Drug Juggling with Chronic Pain

"The person who takes medicine must recover twice. once from the disease and once from the medicine." William Osler, M. D.

One of the biggest issues with chronic pain is pain management and the complications that arise from taking medications to counteract that pain. Addiction to narcotics can become a big problem, but it's not the only danger patients face when dealing with long-term use of pain relievers. Not by a long shot.

Whatever drug you take, there are physical or mental sensations that come along with their use. In many cases there is a rush that patients experience, identical to the rush experienced by those using illicit drugs such as heroin or cocaine. In fact, because many strong pain relievers are opiates - derived from opium, or synthetically engineered to behave like opium - their similarity to street drugs is quite strong. Heroin is derived from opium, but so is morphine. Heroin is actually morphine diacetate, and is only called heroin in its illegal form. It's not exactly the same as morphine, but it metabolizes and becomes morphine within the body.

Narcotics aren't the only available pain relievers, and they aren't the only ones that can become addictive, either physically or psychologically. Anything that alters the way you feel, either mentally or physically, can become addictive. Not just because you get high from it, but because you become accustomed to the sensations generated by the drug. When you no longer feel those sensations, you can become anxious, or any other number of feelings that relate to withdrawal.

Other pain relievers can be things like anti-inflammatories. NSAIDs, or non-steroidal anti-inflammatories, are commonly prescribed to anyone with no history of intestinal issues. That doesn't mean you won't develop intestinal issues from taking them. It's a very real danger of NSAIDs. Ulcers, intestinal bleeding, and other complaints are notoriously common with this type of pain reliever. Some pills are part stomach buffer for this reason, but even the stomach buffers have been known to cause intestinal issues.

Acetaminophen, commonly marketed under the Tylenol brand, has its own set of problem. The biggest downfall is liver damage. Not everyone is impacted, but if you have to take handfuls of pain relievers, and acetaminophen is your drug of choice, you may find yourself experiencing some of the symptoms of liver damage. It's called hepatoxicity, and is a form of hepatitis brought on by the use of medication.

"Drug-induced liver injury is responsible for 5% of all hospital admissions and 50% of all acute liver failures." Wikipedia

Strangely, one of the symptoms of liver damage is low blood sugar, and it's not something that most patients are aware of. Your age can increase the damage done by acetaminophen, and if you're malnourished or dieting you're also much more susceptible to acetaminophen-induced liver damage. Additional symptoms of liver damage include the following:

• fatigue
• weakness
• abdominal pain
• loss of appetite
• jaundice (yellowing of the skin)
• itching
• susceptibility to bruising
• edema (swelling) often in the legs
• mental confusion or coma
• kidney failure
• vulnerability to bacterial infections
• gastrointestinal bleeding

Another type of drug used for chronic pain, depending on the type of pain the patient is experiencing, is something called a neuropathic pain reliever. They're actually given post-operatively as well, because they reduce the need for narcotic pain relievers. Gabapentin (marketed as Neurontin), and Pregabalin (marketed as Lyrica), are two of the more common drugs prescribed for neuropathic pain. Both drugs were initially developed for seizures and epilepsy, but it was later found that they could be used to treat pain in a certain number of patients. They don't work for all types of pain, and they're only effective for a portion of the population for some reason. The benefit to these drugs is that they are non-narcotic and have fewer side-effects than many other pain-relief medications. However, both drugs have issues with withdrawal and neither should be discontinued abruptly.

It would be impossible to list all available drugs used for pain relief, as the gamut ranges from aspirin to OxyContin and morphine. Some are extremely dangerous, and some are also extremely addictive. A small mistake can be responsible for a patient ending up either in the hospital, or dead. Taking pain relievers with anything other than water can be disastrous, unless it's recommended they be taken with milk to slow absorption even further. Taking medications with grapefruit juice has caused a number of fatalities, mostly in the elderly population. It's not the citric acid or flavonoids in the juice (despite information released in earlier reports) that causes the problem, it is organic compounds that are furanocoumarin derivatives, which increase blood concentrations of the drug. The problem is actually called 'The Grapefruit Juice Effect' and as last reported at least 85 drugs are susceptible to this effect.

Chronic pain has to be treated differently than acute pain. Acute pain is generally short-term, and it's much safer to give strong pain-relievers to someone over the short term, than it is to give them over many weeks, months, or even years, of a patient's life. All medications have an impact on the human body, or there would be no point in taking them, and that impact is only increased over time. Our tolerance to a drug may increase, but that does not mean the long-term effects aren't just as dangerous.

One approach is to juggle different drugs at different times, to lessen the impact of long-term usage. For example, you might take a narcotic for a few weeks, but then switch to a less addicting drug such as regular acetaminophen. Your pain level will likely increase, but you're aware it's a temporary thing until it's relatively safe to go on something more effective. Maybe you're put on Tylenol 3s, which contain codeine (another opioid, but far weaker than morphine). After a while the Tylenol can become a danger to you, so your doctor may try a neuropathic pain reliever. And so on...

This approach is only going to be necessary for those who are on very long-term medications, but since that does happen it's worth taking a look at. In my own case, I've faced all of these potential issues. I've been on one form of pain-reliever or another for the last several years. I've experienced a trip to the hospital from hepatoxicity, as well as a massive drop in blood sugar from another incident with liver damage. After being on certain medications for a while, I start to feel like I'm being poisoned, which is quite likely exactly what's going on. I have a sensitivity to narcotics which makes me nauseous, and means that I have to take Gravol (dimenhydrinate), also known as Dramamine in the United States. The pain medications that have been prescribed for me include morphine, Percocet, OxyContin, Tylenol 3s, and Gabapentin, though not usually in combination. At one point, after surgery, I was given morphine and OxyContin together, along with an antiemetic for nausea. It's not surprising that I have first-hand knowledge of the difficulties faced by anyone who requires long-term pain management.

It's not uncommon for patients to become rather expert on the various medications available for pain. They start mixing and matching, trying to find the most effective solution. You absolutely must talk to your pharmacist about contraindications, however - otherwise known as drug interactions. Some medications should never be taken with other types of medicine. Some will cause severe psychosis, some will cause death. Your pharmacist is your best friend if you need to take any pills whatsoever. They know far more than your doctor will ever know about the medications that are being prescribed for you. A good pharmacist will not only know about prescription drugs, they will also know about the over-the-counter (or OTC) drugs. A great pharmacist, however, will understand the interactions with herbal medications and supplements as well. Do yourself a favour and look for one of those. Find a pharmacist who is concerned enough to take an interest in your medical care. Not only can they help after you've been given a prescription, but they can also make recommendations that you can discuss with your doctor. It might just be the medication you've been searching for that will give you the right balance of pain-relief with as few side-effects as possible.

Don't forget to be vigilant about what is going on in your body. Pay attention to symptoms and make sure you tell your doctor and pharmacist what's happening. You're the only one who knows what's going on there. Your doctor can't feel your pain or symptoms. Above all, be honest with yourself. If there's even the smallest part of you that thinks you're addicted to your medications, do something about it. Have your doctor wean you off the medication and put you on something else. Many patients know they're addicted to their pain medications, but they've given up on kicking the habit simply because they still need pain relief. Don't fall into that trap. There are usually other options for pain relief, but you're only going to know about them if you go looking for answers.

"We are prone to thinking of drug abuse in terms of the male population and illicit drugs such as heroin, cocaine, and marijuana. It may surprise you to learn that a greater problem exists with millions of women dependent on legal prescription drugs."  Robert Mendelsohn, M. D.

How Medications Can Destroy Your Marriage

One of many things a doctor will probably never bother to explain to you are the side-effects from your prescription medications. Not only will they not bother to tell you there might be side-effects, but they won't tell you that some of those side-effects are going to have an impact on your relationships. Part of the reason doctors don't explain these things to their patients, is because they never bothered to learn about it themselves. They blithely accept the pretty brochures handed out by pharmaceutical sales reps, and don't take the time to look into it a little more deeply.

For one thing, they haven't really got the time these days. Doctors are bogged down with paperwork of every kind, making phone calls they didn't have to make twenty years ago, or being forced to see a patient in order to get paid when before they could just handle the issue over the phone. Another reason doctors don't read the full literature or investigate the drugs is because it's not exactly their job to do so. The majority of people look to doctors as their sole healthcare provider, when the reality is that they are only a portion of the system. Doctors should know what the drug is supposed to be prescribed for, certainly, but the real responsibility falls on the shoulders of your pharmacist.

Pharmacists (or chemists or druggists as they're known in other countries), are widely discounted as a minor cog, when they're really one of the biggest pieces of the medical machine. They study nothing but drugs, chemistry, interactions and anything related to pharmacology, and they study those things for years. Doctors study anatomy and the mechanics of diseases. A portion of their study goes to pharmacology, but very little of it in comparison with a pharmacist.

You're probably wondering how this relates to your marriage, partnership or other relationships. Well, here it is. Drugs can cause massive reactions in people. They're supposed to affect your body, because there's no point in taking them if they don't, and when you affect one part of the body you're going to affect others. Every part of you is connected to something else, and in the end every part is connected to everything else in your body. If you take pain relievers for an ankle injury, your body distributes that pain reliever everywhere. It has no idea that it's meant only for your ankle. Some pain relievers work a different way, focusing on the pain centers of your brain, basically allowing it to tune out your pain.

As much of a bad rap as pain relievers get because of their tendency to give people a high, there are many drugs out there that have a much more dangerous impact. There are two families of drugs that are notoriously bad for this - anti-depressants and benzodiazapenes. Anti-depressants are designed specifically to mess around with your brain chemistry, because they're suppose to try to re-balance an imbalance there. Brains are a very dangerous area to play in. After all, our brains are like a central computer system. They control every single aspect of our living bodies. Complete inactivity in the brain means you don't breathe and your heart doesn't beat. The brain sends out electrical signals to make sure those things get done.

Benzodiazapenes are given for their sedative effects for a variety of issues, from insomnia to anxiety. They can have paradoxical effects, however, meaning they can cause aggression and disinhibition. In other words, you might not only be ticked off for no reason, but also lack the inhibitions that would stop you from acting upon your angry urges.

A third type of drug that isn't given a great deal of notice by the medical community is steroids. This has nothing to do with the anabolic steroids taken by body builders, though a similar effect can be achieved. Drugs like prednisone fall under this category. It's a corticosteroid, and despite being considered safe for general use it's really not a drug to mess around with. For one thing it has a pretty big impact on your organs. For another, and this one is important, it will spike your blood sugar and can potentially lead to an unwanted diagnosis of diabetes. High blood sugar has a big effect on mood all by itself, but prednisone has another dangerous level to it. Two of its major side-effects are mania and psychosis. Anabolic steroid user will occasionally exhibit something called 'roid rage, in which they lose all semblance of self-control and passivity. The manic and psychotic side-effects experienced by those on prednisone are remarkably similar.

In legal circles there is something called 'The Prozac Defense' which is when a lawyer defends his client by showing they were on anti-depressant medication at the time they committed the acts they were charged with. Now, as difficult as that might be to swallow, there is a very big element of truth to this defense. There have been many cases where those who have been medicated with certain kinds of drugs have gone off the rails, and a large portion of gun-toting, mass-murderers have been shown to have legally-prescribed, pharmaceutical drugs in their systems at the time they went on their bloody rampages.

So, try to imagine living with someone who is on any one of these drugs. Not everyone experiences these side-effects, of course, but it happens often enough that people need to be aware of it and watch for signs that someone might be out of control. Before you even take your first dose of a new medication make sure you discuss side-effects with your pharmacist, and then make sure you read the entire information sheet that comes with the drug. Even better, check out the drug online. New information becomes available all the time. Once the drug is being taken, watch yourself or your partner for signs of these side-effects. Be aware of them before they're severe enough to be dangerous.

Under certain circumstances a person will not be able to stop taking their medication - either right away or at all. Some medications can't be stopped suddenly because of the dangers of sudden withdrawal. Some can't be stopped at all because they're vital to the patient. Occasionally the side-effects and their risks have to be weighed against the benefits the drugs provide. Maybe it doesn't seem like a big deal at first, and you and your partner feel you can get through it. Sometimes the side-effects ease up after the patient becomes accustomed to the drug being in their system, but then other times they just get worse.

The fact is, marriage is difficult all by itself. When you add the potential for mania, anger, psychosis, sleeplessness, disinhibition, dissociative behaviour, and any other number of possibilities, the toll it will take on your relationship will be unbelievable. If you're aware of it beforehand you might be able to fight your way through it. If you're not, however, and something like this catches you off-guard, you're probably going to assume that the person is just being a jerk for no reason. Suddenly they're screaming at you, or calling you names, which is behaviour that gets old very quickly. As much as we might want to make marriage work, there is only so much strain a relationship can take. Particularly if we don't know that there may be a medical reason for it.

What it all comes down to is knowledge and preparation. If you arm yourself with knowledge every time a new drug enters your life or your body, you're less likely to misinterpret the reason for your sudden problems. Learn, watch, and be ready to take action if something seems off.