She was an elderly lady when I knew her, but Mary had been a hard working hard drinking farm wife before she lost her right foot and ended up in our nursing home.

A lot of her friends (mainly male) were there too, and usually you’d find her in the smoking room with them telling dirty stories and playing cards.

Then one day Mary started throwing up and hurting. Her gallstones decided to act up, and after a week she finally said okay to surgery, but only if her “foot doctor” would do it. That meant sending her 200 miles to the Twin Cities, but by that time she was so high risk for not making it through surgery that we probably would have sent her there anyway.

Surprisingly, the surgery went well, and she came back, pulled out her IV  tubes and went back to trying to smoke.

But she was of the generation when “pain pills” were a sign of weakness, and pain shots (which we had quietly given IV with her antibiotics) were refused.

Yet Mary couldn’t sit for long: constantly, she was asking to be moved to get more comfortable, and that’s when the exhausted nursing home staff called me in.

The solution? We put on a pain patch, and within three hours Mary started feeling better, and within six hours she was able to sit in the wheelchair long enough to finish a cigarette. We kept the patches on for two weeks, then weaned her off without problem.

Unless you have been in pain, you probably don’t appreciate how you feel. I don’t mean a headache, but severe pain: A migraine, a kidney stone, childbirth, a fracture.

For mild to moderate pain, usually pills will do: NSAIDS (e.g. Ibuprofen/Motrin/Advil or Naproxen/Alleve etc). Tylenol also helps. For the burning pain from neuropathy (damaged nerves such as in diabetic neuropathy of the legs) we use the same medicines as we used to treat seizures, or anti depressants.t n
Indeed, anti depressants work with chronic pain, not to make you “high” but to get rid of the blahs/lack of energy that results from chronic pain.

I used to tell my patients: You know that when your dog hurts he sleeps all day in the corner? That’s what we mean by “depression”. You feel tired all the time so you sit still and your body can recover. Anti depressants help this, and when you aren’t so tired  you do things to keep busy so you don’t need as much pain medicine.

But there is a point when you need narcotics. Usually we try not to give them for chronic pain, but sometimes nothing else works as well. And even though people can “get used” to them (i.e. withdrawal when you stop them) we instruct our patients that addicts use drugs to get high. When we treat pain, you merely feel normal, and once the pain is gone, withdrawal is easy, but don’t stop the medicine suddenly or you might have problems.

Yet taking pills all the time is hard. So people wait until they can’t stand the pain and then take two instead of one.

A better approach is to keep a “steady state” of pain relief, and for this you need long acting medicine. Oxycontin was a blessing, but addicts who like the high learned to crush it up and inject it, so there were a lot of deaths from that medicine. Other medicines were MSContin and good old fashioned Methadone, which had the advantage of being cheap. And then there was the “patch”, where a very addictcing medicine named Fentanyl was placed into a patch to give a slow (3 day) relief of pain. And it had another advantage: For cancer patients it meant they didn’t have to worry if they’d keep down the pills.

But now the latest “headup” by the FDA about painkillers is that those who wear the Fentanyl patch are at risk.

The “3500” deaths may or may not be accurate: some of these deaths are from addicts who found out how to remove the medicine from the patch and overdosed. And some are cancer patients who as they became more frail got oversedated from their dosages. I’ve had patients from the nursing home who got sick (usually pneumonia) and the first sign was that they became unresponsive. In their weakened condition, their usual dosage was too high. And now there are reports that a hot tub or shower or heating pad can increase the absorbtion of medicine.

About all we doctors can do is our best, and sometimes it is a fine line between treating pain and causing side effects.

Everything has side effects. Aspirin can cause ulcers, as can Motrin and NSAIDS. The NSAIDS also interfere with the “anti clotting” side effect of aspirin, so raises the heart attack rate in some patients. NSAIDS can also cause you to retain fluid, a bad thing for those with blood pressure, congestive heart failure, or kidney damage. And then there is “Analgesic nephropathy“, which is much less common since Phenacetin was removed from the market thirty years ago, but still is seen with people who take a lot of non prescription pain pills.

Finally, doctors now often use other medicines with pain pills: NSAIDS work best for bone pain, but the medicine we use to control seizures works best for damaged nerves (Burning feet in Diabetes, Tic Doloreaux) and often anti Depressants help with sleep or with the fatigue felt by those with chronic pain.

So what should you do?

If you aren’t getting relief, a pain clinic can help. Often non medicine treatment helps (Yoga, meditation, physical therapy, trigger point therapy). And often once you relieve the pain the pain causing spasm causing pain cycle is stopped.

And for those with cancer pain, often pain specialists with hospice help.

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Nancy Reyes is a retired physician living in the rural Philippines. Her website is Finest Kind Clinic and Fishmarket, and she writes medical essays to HeyDoc Xanga Blog 

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