Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, MD
19 September 2007

ONLY YOU CAN FEEL YOUR PAIN

            Pain is an incredibly complex topic.  From an evolutionary standpoint, pain sensors were necessary to warn the animals about potentially dangerous things around them.  Those sensors were present in lower animals such as dogs or mice or birds or even snakes.  By the time evolution had reached a dog’s level of development, the concept of emotional pain was also present.  Thus, we speak of both emotional pain and physical pain.  In humans, these two pains become mixed because we suffer emotional pain not only from external loss of another; we also suffer emotional pain in relation to what a physical pain might represent.  Thus an individual who comes to the clinic with an abdominal pain finds it tolerable and may not even want medication for relief when it is found that the pain does not represent a cancer. 

            Over the past 30 years, there has been an active crusade in medicine to better treat the pain felt by individuals.  This has been opposed by our legal authorities trying to prevent “elicit drug use”.  Unfortunately, our society has a substantial number of “drug addicts” who seek pain medications for reasons other than the relief of physical pain.  Our government feels that pain medications should be used only for physical pain.  Let me tell you.  This makes the healthcare provider’ job very difficult when trying to decide who should be prescribed “pain medications”.  The gentleman below illustrates some of these problems.

            The gentleman was 68-years-old and had moved to this area to be closer to family.  He and his wife had purchased a local condominium and came to the clinic for the first time to get prescriptions for his medications.  He needed a blood pressure pill and one for cholesterol and then stated that he needed his “pain pills”.  I inquired as to what his pain pills were and he said, “OxyContin 20 mg twice a day”.  He obviously knew just what he wanted.  His wife was with him and rolled her eyes when he made this request.  She obviously didn’t feel that he needed these pain pills.  The mood suddenly changed as he snapped off, “I am the only one that can feel my pain.”

            I next inquired about where his pain was located, what it was due to and how long he had been using OxyContin.  He said that his hips and his knees hurt so bad that he could barely walk.  He had been a farmer all his life, was substantially overweight, and undoubtedly had put a major stress on his joints over the years.  For reasons of his own, he had thus far not chosen to have prosthetic hips placed although there was certainly x-ray evidence to support this surgery.  He stated that he just wasn’t ready for an artificial hip yet.  He said that the OxyContin made his life tolerable and that he had tried many other products such as Tylenol, Darvon, Ultram, and every arthritis pill that he could get over the counter.  He had also tried multiple prescription arthritic medications to no avail. Thus, his former physician had tried short acting oxycodone which gave the gentleman significant relief.  This then graduated into the long term use of the long acting oxycodone product called OxyContin.  The dose he used was substantial but had not caused side effects.  Often narcotic products such as oxycodone cause severe constipation but he had overcome this by modifying his diet and using prunes to make things work.  After further discussion, I renewed his OxyContin prescription for a month.  Federal regulations state that this product can be obtained from the pharmacy only by a written prescription.  As a general practice, prescriptions are only given for a month at time, and the patient must make a return visit to the healthcare provider’s office monthly to renew the medication.

            Safe guards I used to prevent elicit drug use included checking with his former physician regarding the use of OxyContin.  The former physician sent a letter confirming the gentleman’s story.  I inquired as to whether there had been “acceleration” of the drug use and the former physician said there had not been.  I inquired as to whether or not more than one physician had been prescribing for him and the answer was ”no”.

            So I explained to the gentleman with the hip pain that I would prescribe his OxyContin provided I was the only prescriber, that he got it at only one pharmacy and that acceleration of the medication would not be tolerated.   Break these rules and my prescriptions would be voided.

            The reason such precautions are necessary has to do with the effectiveness of oxycodone as a pain reliever.  Just as heroin and morphine are used by drug addicts to obtain the “high”, oxycodone also has this property.  Oxycodone is ballyhooed in our media as “hillbilly high” because the elicit use of this drug apparently blossomed in Appalachia among teenagers years ago.  It is now a national problem.  But used in an appropriate medical situation such as the gentleman above, there is nothing wrong with oxycodone.   Its prescription for a humane medical reason is not to be discouraged.  But because of the social and legal implications of the use of this drug, many physicians will not prescribe it at all or only under the most stringent conditions.  This is unfortunate for those who feel “their pain”. 

            In regard to pain medications, they can be graded.  Tylenol (acetaminophen) seems to work for some individuals very well.  Large controlled studies have found that on average Tylenol is not very effective.  In my opinion this is because some individuals respond to the drug not at all and others respond very favorably.  When you average them all together, the group effect seems minor but the individual effect can be very helpful.  Aspirin would qualify as a similar product but has more side effects including the tendency to cause gastric irritation, high blood pressure and salt retention. Aspirin has the advantage at low dose of 325 mg daily of being protective against heart attack and stroke.  But the 325 mg tablet has relatively little pain relief and it usually takes more,  more often to get effective pain relief.  There are multiple other “arthritis” medicines including Motrin, (ibuprofen), Orudis (ketoprofen) and Aleve (naprosyn).  These products can all be helpful for arthritic pain. 

            Next on the hierarchy of pain medications would come Darvon (propoxyphene) and Ultram (tramadol).  These are prescription medications and on a scale of 10, would be awarded a grade 3-5. 

            Next come the narcotic medications of which codeine is probably the weakest.  Hydromorphone would be in this same class.  Both of these products tend to make individuals nauseous especially women for some reason.  Codeine and hydromorphone would qualify as 6-8 on a scale of 10 level pain relievers.

            Finally, the big guns include morphine and oxycodone.  These are highly controlled narcotics used for individuals with severe injuries, postoperatively, cancer relief or severe chronic pain such as the arthritic gentleman above.

            The healthcare providers at your local clinics are well aware of the considerations regarding prescription of pain medications and various tricks that can be used to alleviate pain.  For instance, the use of Motrin with a narcotic can be very effective for cancer pain but the use of Darvon or Ultram with a narcotic is counterproductive; it can be thought of as kids getting in the way of a man trying to work.  Darvon and Ultram are relatively weak pain relievers but attach to the same receptor that morphine does.  Thus, if Ultram is attached to the receptor, morphine can’t get there and morphine would be much more effective. 

            Healthcare providers are taught that only the individual can feel the pain and part of our training is to try to gauge what the person is feeling.  That is not easy!

This and other columns available at www.macpierre.com.