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Old 07-15-2004, 05:10 AM   #1
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Why do pain doc. worry about addiction if-

The percentage is 1 percent? They say its a myth that peaple become addicted to there meds. maybe tolerant.When i first started meds. my doc. said The percentage is very very low of this happening.And every site i go on to do research on pain says the same thing,that its a myth.But yet,more and more peaple are saying that ther doc. are worried about addiction. wHEN IS THE SUFFERING GOING TO STOP? I had a friend who just had surgery on his ankle,they took a bone from his hip,put plates,and screws in his ankle,and his doc. said the same thing,gave him 20 pills of 5\500 hydrocodone,and a unlimmited supply of i.b 800. And said he doesn't like to perscribe much pain med. because of addiction. But,you can go to the e.r. conplaining of a toothache,and they will give you lortab. I thought doc.[especially pain doc.]
went to school for this? Is there ever going to be anything done about doc. under-perscribing? I know for me,i'm lucky! I have a good doc. Not because he perscribes me pain meds. Becuase he knows i'm in pain,and he knows its his duty as a doc. to treat my pain. My god,theres peaple out there commiting suicide because they just can't handle the pain anymore!

 
Old 07-15-2004, 06:43 AM   #2
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Re: Why do pain doc. worry about addiction if-

Hey Madhatter, The big problem is that there is no such thing as a cirriculum for pain management, The cirriculum needed would be a combination of neurology, anesthesilogy and physical medicine. But there is not a program that young med school students can head off to college to become a board cert, pain management doc.

Anyone with the ability to write a script can hang a PM sign or advanced pain management sign out front and practice away. Does this mean they are qualified? Absolutely not. Is a GP qualified to treat the most severe phsychological illness where you need a specialist in psycho pharmacology, absolutely not. So the groups and societies of PM docs wants a cirriculum but it would take parts from all 3 specialties, and the older specialties like Anesthesiology and neurology don't believe they can learn enough about anesthesiology or neurology to go out and actually practice either by blending 2-3 specialties together to create a Pain management cirriculum. Physical medicine is the closest thing but doesn't have the expertise that anesthesiologist have nor the expertise that a Neurologiist has.

So these programs would have be blended with students and interns in which some would go off to practice anesthesiology or some would go off to practice neurolgy. Creating less than adaquately trained people in anesthesiology and less than adequetely trained people to pass the boards for for either specialty.

Docs that have taken their specialty into this area, have done continued education programs in Pain management and there are medical societies for them to join but no prestige of being board cert, no test to take, simply membership of a medical society like the AAPM.

There needs to be a PM program but medical schools and different specialties are fighting for funding, space and members of achedemia to teach this form of medicine that anyone with a script pad can practice.

You can usually tell how qualified your doc is by the number of modalities he has to offer. A doc that does nothng but medication and trigger points is really limited to the number of people they can help. Although we don't enjoy interventional procedures they are a neccessarry part of PM and there are some of us on the bell curve that need these procedures.

Docs trrained to do nerve blocks, Epidurals, "anesthesiologists",
and docs that do little more than prescribe neurontin and antiseizure meds"neurologists" whose normal client base is stroke victims and headachea, what does a headache patient have in common with a back pain patient? other than pain.So docs need to be versed in more than one modality and one favorite medication. The modalities to treat each problem and abortive meds used by Nueros are pretty exclusive to each profession.

Finding a doc or even better, a group of docs that can offer Medication Infusions like DHEA or Use Botox for nerve pain or has a pump doc on hand that does their anesthesia work like RFA and nerve blocks, medial branch blocks or disc procedures like IDET won't be found in a physical med ciriculum.

The only thing a stroke victim has in common with a CP patient may be neuralgia, But pain caused by brain damage is not the same as pain caused by machanical disfunction, the gateway theory or any other pain generator. You can't treat brain damage with the same modalities you treat an otherwise healthy patient with CP. My buddy had a stroke, has severe PN in one arm,. But anything that might further cloud his head is totally off imits as far as his Neuro's go.

What does a physical medicine doc know about Diabetic neuropothy, Is he going to manage the diabetes that an endocrinologist would normally handle and handle the pain from Perripheral nuralgia.

Pain medicine needs a complete ciriculum and there are some docs working on it but the politics involved in achademia mean the funding for a new specialty will likely be pulled from another and that's the rub. The director of the neuro fdept isn't going to say there is a single cours we can go without, The anesthesia dept isn't going to give up or share funding and the Neuro's have their gig going.

They don't want this new specialty and the best way to fight it is to call PM docs drug dealers, demean the need for this specialty and with all the negative publicity, it's not hard to say, we can't train people to go out into practice where their main function is to prescibe morphine and Dilaudid or OxyContin to CP patients. Each patient should be seen by whatever secialty they would normally fall under.

Then you go back to how much PM training did each specialty actually recieve. On average 1, 3 credit hour class durng their 3rd year of med school. Tought by ancient that are sure opiates will be the fall of most doctors and civilization.

The other point I wanted to make is that , I'm not sure where you live. But adaquate treatement in an ER for Tooth pain is a shot of Marcaine or Novacaine, not a script for Lortab. If the DEA has it's way Hydro products will be class 2 by the end of the year if not sooner, making any thing stronger than Tylenol 4, Darvecet and ultram on the list of the most widely abused and diverted meds in the country.

ER docs catch on and send the tooth ache patients off with a numb lip and instructions to follow up with their dentist. Reclasifying Hydro will make dentistry a whole lot of fun.

As far as your friend, If they are trying to get bone to fuse, Ibuprofen is a big no no. is 20 hydro to weak for sugery?, in our terms yes, but to a patient that doesn't take opiates daily or weekly or ever, Hydro can knock someone like my mom or neighbor into the next atmosphere. The strength difference between Hydro and morphine are 1:1 and it's 75-80% as strong as Oxycodone. Hydro isn't a weak drug, After years on high dose opiates it seems weak to us but it's not to the average happy go lucky person that doesn't deal with pain on a regular basis.

Foot surgery also falls under Podiatry, They rearly do long extensive surgeries that require PCA Although they acount for more than 60% of all OR time in any given hopital, Wheyher it''s fixing a hammer toe, scraping a bunion, or fusing an ankle. But there expertise doesn't go above the knee and there exposure to high dose patients is extremely limted, so If Hydro has worked on the majority of a Podiatrists patients then he will stick with it untill your friend calls back and complains if she isn't getting relief.

I've read and quoted the low statistic studies on addiction, I have also read the statistics that actiual PM docs put out about their practice, an unchecked practice could have, and attract a lot of addicts and the majorty will stay addicts untill the doc is shut down. The real PM doc still has to contend with addicts on a daily if not weekly basis. I have seen numbers that look more acurate in the 10%-20% range but proper screening and patient and drug selection can cut tha number down into the 5-10% range.

Bottom line, Every PM doc , every surgeon and every pharamacist and GP has an addict to deal with on a monthly basis, and the taste left behind once a docs script pad has been stolen, meds called in, scripts forged, all the BS lies about how the dog ate my pills, does play a role in the way every doc treats every patient.

If you want to advocate an actual PM specialty and ciriculum, you need to associate yourself with one of the PM organizations like the AAPM and then Point out the short coming of so many untrained docs practicing PM. I've seen a dozen and half only had one trick up their sleeve, TP injections and anti depressants, Antiseizure meds and relaxation techniques, PT and antiD's, If a PM doc only has the skill to do do TP injection and is lost when it comes to infused meds, nerve blocks, use of lidocain, use of abortives, then we need to point out the short comng of your own doc. Can your GP who is treating your pain and playing PM doc do a DHEA infusion or a Robaxn infusion? Is he set up to do Nerve blocks, medial branch blocks, RFA, IDET, Do you really want a physiatrist near your spinal cord with a needle? I want an anesthesiologist who has done it thousands of times in the OB ward.

Untill patient are unwilling to except whatever they can get and if all they want is narcotics, the GP can write them, does he know how to handle all the side effects, does your GP keep injectable meds like Narcan around incase a patient has a bad response. Does the GP have a crash cart in sterile procedure room where he does nerve blocks, branch blocks, Infusions, IDET, RFA. Can he do a pump trial or manage one.

A PM program would need to make all PM docs more equally qualified so it's not hit or miss when you have waited 3 months to see a doc only to find he doesn't use opiates and treats all his patients with acupuncture. If that's his only tool in the tool bag, the Doc is no more than a tool, "Pun Intended"

Just because anydoc will treat one of uswith opiates doesn't make him a good PM doc, Especially if he's only familiar with the opiate end of PM. There is alot more to PM than writing a script but no laws preventing any GP from hanging a sign out front that says PAin managent.
JMO Take care, Dave

Last edited by Shoreline; 07-15-2004 at 06:44 AM.

 
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Old 07-15-2004, 07:02 AM   #3
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Re: Why do pain doc. worry about addiction if-

I agree with everything you said,but why is it,most of the time,that is the first thing most doc. mention,addiction? When satistics show that when a patient takes his meds. as perscribed,the chance of becomming addicted is very low.Its just sad when you here of a chronic pain patient,who has tried everything out there,and when all that doesn't give any relief,the doc. still wont perscribe becuase of the fear of addiction. I just hate to see peaple suffer when there are medications after all else fails.

 
Old 07-15-2004, 09:47 AM   #4
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Re: Why do pain doc. worry about addiction if-

The study your quoted looked at 10,000 CP patients taking opiates for chronic pain. I'm sure there was a screening process to except someone into a study of the chronic pain populatiion, Not the general population as a whole. It's easy to screen out the already known addicts, the folks that failed the pee test, the folks that faied a pill check or UA. So once you screened out as many predictors as possible, you have created a special population of true chronic pain patients, all legitamtely diagnosed and using pain meds. They tracked them for a year and followed the incedence of abuse and it was an extremely low number.

So this basically says that if you have a true CP patient using meds for pain and not psychological or social isssues the opiates are not going to turn a patient into an addict. They will become physically dependent, but didn't start showing addictive behavior, like doc shopping, compalining of increased pain solely to hoard meds or to keep an ever increasing need for opiates to keep the buzz going, Misusing them by injection or snorting, etc etc.

The basic difference between a CP patient using them for pain and the patient complaining of pain to obtain the meds due to addiction or for diversion. I think there are some that would go in with good intentionns, true pain, But don't disclose history of abuse. I think you can turn an inactive addict into an active addict more easily than you can turn a true pain patient into an addict with a simple pill.


So that study showed the "right" patient will be good 99% off the time. I absolutely agreee. However what is the drug and alcohol abuse statistic for the nation or population as a whole without exclusions, You have some addicts/alcoholics, you have people that see the huge street value in diversion,You find people that are diverting as a way to pay for other meds, "almost a crime of nessecesity," you have some psychologically disturbed that couldn't take any med properly and several other populations out there that shouldn't have access to these meds for one reason or another.

If you were to take a random sample, I think the addiction rate would be higher. You would come across people with all kinds of reasons they shouldn't be given acces to opiates along with true CP patients looking for relief, along with regular people that this PM thing apears to be the new way to deal with the daily aches and pains of getting older. Give that population an opiate with high street value,Titrate it up untill they report decreased pain , leave it there 6-8 months and then slowly titrate it down, I would bet the incedence of diversion, non compiance and addiction could rise to as high as 15%-20 %

That's basically what a Pm doc is doing. He's not getting the perfectly screened population for a study. Hopefully doctors that refer patients to PM, know what they are getting the patient into. What will be offered as far as pain management and alternatives to opiates in the "wrong patient" The referring doc needs to screen and aproptriately send patients to pain management

It shouldn't be based on the GP's archiac views of opiates, It shouldbe based on the patient, either you know the patient is not right for opiate therapy or they may benefit, If they benefit then yes give them a chance to benefit from modalities and medicine. It shouldn't be a way to forward the GP's constanly complaining addict and let the PM doc deal with it. That happens too often.

But PM docs need to screen too. When they screen they are getting 100% of the population, some will be whacko, some will be psychotic, some will be addicts, some will true patients. Some will be people that think PM is the new trend in not feeling your age. There just isn't a way to close the front door and only let true patients in the back.


What you said was interesting and the same way I was brought into PM with opiates. After all else has failed. I thin there are more than 1% of CP patients that haven't even come close to when all else fails. That's a crappy place to be when everything else has failed and you have a list up your arm, of everything tried and tested and surgery and on and on.

There are also some folks that went directly from Go to Dr happy and have never tried anything else, Dr happy works so why bother and take up more time and money when a pill will do the trick. It costs money and time to go to PT or do any therapy several times a weak. It may be beneficial but if a little increase takes care of the backache from the lumpy couch but excercise is the real answer then the doc has to look at the whole picture.

It does become objective, does the doc think you are actually benefiting from the meds, or are you are just masking a problem that needs to be adressed. Without the need to be dependent on the med, the doc, the weather, the pharmacy, a ride? I just don't get how this would be fun or apealing.

But I have seen enough of the human race to know better.Even if the addiction rate is 5-10% in the general population , those 10% make a huge impression on everyone else. Docs have been tought that what they actually see as being the tip of an iceberg. For everyone you catch there are a couple more you would never suspect, drug addiction and diversion crosses all lines.
Take care, Dave

 
Old 07-15-2004, 11:01 AM   #5
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Re: Why do pain doc. worry about addiction if-

Your so right shoreline.I guess i'm not looking at the big picture.I just hate to see lagit chronic pain peaple fall through the cracks of the system.It pisses me off.I guess thats with everything,for example,even the welfare program.Peaple that truly need it,get turned down.I remember being at the grociery store,a guy had foodstamps,along with all this gold he was wearing,$150 pair of sneaks,and a nice car!Yet,he was using foodstamps.

 
Old 07-16-2004, 06:16 PM   #6
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Unhappy Re: Why do pain doc. worry about addiction if-

Hi, well my family doctor just told me yesterday that he is NOT
going to prescribe me any more ultram for my chronic nerve
pain (I have been on it for little over a year) it helps
my pain but makes me slighty sick. Well he said that
I should try other means for my pain, not to be on pain
med's anymore. Well I told him that I have tried tapering before
but the withdrawals are so bad along with my nerve pain
that I end up taking another pill just to end the pain along
with the withdrawals. Well guess what the doctor said?
he said that there should be NO WAY that I should go thru
withdrawals while stopping ultram and that it's just all in my
head, etc.... I either felt like crying and walking out or punching
him in the face. He said that people in pain shouldn't be on pain
med's that they should try something else, (Like I haven't??)
I don't understand it I have been seeing him since this past January.
my previous doctor left the clinic to work elsewhere and I NEVER had
a problem with her, she understood chronic pain.
I have only 10 pills left, I don't know what I am going to do
when I'm out of them. My phsycatrist prescribed me "Amitriptyline"
to help with my nerve pain, and also for my depression,
well I have been on it for only 3 weeks
and I feel no effect from it. I have an appointment on the 29th of this
month so I will ask her for some advice on what I should do.
so now I have to cut the ultram in half and then only take a half
a pill a day for a couple of weeks until I see the physcatrist. Even tho
that I will be in pain and going thru withdrawals.
I have read somewhere on the internet that "Effexor" would help
with the withdrawals from ultram.
Has anyone heard of this before??
I would like to get off of ultram and find something else to help with my pain so then I don't have to go thru this again. It seems like the doctors around here don't want to prescribe pain med's. And they just don't understand pain.
I went to a pain clinic last year and they couldn't even help me. :-(
Kim

 
Old 07-16-2004, 07:40 PM   #7
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Re: Why do pain doc. worry about addiction if-

One time I saw a guy buy food from a grocery with food stamps only to get into his brand new caddy and drive away!

 
Old 07-18-2004, 11:19 AM   #8
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Re: Why do pain doc. worry about addiction if-

Hey Kim, Actually I have seen the opisite, You should not mix Ultram with SSRI", Elevil is an oldie and shouldn't be a problem.

Also understand that part of withdrawal is psychological,you go through a little depression and better forwarned than not to recopgnize it's just the withdrawal making you feel bad.

I went through Ultram withdrawal while still taking opiates. I was using both post op and DC the ultram cold and went with just the lortab. Lord I still went through some nasty ultram withdrawal. It has antidepressant effects and opaiate effects and shouldn't be stopped abruptly. Sad docs know nothing more than what the rep told them 12 years ago about this med.

If your going to use elevil for neuralgia you have to dose TID because it has an 8 hour half life, How is once a day dosing going to last 24 hours, Phsychiatrist know the way to use elevil for depression, and have seen the hype about antiD's and PM, But she's not a PM doc and Elevil rarely works on pain when taken once a day, unless someone is very suceptable to the power of suggestion.

Hang in there and keep looking for a doc that will treat you. If the shrink says your an addict because you want to continue to look for someone that will treat your pain, tell him you are relief seeking, not a drug seeker. If they had pain they would not walk away from the ER or any specialist bewildered how nobody can take them serriosly.

You deserve the exact same curtousy another medical professional would be extended.

Good luck, Dave

Last edited by Shoreline; 08-04-2004 at 03:46 PM. Reason: To corect should not

 
Old 08-03-2004, 08:36 PM   #9
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Re: Why do pain doc. worry about addiction if-

belive i know that doctor don't belive me that i am in pain i went to a er and i was told that i had a bruse jar and the second time i went i had a access jar i went to a oral ser. and he pull a pice of bone out of my jar so i don't know about a that?
now i hert my ankle and i don't know about a er doctor that why i live in pain went to get a apointment 0n 6 22 04 and got one on 9 27 04 what the world comming to

 
Old 08-04-2004, 02:17 PM   #10
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ultram and elavil

Hi Kim,

Actually I think Dave might be right about your doctor not wanting to prescribe Ultram at the same time you're taking amitriptyline. I was taking Ultram along with my narcotic drugs up until my doctor first prescribed me nortriptyline, which is very similar to amitriptyline. He said be very careful not to take the two drugs at the same time because they both have certain anti-depressant properties and should not mix. Maybe you should check on a drug interaction website to be sure it's ok to still be using Ultram? It's possible that the two together could be causing your sick-like feelings. I checked and there are interactions--you might want to run a search on "drug interactions" and both drugs to see the details. I didn't feel any different when I stopped Ultram before starting the nortriptyline, which I have since stopped using because of intolerable side effects. Good luck getting this resolved, and I am sorry you are having troubles with your doctor. He doesn't sound too informed about nerve pain, like my first doctor, but then I switched and since then I've been treated much more competantly.

Also, I read your other posts and it seems that several people are misinformed about Ultram. Ultram is not a scheduled drug because its manufacturer convinced the FDA not to classify it as a narcotic. Yet it is a synthetic narcotic, as are other drugs that are classified as narcotics, like fentynal and Stadol (I think). For me, it had more of the typical narcotic properties, like euphoria and feeling "out of it" than opiates like oxycontin. I did not have withdrawals, but I can see how you would have trouble stopping the drug because of dependence rather than addiction. Your doctor does not seem to understand that Ultram is much different from a painkiller like Advil or Vioxx with no mind-altering effects. I think a lot of other doctors see it as harmless compared to scheduled opiates but they are wrong, probably because they haven't tried it. A lot of people are either addicted or physically dependent (or both) on Ultram, but it sounds like you are just dependent because it helps your pain. I think Dave gave you great advice about your doctor. If the elavil isn't working you should consider finding a doctor who will understand your pain and take you off that and put you back on ultram--it might help if you keep notes or some sort of pain log or graph. Maybe you could ask for a referrel to a pain management doctor because it doesn't really seem like your current doctor is taking your case seriously enough. In my opinion, there is no need for you to suffer because you are being denied a non-scheduled drug that helps your pain.

Take care and good luck!
Stacy

Last edited by Snails; 08-04-2004 at 02:43 PM.

 
Old 08-04-2004, 03:42 PM   #11
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Re: Why do pain doc. worry about addiction if-

Hey Kim, I made a typing error,, you should not mix SSRI with Ultram as the both effect seritonin levels. Elevil is OK but Nortriptaline has a lot more interactions although its a cousin drug. Big mistake, glad I read it.
Take care, Dave

 
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