pain management for addicts

[fivestudent]

I am a 38 yr. old female. I suffer from multiple migraines per day and fibromyalgia and severe lower back pain. I deal with the pain without the use of narcotics or opiates because I have a history of addiction to these substances as I have had migraines all my life. A common relapse issue for me is around pain management. It's a complicated subject. I take a lot of advil and muscle relaxers which do not kill all of the pain and this often leaves me depressed about the quality of my life...being always in pain. But the alternative, being on drugs, is worse spiritually. It's a really tough one sometimes. The latest miracle drug I have found is Tramadol, which relieves pain like a narcotic but does not seem to trigger the addict stuff in me. I am having a hard time though keeping at the 400mg daily limit because of the severity of the pain. I will be going to Stanford soon and hopefully they can adjust it. Do you know any other medicines like Tramadol that are good for pain that are non narcotic?

[J T Junig, MD PhD]

Yes, chronic pain and addiction are a tough combination.  A couple things you should be aware of, though-- first, tramadol is an 'agonist' at opiate receptors, accounting for a portion of it's effects.  Tramadol also has serotonergic properties that contribute to the analgesia from the medication. In my practice I have met a number of addicts to tramadol;  I have had several tramadol addicts present after grand mal seizures, one that happened while the patient was driving, causing a severe car accident!  Seizures are quite common when tramadol is taken at levels over 400 mg per day, or when tramadol is combined with other serotonin drugs like the SSRI's (such as prozac or celexa).

The second thing to realize is that a very common cause of headaches is 'medication rebound';  the first thing to do when treating a headache patient is to stop the medications!  It takes weeks for the body to wash out the meds and recover from the effects of long-term use of medications-- even over the counter meds like ibuprofen or aspirin.  It is difficult to stop everything;  tramadol in particular has very uncomfortable withdrawal symptoms, including feeling like electricity is coursing through your nerves.  Withdrawal from most of the meds is unpleasant but not dangerous, except for valium or xanax-type medications, alcohol, or barbiturates-- all of which can have fatal withdrawal.

One thing to look into is Suboxone;  it is an opiate partial agonist that is being used more and more for chronic pain.  It is primarily used to treat opiate dependence, and it has potent opiate activity;  understand that it is a step down a road that you may not want to take.  I have a great deal of info about Suboxone at my blog, Suboxone Talk Zone, which you can find easy enough with a quick search.  

The other medications for migraines include topomax, depakote, propranolol, gabapentin, tegretol, verapamil... and many others.  For most of them, it is hit or miss.  But before trying anything else I would want to try getting you of everything-- how great it would be if the headaches went away... and they just might!

[dave42a]

I had a similar question for Dr. Junig and he referred me to the answers he previously posted. I think he is quite a guy and wish that he was in my local area.  I have been taking talwin nx for my headaches, which is a mixed agonist-antagonist drug with some different properties than other drugs. Apparently, it is an antagonist at the mu opiate receptor which is what most of the opiates are effective at and has its analgesic effect at the kappa opiate receptor which also provides analgesia in addition to some odd side effects sometimes, especially if you take the maximum dosages. they include hallucinations and delusions but I have found them very effective for my headaches up until very recently where they have become resistant to the drug for the most part. It might be worth a try instead of ultram and if you dont want to go with one of the mu agonist opiates which definitely, in my opinion, have a higher potential for dependence and ultimately, addiction. Talk to your health care provider and see what he thinks. You can always go back to ultram should you not get beneficial effects. Alternatively, perhaps suboxone would work well for you. any health care prescriber with a dea number can give you the talwin nx though and you need a dr who is credentialed to prescribe suboxone and I dont believe that NP's and PA's can prescribe it should one of those be your primary. good luck to you from a fellow h/a sufferer.