Sunday, June 18, 2006

When pain meds make pain worse

Michele G. Sullivan, in Clinical Psychiatry News:
HENDERSON, NEV. — Treating medication overuse headache involves a three-pronged approach of patient education, teaching pain coping skills, and addressing psychological issues that put patients at risk for relapse, Alvin E. Lake III, Ph.D., said at a symposium sponsored by the American Headache Society.

Most patients don't understand that excessive use of opioids can actually make them hypersensitive to pain, said Dr. Lake of the Michigan Head Pain and Neurological Institute, Ann Arbor. “They believe the pain is stronger than the medication, not that the medication is actually making them worse.” This thought process can be the root of ever-increasing medication use, as the patient experiences “pain anxiety” and attempts to forestall pain by premedicating.

The first step is to teach patients how medication overuse exacerbates headache pain, he said. Only when they have a clear understanding of this relationship will they be open to adhering to medication limits.

Sustained opioid use downregulates opioid receptors and upregulates excitatory receptors. This results in increased synthesis of excitatory neuropeptides. “Opioid tolerance is a red flag for induced abnormal pain sensitivity,” Dr. Lake said...

Simply taking away the analgesic isn't the answer, he stressed. Patients need to understand that drugs are not the only way to alleviate headaches, and that they will probably have to tolerate some level of pain. “The evidence, clinically and empirically, shows that it's very difficult for these patients to move to pain-free days. They have to find ways of dealing with headache that doesn't involve drugs.”

Biofeedback, stress management, and antidepressants all may be effective tools in relearning responses to headache pain.


Blogger Fallen Angels said...

I get very bad headaches that are treatment resistent...most of the time I deal with them without meds. Every few months I get one that is just REALLY bad and needs intervention. My partner on the other hand, gets the occasional, mild headache. Several months ago she got one that was a little worse then normal and she started popping tylenol. It got a little better and she would sleep or go out or whatever and then it would get worse again so she would pop more tylenol. This cycle went on for several days and I started warning her about "rebound" headache...she didn't believe me. She does now! ;) One morning she woke after a nice long sleep and her headache had all the features of a migraine. She doesn't pop tylenol for mild headaches anymore...she finds other ways to manage them.

7:37 AM  
Anonymous Jessica said...

This is all so true, and yet few know about it. Even my DOCTOR told me to keep taking OTC painkillers for my headaches, I asked her how often and how high of a dose I can take and she told me as much as the bottle says. For for SIX months I was useing OTC painkillers as often as I could, some times when the pain got bad enough I would pop 6 or eight of them at once! But, the pain never went away. Finally I saw a neuro and she got my off OTCs, I have decided never to take them again.

On a hand out she gave me it says that OTC painkillers should be used only 2 maybe 3 times a WEEK! I was taking more doses in a day! Now when ever I see a friend poping OTCs a lot, I warn them about the effects it can have.

8:37 PM  
Blogger Greg P said...

This is something I deal with all the time. The mental conception I have is that, if we look at the cycle of opioid effect, the problem is not so much the upward slope of drug level after a dose, but the downward slope on the other side of the peak, where certain receptors disengage from the narcotic, triggering a withdrawal (not exactly the same as the drug withdrawal we typically thing of, but that can happen simultaneously) and a "need" for that narcotic again.

From the outside, as a treating physician, you see someone who only manages to tread water with their pain relief, overall not feeling any better, just going from one narcotic dose to the next. Historically, every pain becomes a "10" (or maybe even "11") and the only thing that will help is the narcotic. And resistance -- "you just don't understand how bad this pain is", "if you don't give me that medicine I'll probably have to kill myself, that's how bad it is." But these are not suicidal people.

What it takes to manage this is developing an understanding of the art of gradually withdrawing narcotics (with more suitable subsitutes), along with the intestinal fortitude to carry it out.

6:22 AM  
Blogger dn said...

From the patient side, I second what greg p said. Immediate release drugs seem to get a lot of people in trouble. First they take a big dose, to get relief reasonably fast. Next, the drug levels overshoot and induce needless tolerance. Finally, the drug levels drop rapidly making the pain feel worse than it really is. So they take another big dose to regain function, and so on.

It seems to be a particular problem with migraineurs, since their stomachs empty significantly slower than normal. For the same reason, migraineurs favor water-soluble drugs for faster absorption, but those give the harshest, fastest withdrawal.

Anecdotally, a lot of people with treatment-resistant headache do reasonably well on extended-release opioids. The prohibition industry likes to harp on the dangers of opioids, but when the alternatives are MAOIs and valproate they don't look so bad.

8:37 PM  
Blogger NeoNurseChic said...

Oh man...this one lands in my territory as I'm a trainee member of the American Headache Society. That's kind of the culmination, however, of being a patient with New Daily Persistent Headache, Chronic Cluster Headache, and Basilar Migraine with 8 long hospital stays behind me and several other issues. I've tried over 100 different medications in an attempt to break the constant migraine, but in 5 years, 5 months, and 5 days, I have not had a single pain free SECOND unless I've been asleep. So in nursing school, I was in the honors program, and I was absolutely disgusted by the quality of headache education - or rather, complete lack of headache education - so I rewrote the curriculum into about 6 Power Point presentations that are awaiting real use when I have the time! Last summer, I spent my last few days before starting my full time job at a scientific meeting for the American Headache Society in Philadelphia. I used to work in research at a very well-known headache center, where I am also a patient, and I've spent a lot of time in educator and advocacy roles...sometimes without even realising it!

That being said, this medication overuse headache stuff is always a hot topic. I second what everyone else said above about the need for pain relief and the problems that short-acting pain medications can cause. I know that in my own world of headache pain, there are days when I totally cannot take it. I will flip a lid if I cannot bring the pain down from a 10. I once had about 10 cluster headache attacks in one day and felt extremely suicidal. They don't call them suicide headaches for nothing....they really are a pain that most cannot imagine. Amerge and Frova have been lifesavers for me.

The physicians that I have seen mainly for my own headaches are firm believers that if you take an acute medication more than 2 days a week and you still have a lot of problems with headaches, then you most certainly have to be dealing with MOH - formerly called Rebound headache. It wasn't until last summer at the conference that I learned that not everyone sees it that way. Fortunately, there are physicians out there who know that not every person is going to be thrown into a rebound cycle from frequent use of triptans or even opioids. One neurologist friend of mine once told me that even a baby aspirin a day can cause rebound headache... I was denied pain management for almost all of my headache span. I have never experienced MOH - and yet, many experts jump the gun and dump me in that category because they feel that someone who cannot achieve pain free time must be someone whose brain was oversensitized to opioids and therefore is in some kind of chronic MOH state. Not the case with me - and not the case with a lot of other people out there.

Dr. Fred Sheftell and his crew at New England Center for Headache in CT even found that the long term use of Amerge (naratriptan) for chronic, intractible migraine appears to be very effective and does not cause rebound. I cheered the day I read that study. I congratulated Dr. Sheftell personally for doing that work. Thank GOD someone was finally standing up for this group of chronic sufferers... There have been a number of articles on the safety and efficacy of the daily use of Frova (frovatriptan), but most of these have been short-duration daily use. My neurologist has bent ever-so-slightly to the idea that perhaps that might be a good option for me to take....but the insurance companies in this country prevent that from being very feasable.

Last December, I ended up in the ER for severe back pain after working a slew of shifts in a row in the hospital. This is because I have a slight limp from having avascular necrosis in both knees from repeated oral and IV corticosteroid treatments for, none other than, headaches. I then did 5 months of physical therapy. However, shortly after the ER trip, I had an appt with my psychiatrist. He asked me if I ever felt that my pain was actually treated, and I burst into tears. I said that I've done everything right. I've never taken abortives or rescue meds more than I was supposed to take them. I've taken all kinds of anti-seizure, anti-psychotic, anti-depressant, anti-hypertensive meds that are out there and then some. I've given up weeks of my life for hospital stays that left me minimally better for the short term, but also led to time in the cardiac ICU, 2 DVTs in my left arm, well over 200 needle sticks, 3 PICC lines, anticholinergic toxicity psychosis, allergies to a number of meds, and made me realize that I would never be able to go to medical school in this state - so I went to nursing school instead. It's still a bone of contention for me, but I love what I do nontheless.

My psychiatrist and I discussed chronic pain management for several visits after that. I was afraid to do it because it had always been hammered into my head that chronic opioid use was BAD and that I shouldn't be looking to that at my age. I should continue to suck down pills like Parnate, Elavil, Pamelor, Lamictal, Lyrica, Mexiletine, Cymbalta, Depakote, Verapamil, Lithium, etc.... My psychiatrist finally got me to see that what I was doing was no safer... I would like to have children - but how do I know what these drugs are doing to my body long term? I also work with infants who are in withdrawal from maternal methadone, so I absolutely refused to take methadone. Instead, my psychiatrist talked with my neurologist and my neurologist decided to start me on MS Contin. I achieved significant relief at a much lower dose than anyone expected, and a former neuro of mine told me that he thought I might respond that way, since many who fail every prevent out there seem to do well on pain management. It was the first time in my life where my pain dropped to a 3 on some days without taking a lot of extra abortives and staying in bed from side effects. I was able to take some of my life back that severe, disabling chronic pain and side effects of those powerful "acceptable" medications had stolen away. Granted, I never stopped working, but my quality of life was in the toilet and frankly I was questioning why I even bothered to keep living as it was. The pain was not deadly but so severe that my life was awful - nothing made me happy anymore because everything came with such a huge amount of pain that instead I would sleep all my days off. I stopped doing that with the beginning of MS Contin.

At this point, my baseline for my constant migraine is at least a 5 or 6 every day. Some days, I do drop down to a 3 or so, but that's kind of rare. I don't feel the same effect that I had when I first started the MS Contin, but it is still so much better than how I felt before and when on all those other meds. I continue to go to my psychiatry appts twice a week; I go to neurology appts once a month; I do everything asked of me because I've always been one that tries to be big on compliance...even during times in the past when compliance has almost killed me because frankly some of the meds used to treat headache can be dangerous.

I have really mixed feelings on the concept of medication overuse headache - it is definitely a true phenomenon, but I think that the hard-fast view that all people will experience rebound with all acute medications is a little close-minded as it appears that many people do not fall into that box. Some experience it with certain meds and not with others. Sorry my post is so long here! This happens to be an issue that carries a huge passion for me, and had I been able to go to medical school, I was going to become a headache neurologist. Instead, I'm a neonatal nurse, but hey...there's a reason for everything!

Take care!
Carrie :)

2:02 PM  
Anonymous Elizabeth Niederer said...

Hello shrinkette :-) I've just discovered your blog in a surfing spree, and this post caught my eye. It's a pet subject of mine.

I have chronic sciatica, probably because I'm morbidly obese, perhaps due to other things as well. It took me MANY YEARS to find a doc who a)believed I really was in as much pain as I said I was (because I kept on doing as many activities as I could despite the pain and therefore "must" have been exaggerating) and b)didn't just tell me (usually, but not always, in somewhat more tactful terms) to just suffer until I gained some willpower and lost some weight.

Said doc was not afraid to prescribe OxyContin, God bless him. I've been on a stable, relatively low, dose of the stuff for over five years, and life is far more liveable. No tolerance problems, no dosage adjustments needed, none of that.

I've gotten the OxyContin from the same prescriber the whole time. I get ALL my medications (and there are many, for I have many health woes, including pulmonary hypertension) from one pharmacy. EVERY doctor I see has the same exact list of medications I take and a signed release in hand to communicate with my other doctors or health professionals as needed.

In other words, I am the antithesis of the opiod seeking patient. I hate the stuff and if someone would provide an option that didn't *!&@(* with my brain chemistry in unacceptable ways (don't get me started on antipsychotics and the other fancy pants designer drugs that supposedly do something wonderful to the nerve transmissions or whatever the hell they're supposed to do), I'd change in a heartbeat.

Biofeedback? Learned how to do it in the mid-80's. Stress management? Learned at the hands of experts. Antidepressants? Been taking 'em for over a decade. (They're lifesavers, don't get me wrong; they just have never worked for pain management.) Physical therapy, daily exercise, chiropractic care, energy work, bodywork.....etc. Oh yeah, and don't forget some fifteen-plus years of psychotherapy.

Bottom line: What finally helped was when a doc had the courage to prescribe a politically incorrect drug AND to educate me on its correct use. All the other modalities have their places in my life and help certain things. But this particular chronic nerve pain needed a certain kind of treatment, and it was eons before I got it.

So, I get peeved when opiods get unduly demonized, along with the docs who prescribe them and the people who use them. People in misery shouldn't have to be afraid of using what could be a life-changing treatment option because of misinformation about "addiction."

Thank you for listening to my rant, and thank you for your blog. It's a fun and interesting read :-).

1:15 PM  

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