The Opioid Use Hiding Behind the Alleged Superiority of “Nonopioid” Chronic Pain Treatment

 

The SPACE randomized clinical trial, which 234 veterans with chronic back or knee pain completed, has been touted as demonstrating that opioids are superfluous to chronic pain management. According to JAMA’s summary of the trial,

In the opioid group, the first step was immediate-release morphine, oxycodone, or hydrocodone/acetaminophen. For the nonopioid group, the first step was acetaminophen (paracetamol) or a nonsteroidal anti-inflammatory drug. Medications were changed, added, or adjusted within the assigned treatment group according to individual patient response.

and not only did those in the “nonopioid” group experience fewer side effects, but

the use of opioid vs nonopioid medication therapy did not result in significantly better pain-related function over 12 months (3.4 vs 3.3 points on an 11-point scale at 12 months, respectively).

Overall, “nonopioid” treatment appears to win. Omitted from JAMA’s summary of the SPACE trial, though, is the interesting nugget that one of the medications “changed, added, or adjusted” within the “nonopioid” group was tramadol, an opioid. The treatment regimen for the “nonopioid” group can be read off the right-hand column of this graphic helpfully provided by F Perry Wilson of MedPage Today:

Admittedly, tramadol is considered an unusually mild opioid – or was considered unusually mild until recently, when it was scheduled as just another dangerous drug. Furthermore, only 13 of the patients in the “non-opioid based” group received tramadol, meaning most did not. Wilson reports,

Now, I know what you’re thinking. Isn’t tramadol an opioid? I asked lead author Dr. Erin Krebs that very question. She reminded me that this trial started in 2010: “This was before all the concerns about opioid overdose and addiction and back then a big concern was is it ethical to deprive patients of opioids if they fail all these non-opioid medications.”

It wasn’t until August 2014 that tramadol became an “officially dangerous” schedule-IV drug, after having been completely unscheduled for nearly 20 years. So the SPACE trial began back in those halcyon days when tramadol was considered “the safe opioid,” and that, along with basic compassion, appears to be the SPACE trial’s excuse for including tramadol users in the “nonopioid” category.

Indeed, tramadol isn’t just an opioid. It’s also an SNRI, a type of antidepressant, which may help explain tramadol’s formerly-mild reputation: antidepressants also help people cope with chronic pain. As the graphic above shows, stage 2 of “non-opioid based” treatment includes nortriptyline and amitriptyline, both tricyclic antidepressants, presumably for the same reason. A patient receiving tramadol isn’t just getting his opioid receptors tickled; he also benefits from accumulating serotonin and norepinephrine, both of which can improve a chronic sufferer’s mood and function without the opioid “rush.” For someone interested in using opioids as conservatively as possible – stretching small amounts of opioid-receptor tickling into the largest-possible therapeutic benefit – tramadol might seem like a wonder drug.

For many patients, tramadol was that wonder drug, and its scheduling as a controlled substance has proved a burden. As one patient regularly prescribed tramadol back when it was unscheduled puts it,

Fortunately, feeling like a scumbag addict is a great motivator for staying away from opioids, despite the fact that they do take away 100 percent of my pain and allow me to physically function through an average day. Politicians say you’re just weak. [Prospective] employers see you as a potential pill-popping train wreck. Co-workers and subordinates look at you like you’re Dr. House. Friends and family will compare your pain to theirs and blow it off. (“Your back hurts? That’s nothing. I lost three fingers working at the guillotine factory. You don’t see me suckin’ down pain pills”) I simply have to measure the physical pain against the psychological/emotional pain and realize that the latter is greater. Problem solved.

“I simply have to measure the physical pain against the psychological/emotional pain and realize that the latter is greater.” Arguably, that’s a description of tramadol’s scheduling working exactly as it should, deterring law-abiding patients from relief unless their pain is great enough to be worse than the added social stigma and inconvenience.

JAMA must be perfectly well aware that tramadol is an opioid, one which became scheduled before the end of the SPACE trial period. There’s no excuse for JAMA’s summary describing a treatment including tramadol in its final stage as “nonopioid.” SPACE’s “nonopioid” treatment would be better described as “conservative use of a mild opioid as a last resort” treatment, which is exactly how many people supporting opioid usage for chronic pain believe opioids should be used: sparingly, as one of many treatments when less-aggressive management has failed.

Obviously, those who have access to the full text of the SPACE study can read the whole thing and discover for themselves that “nonopioid,” in context, doesn’t really mean “nonopioid.” Science journalists know, though, that many readers only read their summaries of studies, or at best, the study abstracts, rather than the studies themselves, since time and access are scarce. I don’t have access to the full text of the SPACE study, but if we assume that, of the roughly 240 veterans who completed the study, half, or about 120, were in the “nonopioid” group, and we know that of those, 13 received tramadol, then about 10% of “nonopioid” subjects received an opioid. That doesn’t, by itself, prove that roughly 10% of chronic pain patients would benefit from opioid use, but if at most 10% of the roughly 100 million chronic-pain sufferers in the US, or about 10 million people, may benefit from conservative use of opioids, then claims that the SPACE study proves opioids have no place in chronic-pain management are greatly exaggerated.

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  1. Larry3435 Member
    Larry3435
    @Larry3435

    I have never had chronic back or knee pain.  But I have experienced post-surgical pain.  In 2013-14 I had four major surgeries.  In each case, the severe pain lasted between one and two months.  With all due respect to everyone’s right to their own opinion, I just want to say that if you have not experienced that kind of pain, then you have no idea what you are talking about.

    Fortunately for me, in 2014 it was still possible to get needed painkillers.  Even then I observed that some of the doctors were afraid to prescribe opiates.  I was lucky, though; I had a couple of doctors who were more concerned about their patient than about kowtowing to the DEA.  I’m not sure how many of those are left.  The pressure keeps ratcheting up, and it is more and more difficult for doctors to prescribe the responsible use of needed painkillers.

    Let me add, in my case I firmly believe that there was absolutely zero chance that I would become addicted to opiates.  Frankly, I hated the stuff and I got off of it the moment that my pain level allowed.  The idea of taking that stuff recreationally is, to me, utterly insane.  But, I do understand why using opiates to treat chronic pain (i.e., over an extended period of time) creates an increased risk of addiction.

    Which brings me to the risk of overdose.  The responsible use of opiates for temporary pain relief, under medical supervision, creates very little risk.  The real risk happens when patients who are denied needed painkillers are forced to the streets to buy heroin or God-only-knows-what.  In my opinion, the bureaucrats who are creating that problem are not only murderers but also torturers.  I live in absolute terror that my medical problems will recur, that I will need more surgery, and that I will have to recover from that surgery without the painkillers that helped my make it through (barely) the last time around.  I take this very personally, and my feelings about the ignorant bureaucrats who are on a crusade to (ultimately) ban the medical use of opiates cannot be described within the bounds of the Code of Conduct.

    • #31
  2. Fake John/Jane Galt Coolidge
    Fake John/Jane Galt
    @FakeJohnJaneGalt

    Ralphie (View Comment):
    My mom was given tramadol years ago for a pain problem (can’t remember) and discovered that her mysterious cough she had quit, so the dr. kept her on it. She used to cough all day and night and they could not find out what caused it or how to treat it. This was an accidental find. There is a cough dr. somewhere that had a short post about tramadol’s effectiveness in this area.

    Our dog took it for years too.

    Opiods work for coughs.  It is why the good cough medicines have codeine in them.

    • #32
  3. Doctor Robert Member
    Doctor Robert
    @DoctorRobert

    Phil Turmel (View Comment):

    Larry3435 (View Comment):
    After I picked my jaw up off the floor I managed to sputter, “But, but, but, you’re an oncologist! Don’t you have patients who tell you that marijuana is the only way to relieve their pain and counter the effects of chemotherapy?” “Yeah,” he said, “but I don’t believe them.” What can you possibly say to that kind of thinking?

    I would acknowledge a data point based on his experience and my knowledge that addictive personalities are habitual liars. But then I’m not biased to accept pro-marijuana-legalization-and-usage hype.

    My experience is that MJ is useless for general pain, nausea, post op pain.  People who are buzzed don’t care as much.

    However, my son, who distills MJ into a non-euphoric liquid that he takes for his arthritis, disagrees with me.

    So the oncologist should not be scorned for his having the same experience as a Doc that I have had.

    • #33
  4. She Member
    She
    @She

    TheRightNurse (View Comment):

    OmegaPaladin (View Comment):
    (our own Vicryl Contessa said that every patient coming to her ER complaining of pain was looking for drugs. Sucks to be the person with a dislocated knee there.)

    In @vicrylcontessa ‘s defense, she’s probably not wrong. Most people in pain are looking for drugs. Whether or not they have legitimate pain is beside the point…

    I don’t think she’d ever begrudge someone who was in there with a severe migraine, throwing up, with a blanket over his head or someone with a bone sticking out of their leg. But someone who is laughing, texting, complaining about not having enough ice…? Maybe less likely to think that pain is really real and maybe more likely to think that the patient is drug-seeking.

    Think this points up another problem, which is the loss of “community based” healthcare in favor of drive-by clinics like MedExpress, and larger, more remote “health systems” gobbling up the small local hospitals, as has happened in most places, but thankfully not yet here.

    When we moved to Claysville (actually, we live in a field, some distance from Claysville, but that’s our postal address), you entered the town by passing the office of Dr. Little, the dentist (on the right), and a couple of blocks later, you exited it by passing the office of Dr. Large, the physician (on the left).  Neither is still with us, but I have fond memories of Dr. Large taking care of his friends and neighbors and accepting payment from them in the forms of honey, pork chops, and chickens.

    I consider myself very fortunate, because I worked at the local hospital for decades, and I think of many of its employees, from top to bottom and vice-versa, personal friends.  So, when I show up with a pinched nerve, I get the “good stuff” from my physician who says to the medical assistant, “I’m careful about who I prescribe this for, but I know this lady will not abuse it or become addicted, and obviously she’s in real pain.”

    When doctors could say that, or even the opposite, about the majority of the people they cared for, I can’t help thinking that people got better care.  Now, they rarely know.

    • #34
  5. Rodin Member
    Rodin
    @Rodin

    TBA (View Comment):
    I’ve said it elsewhere under different topics but a free society that removes things based on the possibility that someone might misuse those things is not actually a free society.

    Whenever there seems to be a big publicity push on anything, freedom erodes. Society is never perfectible.

    I know a family whose  bright, beautiful, college-aged daughter died of a heroin overdose. Absolutely tragic. But equally tragic would be chronic pain patients being forced to suffer because they are denied opiates to treat their pain.

    I don’t know how many opiate deaths are “too many” from a policy standpoint. My basic measurement is vehicle deaths. We accept that level of death in our society without a major campaign to place additional restrictions on the use and ownership of vehicles because we value the functionality and freedom. Let’s call it “1 Omega”.

    Currently 1 Omega is about 40,000 deaths. Opioid deaths are about .25 Omega. “Gun-related homicides” (whatever that means) are about .25 Omega. Drowning deaths are .1 Omega. Cancer deaths are 15 Omega. Heart-disease related deaths are 15.25 Omega.

    • #35
  6. Ontheleftcoast Inactive
    Ontheleftcoast
    @Ontheleftcoast

    Joe P (View Comment):
    Academics hate it.

    Then I guess I’m a free range academic, because I hate it too.

    • #36
  7. Rodin Member
    Rodin
    @Rodin

    Ontheleftcoast (View Comment):

    Joe P (View Comment):
    Academics hate it.

    Then I guess I’m a free range academic, because I hate it too.

    “Grain fed”?

    • #37
  8. Ontheleftcoast Inactive
    Ontheleftcoast
    @Ontheleftcoast

    TheRightNurse (View Comment):

    OmegaPaladin (View Comment):
    (our own Vicryl Contessa said that every patient coming to her ER complaining of pain was looking for drugs. Sucks to be the person with a dislocated knee there.)

    In @vicrylcontessa ‘s defense, she’s probably not wrong. Most people in pain are looking for drugs. Whether or not they have legitimate pain is beside the point…

    I don’t think she’d ever begrudge someone who was in there with a severe migraine, throwing up, with a blanket over his head or someone with a bone sticking out of their leg. But someone who is laughing, texting, complaining about not having enough ice…? Maybe less likely to think that pain is really real and maybe more likely to think that the patient is drug-seeking.

    The way the studies are shaking out, it looks as though long-term opiate use alters the pain threshold, which is probably part of the clinical picture in chronic well justified medical use. That doesn’t make the patients addicts, but it does affect the attempt to find other ways to manage those patients’ pain.

    One thing I’ve see over the years is that

    1. Discovery of a new family of neurotransmitter and/or neuroregulatory receptors produces interesting research.

    2. Once a drug is developed, whatever receptors that drug affects become the mechanism for whatever

    3. This is followed by realization of another level of complexity when the promised drug effects turn out not to have been that magical for everybody and the purported mechanism turns out not to be all that, or at the least not all of that.

    4. Then there is debunking of the original studies which tended to be cherry picked.

    5. Wash, rinse, repeat.

    Medical cannabis is still around stages 2-3.

    • #38
  9. Larry3435 Member
    Larry3435
    @Larry3435

    Doctor Robert (View Comment):

    Phil Turmel (View Comment):

    Larry3435 (View Comment):
    After I picked my jaw up off the floor I managed to sputter, “But, but, but, you’re an oncologist! Don’t you have patients who tell you that marijuana is the only way to relieve their pain and counter the effects of chemotherapy?” “Yeah,” he said, “but I don’t believe them.” What can you possibly say to that kind of thinking?

    I would acknowledge a data point based on his experience and my knowledge that addictive personalities are habitual liars. But then I’m not biased to accept pro-marijuana-legalization-and-usage hype.

    My experience is that MJ is useless for general pain, nausea, post op pain. People who are buzzed don’t care as much.

    However, my son, who distills MJ into a non-euphoric liquid that he takes for his arthritis, disagrees with me.

    So the oncologist should not be scorned for his having the same experience as a Doc that I have had.

    Sorry, but I still don’t understand that.  Is the doctor supposed to be in terror that his patient might experience a little buzz?  Someone is a patient with cancer, possibly terminal, having been dosed repeatedly with chemotherapy poison and so nauseous that he can’t hold down food, but God forbid we believe him when he says that marijuana helps his condition.  Nah, he’s probably just in it for kicks.  No, I don’t understand this thinking at all.  And I will lavish my scorn where I think it’s due.

    • #39
  10. TheRightNurse Member
    TheRightNurse
    @TheRightNurse

    Metalheaddoc (View Comment):
    Did they subdivide the pain into specific types? Some kinds of pain related to inflammation (ie arthritis) will respond to NSAIDs. But what about neuropathic pain or disc pathology or torn meniscus? Different pathologies are gonna respond differently.

    …and opiates do not work at all for nerve pain.  At least,  not on a physical level.  As a psychological crutch, sure.

    • #40
  11. TheRightNurse Member
    TheRightNurse
    @TheRightNurse

    Larry3435 (View Comment):
    Someone is a patient with cancer, possibly terminal, having been dosed repeatedly with chemotherapy poison and so nauseous that he can’t hold down food, but God forbid we believe him when he says that marijuana helps his condition.

    Most decent doctors really don’t care at the point of terminal cancer.   Then,  it’s whatever gives you relief.  That’s where it gets stupid to restrict opiates.  They’re dying anyway!   Why torture them about addiction when they won’t be alive long enough to get addicted?

    • #41
  12. Judge Mental Member
    Judge Mental
    @JudgeMental

    TheRightNurse (View Comment):

    Metalheaddoc (View Comment):
    Did they subdivide the pain into specific types? Some kinds of pain related to inflammation (ie arthritis) will respond to NSAIDs. But what about neuropathic pain or disc pathology or torn meniscus? Different pathologies are gonna respond differently.

    …and opiates do not work at all for nerve pain. At least, not on a physical level. As a psychological crutch, sure.

    I had a dental surgeon who would prescribe the low dose hydrocodone with prescription strength Ibuprofen.  So, a low end solution for each of two pain strategies.  Worked very well for me.

    • #42
  13. Ontheleftcoast Inactive
    Ontheleftcoast
    @Ontheleftcoast

    TheRightNurse (View Comment):

    Midget Faded Rattlesnake (View Comment):
    Additionally, in 2014, hydrocodone was rescheduled from Schedule III to Schedule II, and as a Schedule II substance, the manufacture of hydrocodone must not exceed a DEA production quota which has been decreased for two years in a row.

    This is one of the largest issues in the Opiate Crisis which I have written about previously. People do not seem to understand that this doesn’t just limit purchasing, but it limits and penalizes prescribing, manufacturing, and filling legal prescriptions.

    It’s madness.

    From the standpoint of public health and patient care, maybe it’s madness.

    These policies also expand the illegal market. Unfortunately, there there is a large constituency in the regulatory state and its minions who benefit from there being an illegal market.

    I know. Don’t (immediately) ascribe to malice what you can explain by stupidity, but don’t rule out malice.

    But this has been going on a long time.

    • #43
  14. TheRightNurse Member
    TheRightNurse
    @TheRightNurse

    Judge Mental (View Comment):

    TheRightNurse (View Comment):

    Metalheaddoc (View Comment):
    Did they subdivide the pain into specific types? Some kinds of pain related to inflammation (ie arthritis) will respond to NSAIDs. But what about neuropathic pain or disc pathology or torn meniscus? Different pathologies are gonna respond differently.

    …and opiates do not work at all for nerve pain. At least, not on a physical level. As a psychological crutch, sure.

    I had a dental surgeon who would prescribe the low dose hydrocodone with prescription strength Ibuprofen. So, a low end solution for each of two pain strategies. Worked very well for me.

    The idea is that you start low, however, there’s a real problem with Tylenol toxicity.  Ibuprofen tends to increase bleeding, so is often not a surgeon’s favorite option.

    It is best if you instruct people on pain levels.  If it is low, don’t bother.   If it’s enough to distract you,  go low.  If it’s enough to make you wince, distracts you,  AND prevents you from doing activities, try something stronger.  If you’re crying or vomiting from the pain, see a doctor, because whatever you’re doing isn’t working.

    • #44
  15. Ontheleftcoast Inactive
    Ontheleftcoast
    @Ontheleftcoast

    TheRightNurse (View Comment):

    Judge Mental (View Comment):

    TheRightNurse (View Comment):

    Metalheaddoc (View Comment):
    Did they subdivide the pain into specific types? Some kinds of pain related to inflammation (ie arthritis) will respond to NSAIDs. But what about neuropathic pain or disc pathology or torn meniscus? Different pathologies are gonna respond differently.

    …and opiates do not work at all for nerve pain. At least, not on a physical level. As a psychological crutch, sure.

    I had a dental surgeon who would prescribe the low dose hydrocodone with prescription strength Ibuprofen. So, a low end solution for each of two pain strategies. Worked very well for me.

    The idea is that you start low, however, there’s a real problem with Tylenol toxicity. Ibuprofen tends to increase bleeding, so is often not a surgeon’s favorite option.

    It is best if you instruct people on pain levels. If it is low, don’t bother. If it’s enough to distract you, go low. If it’s enough to make you wince, distracts you, AND prevents you from doing activities, try something stronger. If you’re crying or vomiting from the pain, see a doctor, because whatever you’re doing isn’t working.

    And remember that if you have to go down that route, whatever you do WILL have adverse effects. At that point you’re looking for least bad.

    • #45
  16. Ontheleftcoast Inactive
    Ontheleftcoast
    @Ontheleftcoast

    On #38 I left something out:

    Tolerance to the analgesic effects of opioids develops rapidly. Tolerance to the respiratory depressant effects develops very slowly if at all. This is a cause of morbidity and mortality with long term use. (It looks as though the opioids in kratom may produce less respiratory depression.) It would make sleep apnea more dangerous. It does not mean that opioids should never be used long term for pain.

    IMHO it does mean that the FDA DEA’s idea of classifying kratom as a Schedule I drug is incredibly stupid. It should be researched, not banned.

    Then there’s this:

    In addition, recent studies have made it clear that continued exposure to opioids induces more than tolerance. It also induces a degree of hyperalgesia. Whereas, in principle, tolerance can be overcome by increasing opioid dose, hyperalgesia is made worse in the long run by increasing the opioid administration.

    [Emphasis added.]

    The odds are that if you are on long term opioids you have some degree of hyperalgesia. It will exacerbate the discomfort of withdrawal… as in a delayed dose. This is part of the reason for sticking closely to a useful individualized dosage schedule and, while it was not yet known when Oxycontin was developed, would support the use of time release opioids.

    • #46
  17. Ben Lang Member
    Ben Lang
    @BenLang

    I had an interesting experience recently – I have chronic back pain due to a car accident I was in some 7 years ago (if anyone has the opportunity to get crushed by a large commercial van full of elevator replacement parts…avoid this experience).

    My Dr. has prescribed hydrocodone and a muscle relaxer to be taken as needed and I refill this prescription several times a year (Thankfully, I need these far less now I have been doing yoga multiple times weekly for 3-4 years). This was all good until I got a very bad respiratory infection this year and was given some excellent cough syrup with…you guessed it, hydrocodone. Due to the severity of my sickness (I’m an asthmatic) I had to renew this cough syrup 4-5 times. This led to some very interesting questions…not from my Dr. but form the pharmacy and from my insurance company, who would not cover the medication any more because I was getting too much in a short amount of time. This led to a rather costly bill.

     

    Thankfully, I’m finally recovered and can stop living in a fog of medication during the day….it was getting difficult to function at work, especially when I needed to interact intelligently with network technology or a client. I was extremely reticent to do any work in a data center without my full faculties present.

    • #47
  18. Roderic Fabian Reagan
    Roderic Fabian
    @rhfabian

    I hope that people will not be using tramadol as an excuse to dismiss the entire SPACE trial and then go on using powerful opioids for chronic pain to their heart’s content.  In all likelihood tramadol is a lot milder and less likely to cause death and disability than strong narcotics.

    It’s hard to find hard numbers for deaths from Tramadol abuse.  The CDC is no help because they lump all synthetic opioids together, i.e., tramadol gets lumped with fentanyl, one of the strongest and deadliest narcotics we’ve ever seen on the street.   Fentanyl abuse is definitely killing people in increasing numbers, and tramadol is not in that class.

    The average life expectancy of Americans has been trending down for the last 10 years, the first time we’ve ever seen a reversal in what used to be a steady upward trend.  And that is due mainly to drug and alcohol abuse.  The number of people dying from prescription opioid abuse is increasingly exponentially.  If doctors would stick to the “non-opioid” list of drugs provided by the SPACE trail to treat chronic pain I think it would go a long way to helping stop this horrible trend.

     

    • #48
  19. Midget Faded Rattlesnake Contributor
    Midget Faded Rattlesnake
    @Midge

    Larry3435 (View Comment):

    Doctor Robert (View Comment):

    Phil Turmel (View Comment):

    Larry3435 (View Comment):
    After I picked my jaw up off the floor I managed to sputter, “But, but, but, you’re an oncologist! Don’t you have patients who tell you that marijuana is the only way to relieve their pain and counter the effects of chemotherapy?” “Yeah,” he said, “but I don’t believe them.” What can you possibly say to that kind of thinking?

    I would acknowledge a data point based on his experience and my knowledge that addictive personalities are habitual liars. But then I’m not biased to accept pro-marijuana-legalization-and-usage hype.

    My experience is that MJ is useless for general pain, nausea, post op pain. People who are buzzed don’t care as much.

    However, my son, who distills MJ into a non-euphoric liquid that he takes for his arthritis, disagrees with me.

    So the oncologist should not be scorned for his having the same experience as a Doc that I have had.

    Sorry, but I still don’t understand that. Is the doctor supposed to be in terror that his patient might experience a little buzz?

    I think it’s less that than the belief of analytical minds that we ought to be able to dissect distress into its component parts and be able to clearly label which part is specifically “pain” and which parts may simply be “caring” about the pain. It’s really frustrating for some people to call “caring less about the pain” a valid treatment for pain, especially when the “caring less” involves getting people sloppy and doped up.

    Unfortunately, pain appears to be less an incoming signal to the brain than the brain’s perception of total threat, in which case “caring” does matter to pain levels.

    Antidepressants may, in their own way, help people “care less” about pain, but getting a “dopey” feeling from an antidepressant is rarely pleasant, and so people seem less likely to worry about other people overindulging in antidepressants to escape their problems. Conservatives especially tend to worry about using escapism to ignore problems rather than address them head on, and “fun drugs” are a kind of escapism. It unfortunately true that escapism is a great way to get through otherwise-incapacitating discomfort, but it’s hard to quiet the suspicion that escapism is inherently dangerous, since escapism is a risky habit for the not-otherwise-incapacitated. Often, people taking an antidepressant become more active and productive before they notice getting any happier, so the kind of “caring less” about pain antidepressants produce seems to be of a less escapist kind.

    I don’t think it’s easy for people to let go of their general fears involving escapism and productivity just because they’re in the presence of someone who’s genuinely reached the point of being too badly-off to have those concerns anymore.

    • #49
  20. danok1 Member
    danok1
    @danok1

    FWIW, I’ve been prescribed Tramadol for a few years now. I take it when I need it. It works for me, and I’m in no danger of developing any addiction. I resent politicians trying to bar me from pain medication that works, for what appears to be a dubious benefit (in that Tramadol addiction is not a scourge to our nation, AFAIK).

    TheRightNurse (View Comment):
    It is best if you instruct people on pain levels. If it is low, don’t bother. If it’s enough to distract you, go low. If it’s enough to make you wince, distracts you, AND prevents you from doing activities, try something stronger. If you’re crying or vomiting from the pain, see a doctor, because whatever you’re doing isn’t working.

    This is pretty much what my rheumatologist told me.

    • #50
  21. TheRightNurse Member
    TheRightNurse
    @TheRightNurse

    danok1 (View Comment):
    FWIW, I’ve been prescribed Tramadol for a few years now. I take it when I need it. It works for me, and I’m in no danger of developing any addiction. I resent politicians trying to bar me from pain medication that works, for what appears to be a dubious benefit (in that Tramadol addiction is not a scourge to our nation, AFAIK).

    TheRightNurse (View Comment):
    It is best if you instruct people on pain levels. If it is low, don’t bother. If it’s enough to distract you, go low. If it’s enough to make you wince, distracts you, AND prevents you from doing activities, try something stronger. If you’re crying or vomiting from the pain, see a doctor, because whatever you’re doing isn’t working.

    This is pretty much what my rheumatologist told me.

    Hey,  I’m on the tramadol train with you.

    • #51
  22. Midget Faded Rattlesnake Contributor
    Midget Faded Rattlesnake
    @Midge

    Roderic Fabian (View Comment):
    I hope that people will not be using tramadol as an excuse to dismiss the entire SPACE trial and then go on using powerful opioids for chronic pain to their heart’s content. In all likelihood tramadol is a lot milder and less likely to cause death and disability than strong narcotics.

    I hope not, too. The SPACE study supports the belief that opioids should be used conservatively in chronic-pain management, and that many patients may be better off without chronic use of opioids of any kind. It just didn’t seem reasonable to me to elide “conservative use” with “no use”.

    It’s hard to find hard numbers for deaths from Tramadol abuse. The CDC is no help because they lump all synthetic opioids together, i.e., tramadol gets lumped with fentanyl, one of the strongest and deadliest narcotics we’ve ever seen on the street. Fentanyl abuse is definitely killing people in increasing numbers, and tramadol is not in that class.

    Wow, the CDC does that? Weird. Would not have guessed. Tramadol and fentanyl are both synthetic, but other than that, very different opioids, as you say.

     

    Roderic Fabian (View Comment):
    The number of people dying from prescription opioid abuse is increasingly exponentially. If doctors would stick to the “non-opioid” list of drugs provided by the SPACE trail to treat chronic pain I think it would go a long way to helping stop this horrible trend.

    There’s no such thing, really, as a “wonder drug”, but it would be easier to stick to SPACE’s “nonopioid” regimen if tramadol were still unscheduled. Schedule IV is one of the less-restrictive schedules, but still carries enough stigma to make tramadol seem like one of the “culprits” when it’s reasonable to question whether it really is.

    • #52
  23. Midget Faded Rattlesnake Contributor
    Midget Faded Rattlesnake
    @Midge

    Ontheleftcoast (View Comment):
    The odds are that if you are on long term opioids you have some degree of hyperalgesia. It will exacerbate the discomfort of withdrawal… as in a delayed dose.

    I got hyper-something-a through long-term Benadryl usage. Took me a while to figure out I was getting sick as a dog because I’d skipped the Benadryl. As a result, I won’t take Benadryl now for more than a day or two.

    I’ve notice hyperalgesia even after relatively short usage of hydrocodone-APAP, so I look at hydrocodone as a drug that shifts the pain around to a more-convenient time than something which simply takes pain away. Being able to shift pain to a more convenient time is a powerful tool for managing pain, actually, but it’s not the same as being in no pain.

    Prednisone is another drug where, even with a taper, people can pay for control of their problem by flare-up during withdrawal. If I didn’t know all the nasty things long-term prednisone does, I could see myself being a “prednisone junkie” – neither being doped up nor sick is a great feeling. But it’s powerful juju, and has to be treated with respect.

    • #53
  24. TheRightNurse Member
    TheRightNurse
    @TheRightNurse

    Midget Faded Rattlesnake (View Comment):
    If I didn’t know all the nasty things long-term prednisone does, I could see myself being a “prednisone junkie”

    I love steroids.  I love them so hard.

    So yes on this.  Very much.  Steroids make me feel human and like I can actually function.  That’s a great feeling.  Unfortunately, long term use is very bad, mmmkay.  Currently, I am not diagnosed with anything that would support taking it more than once in a blue moon.

     

    • #54
  25. Ontheleftcoast Inactive
    Ontheleftcoast
    @Ontheleftcoast

    Midget Faded Rattlesnake (View Comment):

    Ontheleftcoast (View Comment):
    The odds are that if you are on long term opioids you have some degree of hyperalgesia. It will exacerbate the discomfort of withdrawal… as in a delayed dose.

    I got hyper-something-a through long-term Benadryl usage. Took me a while to figure out I was getting sick as a dog because I’d skipped the Benadryl. As a result, I won’t take Benadryl now for more than a day or two.

     

    I’ve been leery of old skool antihistamines since the time as a kid that, having been given the stuff for hay fever, I rolled a stop sign (“ohhhhh that was a stop sign”) to cross a four lane street at rush hour which back then isn’t what it is now or I probably wouldn’t be here to write this.

    “Do not operate machinery…” a bicycle in traffic counts as machinery.

    • #55
  26. Ontheleftcoast Inactive
    Ontheleftcoast
    @Ontheleftcoast

    Rodin (View Comment):

    Ontheleftcoast (View Comment):

    Joe P (View Comment):
    Academics hate it.

    Then I guess I’m a free range academic, because I hate it too.

    “Grain fed”?

    Gluten free only. JK.

    • #56
  27. TheRightNurse Member
    TheRightNurse
    @TheRightNurse

    Ontheleftcoast (View Comment):

    Rodin (View Comment):

    Ontheleftcoast (View Comment):

    Joe P (View Comment):
    Academics hate it.

    Then I guess I’m a free range academic, because I hate it too.

    “Grain fed”?

    Gluten free only. JK.

    Also non-GMO.

    • #57
  28. danok1 Member
    danok1
    @danok1

    TheRightNurse (View Comment):

    Midget Faded Rattlesnake (View Comment):
    If I didn’t know all the nasty things long-term prednisone does, I could see myself being a “prednisone junkie”

    I love steroids. I love them so hard.

    So yes on this. Very much. Steroids make me feel human and like I can actually function. That’s a great feeling. Unfortunately, long term use is very bad, mmmkay. Currently, I am not diagnosed with anything that would support taking it more than once in a blue moon.

    Endorsed (unfortunately) 1,000 times. When I’m in a bad flare, prednisone works wonders. I’m back to normal. Actual normal, not “a new normal.”

    Well, except for the insomnia, ravenous appetite, weight gain, etc. Not to mention the long-term effects.

    • #58
  29. Cow Girl Thatcher
    Cow Girl
    @CowGirl

    TheRightNurse (View Comment):
    Most decent doctors really don’t care at the point of terminal cancer. Then, it’s whatever gives you relief. That’s where it gets stupid to restrict opiates. They’re dying anyway! Why torture them about addiction when they won’t be alive long enough to get addicted?

    This is so true…my mother was dying, and it really helped her to be able to just be doped up. And–exactly: if you’re not going to live past a month or two, who cares about addiction!

    I was prescribed Tramadol after a knee-replacement. It was great! But, because I wanted to heal as quickly as possible, I tried to only take it when I felt awful. I hope that this kerfuffle doesn’t result in Tramadol being restricted like hydrocodone has been. For a short term use, I loved Tramadol’s effects.

    • #59
  30. CarolJoy Coolidge
    CarolJoy
    @CarolJoy

    Metalheaddoc (View Comment):
    Did they subdivide the pain into specific types? Some kinds of pain related to inflammation (ie arthritis) will respond to NSAIDs. But what about neuropathic pain or disc pathology or torn meniscus? Different pathologies are gonna respond differently.

    Second problem is it flies in the face of reality. Opioids work for pain. They just flat out do. You can find/do a study that can prove anything if you want to. It’s like those studies that show that anabolic steroids “don’t work”. (Studies done by anti-doping authorities.) They just work and everybody knows it. Trying to prove that they don’t just calls into question the credibility and bias of the authors.

    Yep the opiates-derived drugs work fine for many types of pain. The “evil Inner me” has  little mental images of a terrorist with a sledge hammer smashing the vertebrae of some “expert” on  pain who tells the public that massage, exercise or physical therapy work just as well. Five hours dealing with the type of back  pain I experience sometimes  on a daily basis might make that expert change their mind.

    However the writing is clearly on the wall that our beloved government is gonna shut down opioid use. At least the authorities  plan on shutting down legal opioid use. (While we continue our military operation in none other than good ol’ Afghanistan, opium capital of the world. If you’ re a cynic, you know what I mean by this statement.)

    That legalized shut down is effectively giving them the “we must end America’s drug crisis!”  latest new round of “fact-based ammunition.”

    For over the past four years, it is increasingly difficult to go in and get a prescription for six months of hydrocodone. I used to do that every nine months or so – get 100 pills to last six months and make them last longer.  Now the most I can get is fifteen pills.   They are supposed to last me two months. (And they do – I rarely experience the type of back pain I used to consistently suffer due to no longer being a in the health field and not longer having to lift heavy patients.)

    But many people are now going in and getting the 15 hydrocodone every six weeks. So authorities are wringing their hands on nightly news shows saying, “The number of prescriptions offered to the public is five times higher than it was several years ago. We need to change everything dramatically because people ae more addicted than ever.”

    When in truth, due to the restrictions placed on doctors and patients, people are actually consuming hydrocodone less, but having to have hydrocodone prescriptions issued more often. Only that reasonable statement is not going to find its way to the evening news.

    • #60
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