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Old 07-09-2005, 07:06 AM   #1
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Pain Management for heroin addicts

I am a heroin addict on a methadone script. First of all I would like to answer what alot of people reading this would be saying, i.e "It's your own fault for doing the drug so you can't complain and you don't deserve treatment for pain" Well my answer to that is simply , ok my lifestyle has brought me these problems I have now but how many other people with illnesses that need pain relief lifestyles have caused their condition.
I am talking about SOME people who smoked and have throat , lung, stomach, cancer. Heart conditions. Do we stop their diamorphine and throw them out onto the streets, of course not. Drug addiction is the only medical condition I know of where treatment i.e methadone/diamorphine can be stopped without a reason being given, then that person dies a week later on street heroin and nothing is said. Nobody bats an eyelid.
Now as medicine has moved forward methadone is being used as a maintenance drug instead of a reductionist i.e wheening the patient off because at last the DOH have realised opiate addiction is a chronic relaspsing medical condition. So now we have an aging group of opiate dependent patients, some of who will develop conditions where they have to go into hospital and receive pain management. My fear is that some doctors will not know how to administer pain relief to someone who already has a tolerance to opiates. So they will not get enough pain relief and will suffer pain due to the doctors lack of knowledge in treating an opiate dependant patient with pain relief. My worst fear is prejudice effecting the doctors decision.
There are now documents coming out telling doctors how to give the nessessary pain relief for opiate dependent patients but how many doctors are reading these documents.
Opiate dependant patients need MORE of the opiate drug they are being treated with for pain than someone who is not opiate dependant. I have read the documents and the bottom line is keep upping the dose of morphine for excample until that patient is free from pain or as comfortable as possible. The documents tell of doctors who wrongly think because the patient is on say for instance 150ml of methadone per day, that will take care of their pain!! The patient has become tolerant to the 150ml of methadone so even with that amount of methadone in his/her system they will be feeling pain as much as somebody on no opiates.
This is a big worry to me and I would like to know what information doctors are receiving and do they realise an opiate dependant patient will need more pain relief than a non opiate dependant patient. David

 
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Old 07-09-2005, 03:01 PM   #2
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Re: Pain Management for heroin addicts

Hi David,

You are brave for posting on this board and you have some valid concerns.

From your post I'm assuming that you are not having bad pain right now, but are concerned should you have to go into the hospital for an operation or something like that, that the gas man won't take into consideration the fact that you are not an opioid naive person and your needs regaring pain meds are going to be much different than Jane or John Doe.

If you get a good one and you give him the information about what dose of methadone you are on, he/she should be able to make sure that you are comfortable. It happens all the time when chronic pain patients, that are taking morphine or other opioid meds. who also need to be treated differently.

One thing about your post that caught my eye. You mention that the goal should be to make the patient pain free. Much of what you wrote is dead on, but that part isn't.

The Dr.;s titrate the dose of these meds. with the goal of getting the patient back into the world as a functioning adult. Reducing his/her pain to a degree that will allow them to participate in life. Some pain patientsrun into problems trying to get rid of all their pain.

If the goal is to reduce all pain, doses are going to escalate like crazy and soon the patient will need so much medication that no Dr. would ever agree to take them on as a patient.

They want to reduce the pain from an 8-9 to a 2-4. And the dose to do this, as you say, is going to be different for everyone.

Good luck!!//Chaz

 
Old 07-09-2005, 03:07 PM   #3
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Re: Pain Management for heroin addicts

Hi David,

We all worry about prejudice. As pain patients, we are part of a select group, just as you are as a recovering addict. I applaud your courage and progress in recovery. You deserve pain management at the proper level, just as any other human does. However, you are correct in assuming that most doctors do not understand how to handle the delicate situation of person who is already tolerant and needs pain relief. That is why you need a pain specialist! You must find the most knowledgeable and compassionate and experienced pain doctor you can, and then get a good working relationship with him. I carry an envelope with a letter from my pain doctor, his business card, and copies of my prescriptions and even my MRI's with me at all times. My greatest fear is of ending up in the hospital and going into withdrawals because the doctors and nurses don't understand. That has happened to many of us already. But if you have a dedicated pain doctor, you could call his emergency number and he can intervene with the hospital on your behalf. It also helps to have a knowledgeable friend who can advocate for you in a situation like that.

Educate the public and our doctors? That is OUR duty. We must educate ourselves as much as possible about our pain and the medications we need, and then we must teach others as much as we can! You sound like an intelligent person. Make this your new mission: to use your knowledge and wisdom to help others. Pain patients all around the world need more people like you!

Last edited by pain research; 07-09-2005 at 03:08 PM.

 
Old 07-10-2005, 07:31 AM   #4
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Re: Pain Management for heroin addicts

Hey Dave, Every single CP patient taking long acting opiates for chronic pain is opiate dependent, IN that respect you are no differnt than any other patient with opiate tolerance. What complicates things is the history of abuse and addiction.

The problem is, that by demonstrating an inablity to use meds properly or to get high puts the doc at greater risk for audits, and investigation if he takes on a patient with a history of opiate abuse. Addiction is not the same thing as dependence/tolerance . Tolerance/dependence is a physicological reponse to prologed use of opiate pain meds.
Addiction is entirely different.

A PM doc would be more at ease in treating a patient without a hitory of abuse or self medication. Meth maint clincs don't give heroin addicts a month supply and say see you next month for a reason. The meds are tightly controlled due to previously demonstrated lack of self control and risk of OD.

Although a compassionate doc will recognize a Heroin addict can get hit by a bus or fall from a building or develop cancer, their care has to be more controlled. Although the DEA won't come out and say you can't treat an addict if they develop CP. There is an underlying fear that taking on even one patient that has a history and a much higher abuse potential could be seen as wreckless by the DEA.

More anti diversion techniques could be employed, meaning more frequent drug screening, using weekly supplies instead of monthly, required evals and PM psychology visits, But this still doesn't make it risk free.

In the last year the DEA has cracked down on docs treating patients with no history of abuse, stable patients with chronic or deteriorating conditions must now be seen monthly instead of bi monthly or quaterly as I did for 4 years pror to last January. Many doc used to use fill on or after dates to enforce compliance. I would go to the doc every 3 months and recieve my next 3 months scripts, signed and dated that day but with fill on or after dates . Like fill on or after 7/10, the next would be fill on or after 8/8 and fill on or after 9/6. Each script dated exactly 30 days apart ensuring they can't be filled early with a fill on or after date. Months with 31 days they deducted 2 from the calendar and months with 30 they deducted 1 day from the next month. LIke 9/10 and the next fill date would be 10/9

The DEA felt this was a PM docs way of getting around the post dating restrictions and creating refillable class 2 prescriptions. So the DEA came in and said you must see each patient every month, regardless of whether they have been stable on the same dose for 4 years and there is no hope for recovery. So now I go monthly and show them my bottle of meds so they can check what day I filled it, to ensure absolute compliance. They still track the fill dates, they just can't write it on the script I receive.

The DEA doesn't need a law to create new regulations, the fear of being investigated and closed down for not complying with any and every DEA request is very real.

Although the DEA may not come out and say you can't treat a prior addict, It certainly weighs heavily on the docs decision to take on a patent with a history of drug abuse. To risk his entire practice and the well being of every patient to treat one person who has demonstrated an inability to comply or use street drugs as an alternative isn't something I would want my doc doing as it's a risk to my future care. CP patients don't get second and third chances where an addicts get as many chances as they want

My doc was the one that made ďthe addict hit by a busĒ analogy 5 years ago and said he would give someone one chance. Now he won't take that chance on an addict due to the DEA's position and because the relapse rate is so incredibly high with Heroin, it seems more of a matter of when rather than if the meds will be abused, How does a PM prescribe in this situation?
Quote:
at last the DOH have realised opiate addiction is a chronic relaspsing medical condition.
I'm sorry and I realize this directly effects you but something very similar happened 2 weeks ago in SW Washington.

7000 patients lost their doc because he is being investigated for the death of 6 patients and complaints from family members. Docs are presumed guilty and their privileges and ability to treat patients are suspended when the DEA pulls every medical file out of the docs office to revue a docs prescribing practice. Just as you feel your situation is unjust, so is being presumed guilty until you can prove your innocent, and that's how docs are treated. If the DEA comes and takes my file for revue, he canít treat me without my records.

In many cases, it can take years to clear his name and even then they won't go back to PM due to the potential risk of loosing their livelihood and ability to support his own family.

It effects every patient that has never abused any drug, never filled a script a day early, never taken a single extra pill even on their worst day and has never used illegal drugs. People that are bed ridden or even people with severe pain that can't function won't normally risk their treatment by abusing the meds prescribed or any other illegal activity.

I recognize this is my only hope for any sort of quality of life. The risk of being discharged from my practice due to running out 1 day early or getting caught with any illegal drug in my system isn't an option, if I expect my doc to continue to treat my pain aggressively with controversial meds. It's not a chance many people that can't function without these meds would take. It's also a huge chance for the doc to take when the relapse rate for heroin addicts are so high..

Certainly every practice has a couple patients that are abusing their meds, selling them or supplementing them with illegal drugs. All they can do is screen, demand ultimate compliance, check fill dates to be sure meds were filled precisely on day 30 and use UA's as another tool.

But one patient can bring an entire practice down or 6 patients as in this case.

Three medical clinics in SW WA have been crippled within the past few weeks all run by the same doctor, Dr. Lance Christiansen, OD. It is estimated that 7,000 pts. have been displaced. Dr. C's clinics were "federally designated rural health clinics."

The criteria used in this emergency situation/displacement of pts. was based primarily on:
... six (6) drug related deaths (1 suicide; methadone.) (It was reported that meth was X5 the conversion rate for pts. changing pain meds.)
... a number of both "anonymous" and formal complaints to the DEA about the physician's prescribing practices.
... an absence of evidence regarding alternative treating methods, substantiating diagnoses, etc.

I've had arguments with people that don't believe the actions of one or a few patients can have such a broad reaching effect, but here is a perfect example.

7000 people in CP are suffering due to the actions of 6 patients and a possible error on a conversion. The doc hasn't been convicted, but the patients are out in the cold because of 6 people. I don't know if they had histories of abuse or not, but the actions of a few can be catastrophic to the doc, his practice and family and every patient that doesn't have another choice.

So taking on a patient with a history of abuse comes with a huge risk. Meth maint patients are in a data base and so is every class 2 prescription thatís filled. It may only take one over zealous DEA agent asking how can a doc prescribe more opiates to a patient with such a history, to start an investigation and bring his entire practice down.

You will have a harder time finding care, you will have to try other methods of pain control and jump through the same hoops every other CP patient has. Some of us have tried every non opiate method of PM you can name before a single script for opiates was written. You may have to start the same place we did, Antidepressants, self hypnosis, bio feedback, anti seizure meds, nerve blocks, PT, injections, Tens, TINS and every other non opiate modality until your doc can chart and demonstrate your only option is long acting opiates because nothing else works.



This is the only way most PM docs can safely stay in practice, by documenting every other method tried and failed to manage pain before opiates were used. But even the most diligent doc can go down if one patient OD's or is caught selling their meds or a family member doesn't like the fact he's prescribing while your trying to recover from addiction.

I'm not suggesting that you should not have PM available, but it will be harder to find and I would expect that someone with a history of abuse will have more hurdles, will have to try other modalities before a doc can say only opiates work on your condition. More UA's, shorter days supply than a month to prevent abuse, Meaning you may have to go in weekly at first, if you build trust then bi weekly and if you continue to build trust hopefully a doc would eventually trust you with a one months supply.

I do wish you luck and please understand that just because you have tolerance to opiates, doesn't mean opiates are your only alternative to managing pain. There are implantable devices, and dozens of other modalities used to treat pain aside from opiates. Opiates may work better and faster, but finding another method would likely be something PM docs are going to do before giving you that one chance to prove you would be compliant. You may have to prove your willingness to try other methods and continue your efforts to remain sober in order to show the doc you wonít be a risk to the docs practice and every other patient he sees.

Good luck, DaveC

 
Old 07-10-2005, 08:53 AM   #5
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Re: Pain Management for heroin addicts

Dave, Do you have pain? What is the probelem and do you want to know some other treratment methods?

I was talking to my wife about this and she sees my group of docs too. Only she benefits more from Occiptal blocks, Botox and trigger point injections.The doc had told her that an addict or someone with a history of addiction was the only person he couldn't treat now. He can't give an opiate addict more opiates to potentially abuse, The potential to abuse 30 days worth of meds in 5 days is there. He got that call at my last visit. A patient in the ER, in withdrawal 5 days after the fill dates.

You said addicts were the only ones they cut off cold. They cut off CP patents cold for one mistake all the time. You get clonodine for BP and they suggest rehab and non opiate modalities for pain once you get out of rehab.
What exactly are you asking?
Dave C

 
Old 07-10-2005, 10:47 AM   #6
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Red face Re: Pain Management for heroin addicts

Davey, presuming that your not in pain now and yet are having these thoughts about "how much opiates might I receive in a certain situation," I might suggest that this isn't helpful thinking. I think that we all have enough issues to deal with one day at a time and in your case if you're commited to recovery, a reducing dose of methodone would be a good course of action (I presume) and hence you would then benefit from any potential PM needed at a future date.

If you're not commited to a reducing dose, then I would think that you're having "acting out/sticking thinking" type thoughts. Any addict who is actually consuming their drug of choice will dream of ways the buzz could be better......

Of course this is very much my own opinion of I hope that it doesn't cause you unnessasery offence. I recognise that you are in the process of recovery and this is indead comendable in itself. I wish you the very best in your progress.

 
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