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Pain Treatment |
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Despite all of the billboards and radio ads, not all pain is easily treated. Some of the newer medications, including Lyrica and Cymbalta, reduce pain by increasing the activity in the body’s own pain-blocking pathways. Other medications like Neurontin (gabapentin) or Tegretol (carbemazepine) are effective mostly for ‘neuropathic pain’— pain that arises from chronic irritation of nerve fibers, that results in epileptic-like firing of the neurons. In both cases the pain relief is at best ‘moderate’. One should not expect the non-narcotic medication to relieve pain as effectively as narcotic medication. Sometimes the effect of non narcotic medication is to reduce a certain aspect of the pain. For example, pain can often be broken down into numerous components. There is the sharp, localizing pain— the sensation that makes you jump, or collapse— anything to stop what is causing the pain. Then there is a slower, more diffuse ‘ache’ that may have a throbbing sensation. Sometimes there is yet another type of sensation that can only be described as a ‘suffering’ component. This third type of pain is a major part of chronic pain, or pain that lasts for a long period of time, far beyond the initial injury that started the pain. Some of the non narcotic pain medications will help to reduce the aching pain. Sometimes antidepressants will reduce the ‘suffering’ component.
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The Problem With Narcotics
Narcotic pain medications are not evil. They generally are safe to use long-term with a few exceptions; they do carry risk of overdose when taken in higher doses than one is used to, or when combined with alcohol or sedatives. The danger of overdose is important to note for people who have others sharing the house, particularly children. A person not used to the medication may take a pill, say for a headache, and the action of the medication could be fatal. A second risk relates to the Tylenol that often is combined with the narcotic. Tylenol is extremely toxic to the liver when taken in doses higher than recommended.
The main problem with narcotics lies in the two characteristics that comprise addiction: tolerance and dependence. And there is simply no way to escape these two things when taking narcotics. The first, tolerance, is when the dose of medication required for treating the pain goes up over time. If a doctor is careless in prescribing, the patient can quickly end up on very high doses of medication. When these doses stop working after a few months, the patient may be left with no options at all, except for painful detox to force the tolerance to revert to normal. The second factor, dependence, is more insidious. These medications have effects deep within the primitive areas of the brain— areas that are beyond conscious control. In these areas the medications can have powerful effects on mood and personality. They can destroy one’s ability to form interpersonal relationships. They can make a person ‘one dimensional’, where he/she loses interest in the things that used to be pleasurable. These effects are ‘insidious’ because everybody thinks that they can escape them. But they can’t. It isn’t their fault— it is just what the drugs do. Over time, narcotics will take a person with a wide range of interests and turn them into a person with only one interest: taking the drug. The person thinks about the next dose all of the time. First thing in the morning, they want the drug. Every 4 hours they start to feel sick, and want the drug. They become acutely aware of all of their body sensations, or at least all of the uncomfortable ones. They struggle to avoid taking doses too early, knowing that will leave them short at the end of the month. This is what pain pills do, and why I do not like to prescribe them. When a patient starts narcotics, they think they are lucky to be getting their pain treatment. In reality, their problems have just begun
Ideally, patients with chronic pain will learn to live with the pain. Patients will say that this is silly, or that I am insensitive. But neither is true— I am sorry that some people have horrible chronic pain. And living with pain is possible for some— by learning to avoid things that aggravate the pain, by losing weight to reduce the pressure on painful joints, by learning exercises that will increase flexibility and reduce pain. Some people, for some reason, are much more tuned in to discomfort than others. Where one person may hold his/her back and take pill after pill, another may learn to stay distracted, or to tolerate the pain. There is no doubt that pain can be made ten-fold worse, simply by concentrating on it.
No Way Around It
With all of this in mind, sometimes narcotics just have to be used. And in those cases, I will prescribe them . In such cases I will have expectations of certain behavior, which I use to gauge how you are doing in light of the factors described above. The expectations are nothing dramatic— simply following instructions closely, sharing information openly, and communicating thoughts and behaviors honestly. |
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