TRYING TO GET OFF PAIN MEDS
Modalities such as acupuncture and mindfulness meditation can be extremely useful in easing the process of discontinuing opiate pain medications such as hydrocodone. Contrary to what many people assume, discontinuing hydrocodone can result in better overall pain control, improved quality of life, as well as avoidance of the serious side effects associated with this drug.
New DEA regulations go into effect
If you or someone you love uses hydrocodone to manage chronic pain, you are probably aware that as of October 6, 2014 all hydrocodone products are now listed as Schedule II Controlled substances. This means that prescriptions can no longer have refills and a handwritten triplicate paper script must be obtained from a physician for each fill.
New policy a burden on patients
This may seem like a minor change but it is not. Whereas before this policy change many patients were prescribed hydrocodone-containing medications by their primary care physicians and were seen once a year for follow up, this new policy will mean that they will have to be seen for an office visit every three months and that every month they will have to call the physician’s office, request a new triplicate prescription be written, drive to the physician’s office, pick the paper prescription up, and then drop jt off at the pharmacy. Many physicians are also requiring patients to sign pain management contracts and schedule office visits every three months for monitoring. This means a lot more hassle and expense than most patients are accustomed to.
New policy a burden on physician’s offices
The new policy also imposes a significant burden on physician offices. Whereas before they could fax a single prescription with multiple refills every few months, now they have to track patients much more closely with monthly handwritten prescriptions and office visits every three months. As a result, many primary care physicians are referring chronic pain patients to specialists — pain management specialists, orthopedists, neurologists, and neurosurgeons. Some primary care doctors are encouraging patients to discontinue these medications altogether.
Is this change good or bad?
I have mixed feelings about this change. Even under the previous rules, chronic pain patients taking hydrocodone were commonly treated by pharmacies and medical providers with suspicion and an attitude of “guilty until proven innocent”. Even patients who handle their prescriptions responsibly, have been on a steady dose of hydrocodone for years, and have shown no evidence whatsoever of addiction are often treated as suspected junkies. This dynamic causes many chronic pain patients a sense of shame that, for the vast majority of patients, is unwarranted. The new rules will reinforce this dynamic further.
On the other hand, on numerous occasions I have seen chronic pain patients experience LESS pain when they are off hydrocodone than when they are on it. If this new rule prompts patients to consider seeking to discontinue opiate pain medications, I think that many of them will find improvement in both their level of pain and relief from side effects associated with opiates (such as constipation, sleepiness, hormonal disruption, and the potential for liver damage associated with acetaminophen). This could be a REALLY good thing.
But my pain is really bad — how could I possibly feel better without my medication?
Many chronic pain patients become convinced that they cannot function without their pain medication when they notice that their pain becomes quite severe as each dose wears off. In most cases, hydrocodone prescriptions are written to be taken every six hours. So say that a person gets out of bed at 7:00 am and takes their first dose of the day immediately. They are due to take another dose at 1:00 pm, but by around 11:00 or 11:30 am they are noticing that their pain is creeping back. By 12:30 pm they are looking at their watch to find out how much longer till they can take their next pill because they are really hurting. This phenomena repeats itself several times throughout the day, day after day, week after week, eventually convincing the patient that life without their medication would be unbearable.
The problem, however, is that hydrocodone is a relatively short-acting analgesic (pain reliever). Its therapeutic effect peaks at about 45 minutes then wanes significantly by about four hours. This means that, for many people, hours five and six are marked by increasing pain. In most cases patients assume that this increasing pain is their underlying pain coming back, while in reality what they are experiencing is the beginning stages of withdrawal from a drug upon which their body has become physically dependent.
If the medication is slowly discontinued, eventually the pain caused by fluctuating levels of medication in a person’s system goes away and in many cases patients find that they are able to manage their pain in other ways and that overall they have less pain without hydrocodone.
Even if you are not addicted, stopping hydrocodone can be tough
But the process of getting off hydrocodone can be rough. Even in patients who eventually experience dramatic improvement in their wellbeing once they have stopped hydrocodone, weaning off the medication can involve several weeks of increased pain, trouble sleeping, edginess, anxiety, and digestive disturbance. This is because, when a person has been taking hydrocodone for longer than a few weeks, the body forms a physical dependence on the drug. It is important to note that dependence is NOT the same thing as addiction and that many non-addictive drugs such as corticosteroids, antidepressants, and blood pressure medications also result in physical dependence and discomfort when the drug is withdrawn.
Physical dependence simply means that the body has adapted to a regular supply of the medication. As part of the adaptation that takes place when a patient is taking opiate medication on an ongoing basis, cells develop fewer receptors that bind to opiates. (Receptors are like locks and molecules of opiate medications are like keys.) When the supply of opiates is reduced or discontinued, there are fewer receptors available to bind to the body’s own opiates (endorphins) and symptoms of withdrawal (including increased pain) occur.
Eventually, however, the number of opiate receptors will return to normal and withdrawal symptoms will subside. How long this takes depends on how much hydrocodone a person was taking and for what period of time, as well as how quickly the dose of the drug is tapered. For most patients the acute phase of withdrawal is over within 1-2 weeks, although more mild symptoms (including difficulty sleeping and depression) may persist for longer than that.
Acupuncture and meditation can ease withdrawal and manage pain
As described in the article below, modalities such as acupuncture and mindfulness meditation can be extremely useful in easing the process of discontinuing medications such as hydrocodone. As described in the article, recently the VA Medical Center in Charleston, SC has used these modalities to assist over 400 patients in discontinuing narcotic pain medications.
These same modalities can also offer effective management of the pain that remains once the withdrawal process is over. In fact, in my clinical experience, patients who discontinue narcotic pain medications experience dramatically greater benefit from natural methods such as acupuncture after they stop their medication than they did before.
Consult your physician for advice
Although this article describes what I have observed in several dozen patients in my practice, every patient’s case is different. Please consult the physician who prescribed your pain medication to find out how to go about discontinuing it. Depending on your original dose and other factors, this may be a process that requires medical supervision.
By Tom Cramer, VA Staff WriterMonday, November 17, 2014Steve Jobs, the late co-founder of Apple Inc., once made the following observation: “Less is more and usually more effective.”
Increasingly, the Department of Veterans Affairs (VA) appears to be taking the same view when it comes to dispensing pain medications. At the Ralph H. Johnson VA Medical Center in Charleston, for example, a little less than three percent of the total patient population is on chronic opioid therapy. That’s five percent below the national percentage for patients receiving such drugs.
An opioid is a drug such as morphine or oxycodone. They ease pain, but they can also cause physical dependency.
The Right Reason
“Opioids have been around for 3,000 years,” said Dr. Robert Friedman, head of the medical center’s Pain Management Team. “They’ve been around that long for a reason. They work. But it’s important that we find the right dose, for the right patient, for the right reason. And that’s what our Pain Management Team here in Charleston does.
“We spend a lot of time learning about the patient,” he continued. “Because the fact is, there are a lot of Veterans who’ve been on opioid therapy for a long time who would do just as well, if not better, without opioids — or on a reduced dosage.”
During the last five years, Charleston’s Pain Management Team has helped more than 400 Veterans ease off their pain medications. “A big part of our success,” Friedman observed, “is getting patients involved in their own care, educating them about pain management and supporting them as they try alternative methods for dealing with chronic pain. “There’s nothing magical about what we’re doing,” he added. “All we’re doing is taking the time to talk with our patients and learn about them.”
Twinkies and Milkshakes
The pain specialist said his team takes a holistic approach to treating each patient. “Pain changes your brain,” he observed. “It captures territory associated with mood, emotional regulation and problem-solving. So we don’t just ask the patient how much pain they’re in. “We also ask them things like: ‘How are you sleeping? How is your mood? What is the quality of your life? How are you getting along with people around you? How much are you exercising? What are you eating? ‘What are you eating?’ That’s right. Diet and pain are interconnected. “Let’s face it,” Friedman said. “You’re not going to get rid of your pain by eating Twinkies and drinking milkshakes. You are what you eat.” An Army Veteran, Friedman said he attacks his patients’ pain the same way he would attack an enemy on the battlefield with a team of highly trained professionals.
“We use an interdisciplinary team approach to pain management,” he explained. “This team includes the Veteran, doctors, nurse practitioners, pharmacists and mental health professionals, all working together. We establish a personalized health plan with each Veteran to minimize their use of chronic opioids, reduce their pain levels through alternative methods and improve their quality of life.”
So if you’re in chronic pain and they’re easing you off opioids, what’s Plan B? (It better be good.) Friedman said his team’s holistic approach to pain management involves various complimentary treatments and alternative therapies. “We use multiple tactics to take back your brain from the pain,” he said. “If we can, we prefer to use things like mindfulness meditation, yoga, herbals, fish oil, aromatherapy and acupuncture for Veteran patients living with chronic pain.”
“When Dr. Friedman puts those four needles in the top of my head, all the pain from my waist down is totally non-existent,” said 51-year-old Navy Veteran Steve Pulliam. “I can walk with no pain. It all goes away. It’s amazing.” Pulliam had been under the care of Friedman’s Pain Management Team due to a crushing injury to his right foot and an impact injury to his left knee — both sustained in separate incidents during his time in the Navy. Then came the cancer diagnosis in August 2013. “They told me I had a large mass on my pancreas,” Pulliam said. “We tried some chemotherapy to shrink it, but it ended up spreading anyway. So we opted to discontinue chemo so I could have some quality of life with the time I have left. They tell me I have anywhere from six to 18 months.”
The Sound of the Ocean
Pulliam said he looks forward to his weekly visits to the Charleston VA’s Pain Management Team. “These treatments they’re giving me are making a huge difference in the quality of my life that’s not attainable by any other means,” he said. “It gives you a sense of well-being and eases your mental and physical tensions. It’s amazing when they put the needles in … the gastrointestinal pain goes away, the orthopedic pain goes away.” But acupuncture is just one of many tools in the Pain Team’s toolbox.
“They use body oils … lavender and rosemary,” Pulliam said. “They put that on your stomach. After a few minutes you can actually taste it. After a few more minutes, you start to feel the effects. The lavender calms the [discomfort] in your gut and the rosemary helps with your overall calmness. They also have soft music playing in the background, or something relaxing like the sound of rain falling, or the sound of the ocean. “I know it all sounds like a bunch of mumbo-jumbo,” he added. “But it works. I’m proof of that.”
Then there’s the heat lamp. “They use an infrared lamp to heat up certain parts of my thoracic area,” said the Navy Veteran. “The heat penetrates your skin and reaches the organs inside, warming them up. So you’ve got the heat, the needles and the oils, all working together. You feel like you’re on vacation in the islands, lying on the beach, soaking in the sun. You’re not feeling the pain, so you’re not thinking about it. It puts you square in the middle of calmness. All your stress, all your worries go away. You’re free.”
But how long does the vacation in the islands last? The pain stays away for about a day-and-a-half, on average, Pulliam reported. “If you can take away the hurt for just a little while, it makes all the difference in the world,” he said. “It gives you more strength, more power more endurance to keep going. It resets your hope meter.”
To learn more about pain management at the VA, click here.