Pain management, and how it is suppose to work.

[MyTau]

I've read a lot of pain management forums, and like you I'm on pain meds for all the pain from my illnesses and old injuries. Like most I went from years of NSAIDS until finally my stomachs was pretty trashed and I ended up with GERDS, and one of my valves that is supposed to close when I swallow doesn't always and I end up with food in my lungs. It is very painful to have a violent coughing attack to get the food out. Anyway I finally have Dr's that treat me pain with opiates. At first I was on Oxycontin, but after I got fired because I couldn't do my job, because of the pain of lupus and back problems, so I could not afford it anymore. I was offered Methadone, and I was of course weary because it has a stigma attached to it, and that it is only heroin addicts that use it, but after getting over it, it turns out to work even better then the Oxy. Ok, not to the point of this post, different types of medicine has a different way of working; as you know. NSAIDs work at the place of pain, working on the inflammation, same with Tylenol, but they are not good for long term use on your liver and stomach. Now opiates work on your brain, it is meant to cause euphoria to make you not care about the pain, that is how it works, but because of the taboo, Dr's and patience are reluctant to talk about that. Why? I mean I read all the time about "it doesn't make me high, or euphoric", but if it is not it isn't working right, yes there is tolerance, and when the euphoric stops it works less. Also the sleepiness and drowsiness all are made to make you not think about the pain. It's so taboo that we are conditioned to think that if we are feeling euphoric then we are addicts and that just isn't true. I've talked to many people about this, but they usually only want to talk about it privately as if it is a bad thing. I mean that is the way opiates work. Now with the methadone the euphoric is much less, but it is more stable, imo, and the tolerance goes up more slowly.

I'm curious to read others opinion on this, and if you don't think that is the reason the pain meds work then how do you believe they work? CNS, central nervous system, the meds affects the brain so you don't think about the pain, as much as I have read into this subject I have yet to read any other way they work. I think that is one of the reason so many still feel pain, the DEA, the Dr's reluctance to talk about how opiates work and our way of thinking is so "brain washed" for lack of a better term. We shouldn't fear, or feel guilty about the medicine that helps make us get through the day. I hope to hear your POV!

[MyTau]

Looks like we are both right, I googled how opiates work, (don't know why I didn't before)

"Narcotics work at opioid receptors, where they interfere and stop the transmission of pain messages to the brain.  They also alter one’s psychological reaction to pain.  Patients sometimes report still being aware of pain, but not having such an aversion to the feeling"

I wish Dr's would teach patients more on how they work, an other thing I didn't know was that while on pain medications, our perception to pain changes and we will hurt even more because our bodies are no longer producing our natural pain endorphins. I'm glad I brought this topic up, you can never learn too much. I also realized I was talking to the wrong people, my old Dr included; she said that it is the euphoria is the way the medicines work the most. Of course I later learned the she got some great benefits for prescribing a certain medication (Oxycontin) to patients, one of them being free golf. I'm glad I don't have her anymore, then I got a Dr that was almost the complete opposite, she is the one that reduced my pain meds by 2/3rds. Now  I have one that seems to be in the middle, which is what I need.

[MyTau]

My meds are not where near tos high, as a matter of fact I am on half the amount I used to be having learned to deal with the fact that all my pain isn't going away, but I also feel at times under medicated. Also I'm not talking about high as in what addicts try to obtain, but a sense of well being, and that is a part of what an opiate does. Of course this is why addicts faiI you can't keep up the kind of euphoria they are looking for. I may have to do some more reading about the agnostic part you are talking about, it could be I have been mislead to some extent. I do use other means to help reduce my pain, hot baths, message, and sometimes advil to help with the inflammation.

[OtisDaMan]

Each pain medication has its own way of affecting either the direct signalling of pain, the modulation of the signal, the inhibition feedback via descending neural paths, or on the attentional mechanisms of the brain. In simple terms, the nervous system and brain are one heck of a complicated system with many points at which a pain medication may interfere, creating the analgesia one way or another.

Then there is the added complication of metabolism of the pain medication. In my case I seem to be slow responding to doloxene (about 2 hours) and when I used to use it, the way in which I noticed its effect is that it would twig that I was able to concentrate a bit better on whatever I was doing because I was no longer in great pain. Codeine is another one that takes about 2 hours to start working on me and that is only at higher doses (eg panadeine forte) or at normal doses spread throughout the day. The connection between doloxene and codeine is that both require enzymatic metabolism in the liver; the gene responsible goes by the name of CYP450 2D6. If your variant of this gene is deficient, then your liver may not be able to efficiently metabolise doloxene and codeine. OTOH if you have multiple copies of the gene - which is known among those of arabic background - then even a single panadeine may be fatal. Other medications, such as effexor, may inhibit this gene as well, which renders doloxene and codeine useless or at least less effective.

Ibuprofen and acetaminophen (aka nurofen and paracetamol) act in a very different manner to the opioids. For example, acetaminophen affects prostaglandin (a hormone-like chemical) to achieve its effect. Acetaminophen inhibits prostaglandin biosynthesis in the central nervous system.

Bottom line: euphoria may indicate that a medication is having an effect upon your body but that doesn't really mean much concerning the efficacy of the pain relief. The most important elements affecting pain relief are i) the nature of the pain mechanism (eg nerve damage, organ distress, inflammatory responses), ii) your own personal genetics, iii) other medications that you are currently using.

Rather than use euphoria or lack of it to assess if a pain medication is working, isn't it better to determine whether it is materially reducing the pain that you feel?

[nick30]

the euphoric feelings you are talking about are a side effect of the medication. they actually work as tuck said (and they act on the central nervous system, depressing it, thus making you sleepy).
again, this sleepiness is not wanted but a side effect.
if you have chronic pain and are feeling high then you are probably taking too high a dose.
some meds are worse than others in these regards.
the two opiates you talk about have more euphoric side effects than most painkillers, hence they are more open to abuse.
some drugs like fentanyl are barely noticable at therapuetic levels.
if you expect the euphoric feelings to last forever you will need to drastically increase your intake. If i were you i'd decrease your dose before you end up in trouble. I was also offered methadone but rejected it(due to association with heroin addicts). To each his own.
my way is working ok for me, i hope yours is for you too, but be careful with those beliefs of needing to feel euphoric in order to treat your pain.
good luck mate

nick

[nurseaudrea]

If I thought I was supposed to feel euphoric, or high, I would have to increase the dose of my pain meds to the point that it would be unfathomable. Once you are on pain meds for awhile that "euphoric" feeling goes away just like other side effects like respiratory depression. We know the pain meds are working because the pain is less or more bearable, not because we feel euphoric.

Thinking that way is very dangerous. My sister-in-law's father used to say he knew his pain meds were working when he felt euphoric. Well, he had to take more and more to get that feeling. One day she went to visit him and found him dead in a recliner because he had overdosed to get that "high".

Maybe you should do some more research on how narcotics effect the brain and the receptors. Tuckamore is absolutely right. That is why doctors will say that if you take the meds only for pain there is less a chance of becoming addicted because you are not chasing after the high, you are just looking for pain relief and will not abuse your meds to get high. If you are feeling euphoric and you have been on these meds for awhile it sounds like the dose is too high. You don't need to feel that way to get pain relief. I'm sure others will agree with me.

[Tuckamore]

Hi MyYau,

You offer some challenging thoughts to pain management therapy. It has never been my understanding that opiates/narcotics treat your pain by making you euphoric. In my opinion opiates have and may produce a euphoria either initially or in certain situations but his is not common for true pain management patients. I take narcotics every day and yet by no means do I experience euphoria.

Narcotics/opiates are classic agonist drugs.  These pain medications go to specific receptors in the body and cause the receptors to shut down the pain response. Opiates work as agonists by binding into receptor sites on cells in the brain and spinal cord.  The human brain actually makes its own chemicals that bind these receptors.  These chemicals are called endorphins and enkephalins. Opiates bind to the same receptor sites and change the way your brain and spinal cord process pain signals.  Your pain is then reduced. I am not so ignorant to beleive that initially or possibly for a few these opiates produce a euphoria but that is not how the narcotic/opiate reduces the pain.

My physician is not reluctant to discuss how these medications work. If you are experiencing a "high" daily with your pain medications the dose may be too strong. Sleepiness or lethargy can be a side effect of the opiates, period. It is not "made" to make you think less about your pain. It is simply part of the action of the opiates. When you are in pain, rest is usually an essential part of the bodies ability to heal.

I do not know all these ppl you are talking to that claim their pain medications produce euphoria, or that is it required to obtain a euphoric state in order to achieve pain control. I may be the rare person that this is not true for but if I beleive our members, and I do than euphoria is not the normal for pain management patients/medications. Most claim, as I do to a fuzzy head or lack of concentration and this is in no means a euphoria. I don't know what you are reading but it is not what my training or experience has taught me nor is it what I am currently reading.  

And you are very correct, no CP sufferer should ever feel guilty that they require pain medication to make it through the day. We should not have to suffer in silence or needlessly as many of us have done or continue to do. There is no shame in chronic pain management.

Others will post with their opinions. That's one of the great things about this forum, we are all entitled to our opinion. Thank you for sharing yours and take care, Tuck