Pain meds, helpful informationPosted by BrianG on 4/09/03 at 21:28 (115806)
Although this study was done for Neuropothy, I think it shows that slow release opiates will work (for pain) when nothing else is working. I believe the same is true for PF and TTS. After 42 days, none of the participents had any addiction, or tolerance, issues!!! I realize there is no magic bullet in curing PF, but I do believe this is a safe alternative, especially when surgery is the only recommended treatment. It will most likely allow the patient some time, especially if they do not feel that surgery is the right course for them.
Cut and pasted from Medscape.com
Controlled-Release Oxycodone Effective in Moderate-Severe Diabetic Neuropathy CME
News Author: Laurie Barclay, MD
Clinical Reviewer: Gary Vogin, MD
CME Editor: Bernard M. Sklar, MD, MS
Complete author affiliations and disclosures, and other CME information, are available at the end of this activity.
Release Date: March 31, 2003; Valid for credit through March 31, 2004
Physicians - up to 0.25 AMA PRA category 1 credit(s)
All other healthcare professionals completing continuing education credit for this activity will be issued a certificate of participation.
Participants should claim only the number of hours actually spent in completing the educational activity.
Canadian physicians please note:
Medscape's CME activities are eligible to be submitted for either Section 2 or Section 4 [when creating a personal learning project] in the Maintenance of Certification program of the Royal College of Physicians and Surgeons, Canada [RCPSC]. For details, go to http://www.mainport.org .
March 31, 2003 Controlled-release (CR) oxycodone was effective for the treatment of moderate to severe diabetic neuropathy, according to the results of a randomized, double-blind, controlled trial reported in the March 25 issue of Neurology. The editorialist reviews available treatments and suggests that opioids may be safer in some patients, which is similar to conclusions from a recent trial published in the New England Journal of Medicine and reported by Medscape. The latter study showed the benefit of opioids in nondiabetic neuropathic pain.
'Opioid treatment has played a limited role in the management of diabetic neuropathy, in part because of concerns about the responsiveness of neuropathic pain to opioid treatment,' write Joseph S. Gimbel, MD, from the Arizona Research Center, LLC, in Phoenix,and colleagues. 'Although controlled studies support the use of tricyclic antidepressants, selective serotonin reuptake inhibitors, anticonvulsants, and a number of other drugs, such as ion channel blockers and topical agents, therapy remains unsatisfactory for many patients. Opioids may be effective for pain in diabetic neuropathy; however, data are very limited, and findings must be extrapolated from experience with other types of neuropathic pain or from trials of related drugs.'
In this multicenter, parallel-group study, 159 subjects with moderate to severe pain from diabetic neuropathy received up to six weeks of treatment with either one 10-mg tablet of CR oxycodone (n = 82) or placebo (n = 77) every 12 hours. Doses could be increased every three days to a maximum of six tablets (60 mg CR oxycodone) every 12 hours.
In the intent-to-treat cohort, CR oxycodone provided more analgesia than placebo (P = .002) at an average dose of 37 ± 21 mg per day (range, 10-99 mg/d). From days 28 to 42, overall average daily pain intensity, rated from 0 (no pain) to 10 (pain as bad as you can imagine), was 4.1 ± 0.3 in the CR oxycodone group and 5.3 ± 0.3 in the placebo group.
Adverse events, which were mostly opioid-related in the CR oxycodone group, occurred in 80 (96%) of 82 patients given CR oxycodone and in 52 (68%) of 77 patients given placebo.
'Although opioid tolerance and physical dependence have been reported during chronic opioid therapy, neither phenomenon was demonstrated in this 42-day study,' the authors write.
'The efficacy of CR oxycodone for moderate to severe pain due to diabetic neuropathy suggests that opioid therapy should be included among the therapeutic approaches used for this disorder.' However, the authors recommend careful patient selection, regular monitoring, dose titration, and management of adverse effects to optimize long-term effectiveness.
Purdue Pharma L.P., the maker of oxycodone, supported this study and has financial arrangements with one of its hosting institutions.
In an accompanying editorial, Douglas W. Zochodne, MD, FRCPC, from the University of Calgary in Alberta, Canada, and Mitchell B. Max, MD, from the National Institutes of Health in Bethesda, Maryland, note that 'the findings reassure those physicians who resort to opioid therapy in neuropathy patients that opioid use is evidence-based.'
However, CR oxycodone was not dramatically better than tricyclics or gabapentin because it did not eliminate pain, and 30% to 40% of patients had dose-limiting gastrointestinal adverse effects or somnolence.
'Clearly, more effective treatments with fewer side effects are required,' they write.' Opioids may be safer to use in diabetic patients who have concurrent cardiac and renal disease.
Re: Pain meds, helpful informationKathy G on 4/10/03 at 08:40 (115835)
This is interesting, Brian. One thing that's new and a step in the right direction is the fact that doctors now don't write for Oxycodone on a PRN basis as used to be the norm. Now they realize that the pain killer must be taken on a regular basis so that it prevents the pain from starting and actually controls the pain. In the past, the idea was to wait until the patient was in pain and then to administer the drug. People would suffer pain needlessly. The trend now is to control the pain rather than let it get severe. It seems so much more logical.
Re: Pain meds, helpful informationSharon W on 4/10/03 at 11:44 (115849)
I think that, with many conditions, there is a need for BOTH scheduled and breakthrough pain meds. For someone who is expected to be in pain regularly, I agree wholeheartedly with Kathy's statement that 'pain killer must be taken on a regular basis so that it prevents the pain from starting and actually controls the pain'. But there often is a need for PRN meds, as well, so that the patient can 'rescue' herself if the pain breaks through in spite of the regularly scheduled meds... It gives the patient confidence that, IF NECESSARY, she can make the pain STOP, she doesn't just have to suffer helplessly until she can take another scheduled dose of her other meds -- and that goes a long way toward reducing a person's anxiety, their FEAR of pain.
Re: Pain meds, helpful informationNecee on 4/10/03 at 14:01 (115870)
I agree with what you are saying Kathy but have to wonder......if pain medications were taken on a regular basis, wouldn't our bodies eventually get use to the drug and no longer be effective in relieving pain?
My mom had that problem with her arthritis medication years ago. She had to switch around from one medicine to another because after a while the medicine was no longer working.
I use that method now myself, if I'm taking a particular kind of over the counter drug, I'll switch to something else when I find that it's no longer helping.
Any feedback is greatly appreciated.
Re: Pain meds, helpful informationKathy G on 4/10/03 at 19:13 (115907)
Well, from what I have read, it does truly depend on the individual. It doesn't seem to be attributable to how often the person takes the pain meds but is some intangible that leads to a pain medication no longer being effective. I understand, and believe me, I'm no expert, that eventually all pain meds will become less effective but that the length of time varies from person to person.
I know that my friends with arthritis who are on long-term pain management sometimes have to switch to another medication after a period of time. Luckily, there are many painkillers out there and they're developing new ones all the time so hopefully, they will always have another one to try if one stops working.
I don't know if switching OTC's will help or not. It makes sense. I believe with the OTC's the most important thing is to remember that if the recommended doseage is two tablets, then four tablets isn't going to be more effective. I don't mean that you would think that, Necee, but I am amazed at the number of people who will say, 'I had such a bad headache that I had to take 4 extra strength tylenol to get rid of it.' The fact is that those extra two tylenol didn't do anything for their headache but it sure put a strain on their liver. I used to work with a woman who would take 6 (yes six!) Excedrin, at the same time, for her sinus headaches. I can't imagine what they did to her stomach! She thought she was better off than if she took the Darvocet that her doctor had prescribed for her but in fact, she probably experienced longer, more severe pain taking the Excedrin, not to mention what other problems she was creating in her body.
Of course, she obviously had a very strong stomach and maybe she didn't do any harm to herself but over time, I have to believe she did.
Re: Pain meds, helpful informationKathy G on 4/11/03 at 13:50 (115957)
Oh, and I also remember reading that when one is suffering from a degenerative disease such as arthritis, they are more likely to need stronger doses or a different drug as their condition worsens. That might be what happened to your mother.
Re: Pain meds, helpful informationBrianG on 4/11/03 at 22:30 (115979)
I do agree that breakthrough pain meds do work, in the early treatment of chronic pain. After an undetermined amount of time, the breakthrough meds will no longer be effective. At this time the patient will have to begin a regular dosing of long acting narcotics. The purpose is to keep the pain under control, throughout the day, rather than taking a rescue dose here and there, trying to catch up to your pain, and relieve it for a short amount of time. The next day, it's the same problem all over again.
It's been proven that the best way to treat chronic pain, with narcotics, is to use a slow release drug, taken 2-3 times a day, depeding on how well it works for the patient.
This is something that more young doctors have to be trained in, while still in medical school. I find it's very hard to try to change an older doctors thoughts about using the 'evil' narcotics!! Almost every state has guidelines, which will protect the doctor, and the patient. That said, older doctors are going to have to realize that treating pain is just as important as treating the rest of the physical ailments!! If someone tries to con the doc, let the police and DA handle it, don't punish the majority of the patients who are crying out for pain relief.
I really don't know how a doctor can live with himself, after denying a patient pain control, which then results in the patients suicide. It happens, more than most people would care to believe!
Re: Pain meds, helpful informationSharon W on 4/12/03 at 10:43 (115993)
I don't think you understood my comments completely. I agree with you, and with Kathy, that it's better to keep pain under control with a pain killer taken on a regular basis 'rather than taking a rescue dose here and there, trying to catch up to your pain, and relieve it for a short amount of time'. I wasn't recommending so-called 'breakthrough' pain meds that would be taken every day, often more than once, AFTER the patient is feeling pain. Anyone who swallows prescription pain killers at least a couple of times every day shouldn't be taking Vicodin PRN, she should be taking a regularly scheduled med that's effective on a daily basis.
The regularly scheduled drug might well be something such as oxycontin or methadone, for a person who would otherwise be suffering from very serious pain. Or, as in my case, it might be something like Neurontin that targets a specific KIND of pain... The important thing is that, whatever they are, regularly scheduled pain meds should be strong enough that they control the patient's pain on a typical day.
But many painful conditions do involve the phenomenon of EXACERBATIONS, during which a spike of increased pain breaks through the control normally established by the other med. For those occasions, I do think it's appropriate that the patient has something else (legally and legitimately) available to use as a 'rescue' medication.
I also strongly agree with you, in theory, that treating pain is just as important as treating any other health problem, and that every doctor should prescribe them appropriately. It may take a while, however, before all MDs look at prescribing narcotic pain meds as something that's both safe and necessary for them to do. (In fact, I think tort reform may have to be part of that process.) But IF a doctor makes referrals to a pain management specialist whenever there's an ongoing need for narcotics to control a patient's pain, I doubt if patients would be committing suicide just to make the pain stop -- or if they did, it would be because the pain management specialist wasn't doing HIS job.
Re: Pain meds, helpful informationjohn h on 4/12/03 at 11:11 (115995)
I think rheumatoid arthritis is a good example of keeping pain under control and not just some med here and there. If you are in constant pain it needs to be dealt with as it can lead to depression,panic attacks. lowered immune level to other diseases. PF pain in my mind should be managed as well as the cause for the PF while trying to cure it.
Re: Pain meds, helpful informationBrianG on 4/12/03 at 12:45 (115998)
Unfortuatly it's the nature of the beast, that everyone becomes accustomed to pain meds sooner, or later. In most cases, the dosage can be increased guite a bit. The pain relieving properties will also work better as the dose is increased. At some point though, the side effects will outweigh the benefits of any of the pain meds. There are no upper lmits on dosage though, as it is diffrent for everyone.
For this type of oral dosage, I do think any doctor, with proper training, can prescribe for the patient. When the patient can no longer take oral meds, they can usually go to the next level, whch is an implanted pump. It pumps a small amount of highly concentrated pain medication directly into the patients spinal column. The beauty of the pumps is that a variety of meds can be used to fill the pump, which allows the pump to be customized for each patient. This is where a pain specialist is really needed.
When a patient goes from a high dose of oral meds, to the pump, the conversion rate has to be almost exact. If it's not, the patient can either experience withdrawal symptoms, or on the other end, could accidently overdose. When the conversion is done correctly, the patient will have very little discomfert, and should have even better pain control. I have read, on other forums, about chronic painers that have gone this route. It's not something they really looked forward to, but it undoubtly helped them to live a better quality of life!
Re: Pain meds, Wonder how others Feel about them???Tammie on 4/12/03 at 14:46 (116002)
I posted a bit ago on somthing similar. I would like to hear what others think about this now if you dont mind? First I will say I am under 3 Dr.s Care 2 are pain managemant one is a anesthesia and one is a comprehensive pain Dr. The other is my priamary who sortof keeps me all together!
The anesthesia takes care of all my meds, and only that. I am on thease
ELAVIL 100 MG 1 @ HS
DURAGESIC 25 FENTANTANL
OXYCONTIN 40MG 3X DAY
ToPOMAX 25 mg 3@HS
SYNTHROID 125MG 1daily
EFFEXOR XR 150 1Daily
AMITRIPTYLIN 100 MG 1@HS
Just this Fri. We are changing to reducing the patch and returning to the percocet as break thru as I just am not getting the reliefI should when I need it. Then I tend to sleep and not function by missing pills and eating or drinking And causing my body to react badly. So this chance is to help me So shall see.
But now I will be adding yet another med to my cocktail and I would give alot to be able to drive as I have honestly not drove more then 1 time since I am estimating about 9 months. And the sad thing is I didnt care I hurt to bad to go anywhere and then it became I dont trust myself with all of the meds. When and how do people know or understand when you are a chronic painer that it is ok to drive??? As to me pain meds can be similar to some effects as drinking and illigal drugs. Just curious what others think or know???