Re:Driving an Ambulance in the Age of Narcan
by DanBC on Saturday September 07, 2019 @11:53AM
(#20904544)
The history of medical opioids is weird.
Pain is a complex phenomena.
This has caused a lot of problems with pain treatment. We used to think heroin was okay, then we realised it was addictive. So we moved to other opioids thinking they weren't as addictive, but they are all about as addictive as morphine and diamorphine. We started reducing the quantities of the opioids and adding other meds like paracetamol / acetaminophen. This led to fucking stupid meds like coproxamol -- a mix of dextropropoxyphene (an opioid) and paracetamol. This opioid is very toxic, and it was killing many people in the UK until the licencing changed. And then we tried other meds like NSAIDs and etc. Some of them sort of work for some pain, some are very good for a specific type of pain. But they all have side effects.
We split pain up in different ways. We talk about chronic (long term) pain or acute pain. We talk about medically unexplained pain, and the implication is that the other pain has a medical explanation.
The public have three incorrect beliefs about pain treatment.
1) Opioids are effective
2) Pain is either real or imagined, and imagined pain isn't real pain.
3) The aim of pain treatment is always to eliminate all pain and anything less is a failure.
Turns out none of these are true.
Opioids are a good choice for a limited number of patients. It's really important that people get all the opioids they need at end of life, for example. Or that people going through surgery have them available if needed. But for long term pain they're a bad choice. The person in pain ends up taking very high doses of opioids, with all the side-effects that causes, and they're still in pain. We can see their function - the stuff they do every day - is much reduced. We also see some conspiracy-theory style thinking here - "morphine is dirt cheap and this non-opioid you've got me on is really expensive, because you're in the pocket of big pharma".
We know that patients reject psychological treatment for their pain. They'll say "but my pain is real, it's not all in my head". But many pain patients experience benefit from psychological treatment. (Imagine a purely physical disease like t1 diabetes. Even these patients will get benefit from a psychological treatment. Clearly I don't mean that mindfullness will control blood sugars, but the 3 questions "can you do your bloods every day?", "can you take your insulin at the right dose and right time every day?" and "can you adjust your diet and lifestyle?" -- these are all firmly psychology).
Sadly, lots of people in pain will not experience relief from that pain even if we give them high dose opioids. So pain treatment should be looking at function. The aim should be to allow someone to live their life even if they still have pain.
Pain is a complex phenomena.
This has caused a lot of problems with pain treatment. We used to think heroin was okay, then we realised it was addictive. So we moved to other opioids thinking they weren't as addictive, but they are all about as addictive as morphine and diamorphine. We started reducing the quantities of the opioids and adding other meds like paracetamol / acetaminophen. This led to fucking stupid meds like coproxamol -- a mix of dextropropoxyphene (an opioid) and paracetamol. This opioid is very toxic, and it was killing many people in the UK until the licencing changed. And then we tried other meds like NSAIDs and etc. Some of them sort of work for some pain, some are very good for a specific type of pain. But they all have side effects.
We split pain up in different ways. We talk about chronic (long term) pain or acute pain. We talk about medically unexplained pain, and the implication is that the other pain has a medical explanation.
The public have three incorrect beliefs about pain treatment.
1) Opioids are effective
2) Pain is either real or imagined, and imagined pain isn't real pain.
3) The aim of pain treatment is always to eliminate all pain and anything less is a failure.
Turns out none of these are true.
Opioids are a good choice for a limited number of patients. It's really important that people get all the opioids they need at end of life, for example. Or that people going through surgery have them available if needed. But for long term pain they're a bad choice. The person in pain ends up taking very high doses of opioids, with all the side-effects that causes, and they're still in pain. We can see their function - the stuff they do every day - is much reduced. We also see some conspiracy-theory style thinking here - "morphine is dirt cheap and this non-opioid you've got me on is really expensive, because you're in the pocket of big pharma".
We know that patients reject psychological treatment for their pain. They'll say "but my pain is real, it's not all in my head". But many pain patients experience benefit from psychological treatment. (Imagine a purely physical disease like t1 diabetes. Even these patients will get benefit from a psychological treatment. Clearly I don't mean that mindfullness will control blood sugars, but the 3 questions "can you do your bloods every day?", "can you take your insulin at the right dose and right time every day?" and "can you adjust your diet and lifestyle?" -- these are all firmly psychology).
Sadly, lots of people in pain will not experience relief from that pain even if we give them high dose opioids. So pain treatment should be looking at function. The aim should be to allow someone to live their life even if they still have pain.
For one example of this see "Sean's Story" https://www.england.nhs.uk/south/2019/06/25/seans-story/
There's also a visit to a pain-management clinic in a section of this radio programme: https://www.bbc.co.uk/programmes/b04wv052