(http://seattletimes.nwsource.com/html/localnews/2017067266_methadone22m.html)

“This abstract is from an article in a recent edition of Science. It discusses “spinal memory” and opioids and asserts that opioids dampen pain temporarily but also erase the spinal memory trace. When pain registers in a nerve, it is like turning a light switch on. Ideally, when the pain passes, the light switch should turn itself off. Unfortunately, in the case of chronic pain this switch is stuck in the “ON” position. You experience pain long after the painful event has passed. The article advocates the use of high dose opioids to dampen pain and at the same time erasing the memory of the pain. The pain switch, like a light switch, is turned “OFF,” and the nerve is no longer continuously stimulated sending erroneous pain signals to the brain.

In my book, A Day without Pain (Revised Edition), I discuss the many facets of pain and I advocate for the concept of pain recovery, where the individual devises coping skills to deal with pain instead of using opioid painkillers. I discuss many complementary and alternative therapies to help the sufferer to do so. The use of high doses of opioids targeting the spinal nerves, in such a way as to erase spinal memory might be a step in the right direction to avoid the occurrence of chronic pain after surgery or an injury. I’m all for eliminating acute pain; however, I do not advocate routine and long-term use of opioids for chronic pain unless they are shown to improve function. I hope that with more time and research science can discover even more about pain and how to cope with it without using opioids. Opioids often cause significant side effects and negative effects which limit their effectiveness for long term treatment of chronic pain. I will continue to follow the emerging science and see where it leads, as should you, if you or someone you love lives with chronic pain. As always, I wish you A Day without Pain.

December 22, 2008
Emotions and Suffering

We all have suffered at one time or another. Suffering is your individual response to a painful stimulus. Suffering is a necessary part of the human condition (none of us escape it) and is an inevitable part of life. How much and how badly you suffer is modifiable, and you can learn to diminish it. In fact, the Buddha taught about this in his classic Four Noble Truths 2500 years ago.

Your experience of pain is a composite of biological (physical) and psychological factors. Suffering is that element of pain that is generated from your emotions. Mood changes, anger, frustration, insomnia, and worry are just a few of the emotions that contribute to your suffering, making pain worse. These emotions are your responses to the pain brought about by your attitudes, perceptions, memories, coping skills, and character traits. Emotional reactions to your pain are constantly changing. When you resist the pain you are feeling, such as get angry with it or yourself for having it or tighten your posture, the pain gets worse and you suffer more.

Additional aspects that contribute to your pain can be your outlook, personal history, cultural background, and reactions of family and friends. So you can see it’s not just how you feel pain it’s also important to understand how you feel about pain. This understanding is a key to reducing your suffering. If physical pain were your only concern life would be different; however, negative emotions experienced before, at, or shortly after you experience pain serve to compound your problem. Again, it’s not how you feel, but how you feel that is often the source of your problem. Negative emotions increase pain while positive emotions decrease pain. Pain +Negative Emotions = Suffering = more pain. This, of course, depends upon the state of your emotions. Therefore, if you can find ways to impact your emotions you can improve your pain.

Many with chronic pain experience what is termed “secondary gain.” Secondary gain develops when chronic pain gives you something positive that isn’t necessarily logical or positive. When this occurs you may find you get more attention from others, you may justify why you should be relieved of certain activities, you may gain an “excuse” for your anger, and it may keep you from feeling other emotions. Secondary gain can be tricky because your pain can bring about perceived benefits justifying destructive behaviors. If you don’t see this, you may have a hard time avoiding this trap. This happens as a subconscious process–you don’t intend to benefit from the pain–but, as you derive benefits, you become “trained” to enjoy and expect those benefits all on a subconscious basis. Knowing this is occurring will enable you to reverse the trend associated with secondary gain.

The power of the mind cannot be underestimated. If you think a treatment will work, often it will work even if no treatment took place. This “false belief” is referred to as the placebo effect. It has been shown to be quite effective because it can alter the functioning of organs in your body. You are more powerful than you realize! It is by feeling empowered that you can change your experience of pain.

Many alternative treatments exist that can help you get [back] in touch with your emotions and by controlling them to reduce or even eliminate your pain. Techniques such as yoga, meditation, and Reiki, as well as many more have helped countless people in pain. You need to know that these treatments take time to work, so you need to avoid becoming impatient. Often a pill will seem the better alternative. These techniques do work if only you gave them a chance. Often the effects are short-lived requiring reapplication of the technique. Of course, it is natural to want relief now. You also want predictability in your lives. Medication provides both immediate relief and predictability; however, medication comes with a price: side effects and potential for addiction. Trying alternative therapies and looking at how your emotions contribute to your suffering will help you modify your experience of pain. Your way of thinking, as well as the way you cope with your emotions needs to change if you are to reduce your suffering. I hope today’s topic has helped you to look at pain and suffering in a new light and with a more optimistic view.
Good luck on your journey to discover A Day without Pain.
Mel

Even more recently, pop superstar Michael Jackson died at age 50 in his Los Angeles home from cardiac arrest with the autopsy results pending at this time. News reports stated that he was taking “drugs from prescriptions acquired from multiple doctors.” Stories included information from “sources” stating that he took “straight morphine, Demerol and opiates like Oxycontin. He also takes Valium and Xanax.” Propophyl, a powerful anesthetic has also been implicated as a cause of his death. It would seem obvious from news reports that Mr. Jackson suffered from addiction.

Within the last year, we also lost Heath Ledger to an overdose of the opioid painkiller Oxycontin, anti-anxiety drugs Valium and Xanax, and the sleep aids Restoril and Unisom. And a year before that, Anna Nicole Smith overdosed and died on a combination of anti-anxiety medications and pain killers, specifically methadone.

I can only wonder how many others of lesser celebrity status have died from overdoses of these drugs.

There is an epidemic of prescription drug abuse in this country. The National Institute on Drug Abuse (NIDA) found in a 2003 survey of eighth, tenth, and twelfth graders that 10.5% of twelfth graders reported using Vicodin for non-medical reasons and 4.5% of twelfth graders reported using Oxycontin without a prescription in the past year. In 2006, 16.2 million Americans age twelve and older had taken a prescription pain reliever, tranquilizer, stimulant, or sedative for nonmedical purposes at least once in the year prior to being surveyed.

The Office of National Drug Control Policy Executive Office of the President reported in January 2008 that more teens abuse prescription drugs than any illicit drug except marijuana. In 2006, more than 2.1 million teens abused prescription drugs. Every day 2,500 youth (12-17) abuse a prescription pain reliever for the very first time. Sixty percent of teens (12-17) who have abused prescription painkillers first tried them before age fifteen with age thirteen being the mean age of first non-prescribed use of sedatives and stimulants. I have touched on but a few examples of this growing problem. If you would like to read more you can visit the National Institute on Drug Abuse (NIDA.nih.gov) or the Office of National Drug Control Policy (ONDCP.gov) websites.

These celebrity deaths are symptomatic of the effects of potent pain killers on individuals. Were they addicted? Were they addicts? We don’t have enough information to say. What I found intriguing and concerning is the implication that for them to be addicts would be such a terrible thing.

In Mr. Gans case, the coroner, Mike Murphy, seemed to go out of his way to state that “I want to make it very clear that this is not an issue of drug abuse,” again, as if this would be much worse than dying of the combination effects of taking a drug. This is a result of the stigma associated with drug abuse and addiction. Would his suffering be any less significant if he were an addict? In Michael Jackson’s case, we are reading that it was the fault of the doctor who prescribed the medication. We seem to be looking for someone to blame.

But what if there’s no one to blame? Addicts are sick–the disease is called addiction. It’s a brain disease and the symptoms of addiction are behaviors like being dishonest, fearful, and angry. Addicts display behaviors, which are often disturbing to the person’s well-being and to the people who care. But these behaviors are symptoms of an illness. Addiction is not a moral weakness, nor is it related to lack of will power or character. The disease of addiction is prevalent in our society–10-18% of the public are suffering and dying from it on a regular basis–from overdose, medical complication, accident, suicide, organ failure, or infections.

It seems to me that the media is suggesting that it’s ok to die from “chronic pain syndrome” but not from “drug abuse”–since drug abuse is much worse–something to be ashamed or embarrassed about.

The truth is that some people with chronic pain abuse drugs and others become addicted, usually inadvertently. No one starts using medications with the intent to become dependent or addicted–some people are “wired differently”–they take a medication, and without realizing, increase the dose in the face of increasing symptoms and decreasing function. The net effect is the drug works less well, life gets worse; they spin out of control and end up doing things that make matters worse. Combinations of drugs are added to treat the symptoms caused by the first drug. This is the spiral of addiction. The “loss of control” of the ingestion of mood altering substances defines the disease. It appears to be willful, but these drugs work in a part of the brain that ends up associating the drug with survival. People seek the drug with little regard for nourishment, relationships, and sleep. The drug takes over the “drive system” mediated by the chemical “dopamine” which is the main neurotransmitter in the brain’s reward system–and when it’s gone, the person craves the drug physically and emotionally.

We will never know exactly what happened to these folks leading to their deaths. We can speculate all day, but I think what’s much more important is that many more people are suffering from chronic pain, problematic drug use, and addiction. Because of the stigma associated with addiction, we are missing the chance to reach out and help them. I say, let’s devote our attention to the living.

In Chapter 4 of ADWP, I say, “Those doctors who are reluctant to prescribe them are labeled ‘opiophobic.’ In this decade, there has been a proliferation of pain clinics notorious for overprescribing large amounts of painkillers without proper evaluation and follow-up. Impediments to the use of opioids include concerns about addiction, side effects, tolerance, and possible problems with regulatory agencies for overprescribing.”

As the article explains, many people die from misuse of such medications before finding their way into treatment. The article goes on to say that over 5,000 people begin to abuse prescription painkillers every day—a dismal statistic. Doctors should use caution when prescribing pain medications. As a specialist in addiction medicine, I treat many individuals who develop an addiction to prescription pain medication. Some people can’t recognize the problems associated with prescription drug abuse and other people and their families simply don’t know what to do about it. After all, “I take these medications as prescribed and I have pain! If I stop, what will I do about the pain.”

Professionals often disagree about the best course of action, so often, doctors just continue prescribing. When prescribing pain medications doctors should always ask critical questions such as:

How much of the drug does the patient need to relieve/manage pain?

What is the best way to screen for and prevent the development of addiction?

If addiction occurs, what is the best way to deal with it?

How do I ensure I comply with safeguards to prevent medication from falling into the wrong hands?

How do I maintain control without causing an unnecessary burden for those who need the medication and use it responsibly?

If a patient is getting worse functionally, am I prepared to facilitate withdrawal of opioid medications?

Am I familiar with alternative physical and emotional approaches to chronic pain (see chapters 6, 7, 8, and 10 in ADWP).

These are important considerations. And while no one has all the answers, this article suggests that the nature of the opioid problem has the attention of key national agencies. I am hopeful that the need for a balanced approach is recognized and that national strategies can be implemented for prescription drug abuse and that needless deaths can be reduced in the future.