone is a Schedule 2 drug, that is correct. It means that they must be accounted for in a certain way and that they do have therapeutic value, as well as a potential for abuse. Drugs like LSD, Heroin and Cocaine are Schedule 1 drugs; they are viewed as having no medical or therapeutic value with a very high potential for abuse. A form of Cocaine is used to numb a person’s throat before intubation prior to surgery. Schedule 2 drugs are kept under lock and key with limited access. In the hospital setting, passcode for each medical professional are needed to access these drugs. In a less acute setting, such as a SNF, a set of keys kept by the nurses may be all that is used. There is a count done of these drugs before each shift by the nurse of the previous shift to the nurse coming on. Another difference between Schedules 1 & 2: Schedule 1 drugs are illegal under Federal law. This includes Marijuana.

  • Kim
    4 years ago

    Wren, thanks for taking the time to tackle such a sensitive subject.

    This term, I am studying Foundations of Addiction, it’s a pretty intense class, but I have learned a lot, so far. And, you are absolutely right, there is difference between being addicted and being dependent, and the two are not interchangeable, like many seem to think. Most people who follow their doctor’s instructions, and take the medication as directed, do not end up addicted, despite opinion that says otherwise. Studies are out there, people just need to read up on the subject 🙂

    I am very fortunate in that my family doctor has agreed to prescribe my pain management. The health company that he is affiliated with takes pain management seriously, and have safe guards in place to protect themselves and the patients. I’ve never minded having to call every few weeks to get a refill, nor have I minded running to the office to pick up my script. However, I can do so with ease as my doctor’s office is just a few miles from my house. I understand that for many, this can be a huge challenge though.

    I also don’t mind about the possibility of random drug tests or pill counts. To me, it’s reassuring to know someone is looking out for my best interest.

    I very recently signed a newer version of a pain management contract, I was thrilled at the overall content and the fact that my doctor (and his company) truly seem to understand the need for pain management and their definition of certain terms like addiction and physical dependence.

    My pain medication allows me to LIVE my life. I could not imagine having to do RA without pain management…

  • Wren moderator author
    4 years ago

    Hi, Kim!
    Thank you so much for taking time out of your busy day to comment and add to this conversation about narcotic analgesics. I believe that much of the misinformation about the abuse of these drugs comes from our rather lazy media: journalists writing hot-button stories without taking the time to research the subject. As a journalist myself, I know how this happens, but I don’t see any excuse for it. Bad reporting and sensationalism has done huge harm to people who have a legitimate need for the effective pain relief opiates can bring. They’ve created the false impression of irresponsibility and addiction… and of course, I could go on and on. This is one of my own “hot button” subjects, so I’ll stop.

    Thanks also for your kind words. I’m so glad that these drugs are available for us so we can continue to live as normally and as well as possible as we cope with this painful and challenging disease. Best wishes to you. 🙂

  • elisee55
    4 years ago

    As a patient with severe pain from fibromyalgia, RD, and spinal degeneration, I cannot even carry on a conversation coherently when pain is uncontrolled. I have been using a newer pain medication that is also controlled under both US AND Canadian regulations. I have no issue with regulating these strong medications.The slippery slope is real. My medication is delivered through a transdermal system which I apply weekly. I feel that using a delivery system that, for the most part, avoids the ebb and flow of controlling my pain, I get more quality of life, save my digestive tract a bit, and reduce the temptation to increase the amount of medication I take. Having a doctor that regularly prescribes medications and who also manages all the ongoing medical issues their patients may have is also important. There is a better chance of avoiding adverse drug interactions. I know that many patients feel that the regulations are overkill. However, I meet ,many many people who really have no idea how potent and potentially dangerous these drugs can be. It is important to protect those people too, who, by virtue of their personal circumstances, really ARE at risk of addiction by no fault of their own. It is important to protect people from accessing drugs meant to help others. We can help by using these medications responsibly.

  • Wren moderator author
    4 years ago

    Hi, Elise!
    Thanks so much for taking the time to comment and share your views. As it happens, I agree that these drugs should be monitored by your doctor to avoid the potential for overdose and to stay informed as to how well (or not) the drug is working. I get my medical care from the VA. I have to call each month to ask my doctor to refill my prescription. Here’s the thing: they will not fill more than one month’s supply at a time. This way, if I were to over-use, I would run out before the month ends, and simply have to live without pain relief until the following month, however long it might be.

    To me, this seems a simple fix for most legitimate users. It doesn’t fix doctor-shopping, etc., and I’m not sure what will. I just wish the “addict/criminal” stigma could be removed somehow. The vast majority of RD patients are not addicts or criminals. Their need for the drug is legitimate, and they use it correctly.

    I’m impressed that your doc is so forward-thinking as to prescribe a patch that works for a week at a time–and that it relieves your pain so you can live (mostly) normally. This also seems like a very good fix for the opiate abuse problem. I wonder why it’s not used more?

    Thanks again. Responsibility is key. 🙂

  • Helen
    4 years ago

    This article is one of the finest descriptions of pain control in RA I’ve read. The distinction between addiction and dependence is very clearly outlined. I think the medical community and politicians need to become more aware of chronic illness and medications versus addiction and drug seeking. This difference is a significant one. People who are drug addicted without chronic illness do require compassion and support. Their situation is not the same as someone with chronic illness who depends on medications to have any semblance of a good quality of life. Wren thank you so much for this thoughtful and accurate overview.

  • Wren moderator author
    4 years ago

    Hi, Helen!

    Thank YOU for your kind words! I’m delighted! “People who are drug addicted without chronic illness do require compassion and support.” I so agree with this assertion. Addiction is prompted by or becomes a mental illness, and it should be treated that way. Unfortunately, many people are very quick to judge others without knowing their circumstances, which is sad. And that legitimate, responsible narcotic medication users are judged in the same way is even worse.

    Thanks again–this time, for stopping by and taking the time to comment. Hope to hear from you again! 😀

  • Kellie
    4 years ago

    I am going to see my new Rheumatologist this week. I am hoping he will prescribe a new pain medication for me. The Norco doesn’t work well. I have actually been getting my pain meds from my regular doctor. My old rheumatologist office quit giving pain meds. Ridiculous! It’s the government deciding who needs pain meds. Here in Florida there is a lot of oversight. I believe that some classes of patients should be exempt. Cancer, RA, Lupus, etc.

  • Wren moderator author
    4 years ago

    Hi, Kellie,

    I agree with you. People with chronic or intractable illnesses that cause severe pain as one of their symptoms should be allowed to be exempt from these overly punitive laws. I’m appalled, too, every time I hear about a rheumatologist who won’t prescribe narcotic pain meds to their patients. At the very least, they should be referring their rheumatic patients to pain doctors/clinics so their pain can be treated effectively–or at least to the point that they can function with some degree of normalcy. I believe that to leave these patients helpless in the face of overwhelming pain is negligent.

    My own rheumatologist tells me that if the pain med he prescribes for me relieves my pain by 70 percent, we should both be happy. He says that’s the most I should expect from any pain med, and I believe him. And believe ME, I’m more than grateful if they work that well.

    I hope your doc will be able to prescribe something that will help more to relieve your pain. Thanks so much for stopping by and for taking the time to share your thoughts. 🙂

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