by Oscar London, MD
January 03, 2000
[This is a copy of an article by Oscar London, MD, medical humorist, appearing on Dr.Dean Edell's website.]
This may seem an odd New Year's resolution for a doctor to make, but I resolve that starting in 2000, besides initiating Nude Wednesdays, I will do my best to relieve pain and suffering.
Not that I don't try to already, but like so many doctors, I've been reluctant to prescribe high-dose narcotics for severe, chronic pain. This reluctance is out of fear of my being relieved of my medical license, at the expense of my patients being relieved of their pain.
Herpes Zoster (shingles) is one of the most painful conditions in medicine. A blistery, fiery eruption. Often, larger than standard doses of narcotics are needed for pain relief. But most of us stop short of prescribing higher than standard doses: Better to let our patients suffer shingles than to lose ours.
For slightly less painful maladies, better eight indomethacin tablets daily than six oxycodone. But indomethacin, a non-steroidal anti-inflammatory drug (NSAID), works only for mild to moderate pain. The NSAIDs boast a long and scary list of side effects involving the stomach, kidneys and platelets.
You see the smiling faces of satisfied "patients" on the TV ads for these prescribed, non-narcotic painkillers. Doctors see the scowling faces of real patients, who've tried these drugs, in the courtroom.
In 1998 the American Geriatric Society issued a policy for doctors strongly suggesting that, in the elderly, using opioids is much safer than using non-steroidal anti-inflammatory drugs.
For one thing, opioids (morphine, codeine, hydrocodone et al.) are among the very few drugs that cause NO end-organ damage, emphatically unlike the NSAIDS.
Addiction doesn't come from using narcotics for physical pain; it comes from using narcotics for psychic pain.
We are shamefully depriving our patients with great physical pain of the only thing that works - opioids.
Dr. James Cleary of the University of Wisconsin, a cancer-pain specialist, points out that less than 0.1% of people "treated in a proper medical setting with no history of previous abuse run into problems with addiction."
In addition, Dr. Cleary believes physicians have an obligation to treat non-cancer pain as diligently as we treat cancer pain. We have the greatest weapon against pain - the opioids - and we keep it under lock and key as if it were a tube of anthrax spores.
Those of my patients who've kept 12 paces ahead of the Grim Reaper by jogging themselves into old age often end up with horribly painful, osteoarthritic hips and knees.
In my opinion, too many old-timers get little relief from the politically correct but predictably toxic NSAIDS. Untutored by their doctors, they are fearful of opioids, and are rushed into life-threatening operations to replace knees and hips.
Post-operatively, their surgeons solemnly prescribe slightly inadequate doses of narcotics for too short a time. These patients might well defer their surgery for years, or even obviate it, by taking a proper dose of opioids PRE-operatively.
In 2000, I'm going to educate and medicate my arthritic patients accordingly.
People on long-term opioids, are not strung-out in opioid dens, but, rather, are fully alert and back on the golf course or the tennis court. They are blissfully happy, not because of fuzzyheaded addiction, but because their chronic pain is, if not totally gone, a lot better.
Dr. Cleary defines addiction as "loss of control over drug use." Another pain specialist, Dr. Harvey L. Rose of Carmichael, California, usefully defines addiction as "when you take a substance or participate in an activity that causes you harm; that harm can be financial, psychological, social, physical, or legal."
If you're in control of your drugs and your habits and they aren't harming you, then cautiously up the dose of the drug or the derring-do, if you must, and enjoy the relief they provide.
Dr. Rose believes, and I agree, that there's "more suffering from taking too little pain medication than from taking too much." The major harm from taking opioids on a long-term basis is constipation. And that's treatable and doesn't always happen.
Until recent years, Chronic Pain Clinics, often a suffering patient's last refuge, devoted all their energies to getting patients OFF narcotics. Nowadays, when appropriate, they humanely increase a patient's narcotic dose to a level adequate for pain relief.
These clinics still insist on first trying non-narcotics, such as Neurontin and Elavil, which work only fairly well in 25% of patients while stunning 100% of them with side effects.
Opioids work very well at least 95% of the time and cause no problem that one or two Senokot-S tablets each night can't handle.
For years my chronic pain patients drifted from one pain clinic to the other, like penitents crawling on their bare knees over cobblestones to famous shrines, miserably unhappy and in agonizing pain. Finally an enlightened use of narcotics has brought many of my pain patients solace.
For moderate to severe pain doctors often turn to combinations of opioids and acetaminophen such as Vicodin, Tylenol with Codeine and Percocet. These pills are of short duration, provide a potentially mind-numbing, euphoric rush and wear off quickly. Taking more than 12 of these combination pills a day for chronic pain, is often the death of the patient's kidneys (again, not from the narcotic, but from the acetaminophen.)
A recent long-acting formulation of opioids leaves out the contaminating acetaminophen and, being long acting, avoids the euphoric rush. These long actors often give 24 hours of marvelous pain relief (and constipation). Golfers can toss aside their canes and pick up their putters, confident they can finish 18 holes without having to rush to the bathroom.
One such long-acting opioid is called MS-Contin (the MS standing for morphine sulfate) and made $180,000,000 for its manufacturer the first year. A rival narcotic drug, just as effective, called Oxy-Contin then came out and made $240,000,000 the first year. Why? Because the prefix Oxy, standing for the potent narcotic, oxycodone, does not carry the stigma of the infamous morphine.
Doctors should know that their license will remain secure if they can document in the charts of patients on long-term narcotics that their pain and function have been notably improved.
The ability of doctors to heal and to harm has never been so aptly illustrated as in their power to prescribe or withhold narcotics.
[Reprinted under the Fair Use Doctrine for educational purposes only.]