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    The opioid pain paradox

     

    Harm reduction via opioid agonist substitution therapy, decriminalization (as in Portugal), or supervised injection facilities has been a measurable reality. Yet more money is spent on enforcement despite its failures. People tend to self-medicate, and depending on their varied brain chemistries, have turned to alcohol, stimulants and opioids, even food, just to feel “normal.”

     

    Further reading: Malpractice reforms could ease physician burdens

     

    The specific opioid antagonist naltrexone is used to treat alcohol addiction and is a component of a diet pill (Contrave), suggesting multiple pathways to opioid receptor activation. To be free of pain, emotional and physical, has become the Holy Grail of our culture, and doctors have been conscripted to join the search.

    My friend, now in his late 60s, is currently doing well. He has intermittently been prescribed antidepressants, and had one more short psychiatric admission years later, precipitated by the stress of his wife’s losing battle with breast cancer. He had a brief flirtation with opioids when he found they could calm him down, but quickly realized the folly of this, and desisted. He is to this day grateful that I tried so desperately to keep him out of the hospital those many years ago.

    My medical student seemed quietly upset. She will likely not look to treat chronic, opioid-requiring pain patients, and will refuse their care or refer them out, as so many of us feel compelled to do.  

    Robert Bobrow, MD
    Dr. Bobrow is a Clinical Associate Professor of Famiy Medicine at Stony Brook University, Stony Brook, NY. He directs an Opioid Overdose ...

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    • Anonymous
      Some of us have been in medicine long enough to remember when Darvon and Darvocet, Fiuricet, Fiurinal, and numbers of other non-opioid and non-addicting medications were commonly used effectively to treat pain. Interestingly, all those alternatives to opioids were removed by the FDA just as the pharmaceutical companies all announced "bigger and better" oral formulations of opioids to be released. This all occurred simultaneously to each state's medical boards suddenly dictating physicians to be ultra-conscious and responsive to "PAIN" symptoms from patients. On hindsight, obviously none of this was an accident and none of it occurred in a vacuum. The fact that the FDA cooperated by removing the competitors to those new oral opioid meds remains very disturbing. Now that there is new litigation in the works, regarding the pharmaceutical aspect of our current opioid epidemic, perhaps people will begin to really delve into how this situation evolved in our country.
    • [email protected]
      Bob, I cannot offer you professional feedback, as I am not a medical professional. But as an engineer and a patient on the recovering end of a very long and painful journey, it is my opinion there is no simple solution to this dilemma. We would term it as a higher order, or multi-dimensional, or whatever works. But maybe I can offer you my perspective. I was injured in my last combat tour. A simple, almost embarrassing grade 2 or 3 tear of multiple muscle groups in my calf (Soleus, Gastroc, and plantarus). As a leader, I had to endure the pain to see the deployment through. Sadly, it went downhill from there. The scar tissue and fascia required a four-compartment fasciotomy, and eventually it plugged the popliteal opening and began killing the nerve. Every step was like an ice pick sticking into the center of the calf. Finding a doctor willing to treat the pain in a sequential, planned, and caring manner seemed to be the hardest challenge of all. Since these are not just sympathetic nerves, blocks would just waste the muscle. I was literally begging orthos to help find a way to end the hell I was in. Even the chainsaw in my garage was tempting one day. FINALLY, a pain specialist took a risk to treat the pain with carefully dosed NORCO and targeted bupivocaine blocks to identify the location of the deinnervation and we got it released. By that time, CRPS symptoms had begun, and we had to work fast. The popliteal opening had almost completely closed and scar tissue was adhering to the tibial nerve all the way to the sympathetic branches. The only thing that kept me from putting a bullet in my brain was a caring doctor willing to treat the pain with multiple approaches, a plan, and yes, a simple narcotic. That NORCO was a significant contributor to saving my sanity, and possibly my life. I wasn't depressed because of an imbalance. I was enduring nerve pain 24/7 I wouldn't wish on anyone. Through this adventure I met several of the most uncaring, mistrusting, and acutely accusing medical professionals I never thought existed. Even when faced with an OBVIOUS, well-documented need, the fear of treating patients with pain has taken an almost medieval level of fear. Fear of being raided by state police. Fear of being charged with murder if a patient overdoses. It doesn't have to be this way. Now that we're done, I actually have what feels like a criminal record. After begin gutted like a fish last year for a burst appendix, I was given FIVE norco. FIVE! Why? Because they saw I had a history of being a pain patient in the mandated narcotic tracking system. No one asked about the history. Not one discussion of pain. If I had access to heroin that week, there would have been no question I would have used whatever I could get my hands on. I wonder how many give in to suicide. I can assure you this fear is harming patients because I lived it. There was a time doctors took an active role in managing pain. You protected patients from the alternatives by giving them MANAGED care. Now you send them home with Ibuprofen and if they are lucky, they are told to suck it up. And we wonder why there has been a surge of narcotic addiction, especially in blue-collar working states. If you want to quell the crisis, you must work to return to taking care of patients. Had I known then what I know now, I might have traveled to France to have my leg removed below the knee. Because the only other option was a needle from the street. This needs to be fixed.

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