Every time I hear a clamor for dosage restrictions of opioids or hear such statements as “no one could possibly take that much medication,” I suspect the person uttering the statement is pretty ignorant about therapeutic tolerance and the legitimate need for opioid dosage escalation in selected patients.
What is Tolerance?
Let’s review. According to the American Pain Society, therapeutic tolerance is defined as “a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the opioid effects over time.”1 This is not to be confused with physical dependence or addiction, which are defined in the Table below.
Neuropathic pain can develop after nerve injury, when deleterious changes occur in injured neurons and along nociceptive and descending modulatory pathways in the central nervous system.
The myriad neurotransmitters and other substances involved in the development and maintenance of neuropathic pain also play a part in other neurobiological disorders.
“Just another reason why over two-thirds of abused pills DON’T come from doctors!” - James Murphy MD
FedEx is facing drug-trafficking charges after a federal grand jury in San Francisco indicted the overnight shipping company, accusing it of conspiring to deliver prescription drugs for illegal Internet pharmacies.The indictment says FedEx knew for a decade that such pharmacies used their services. FedEx took steps to protect its business by setting up special credit policies for Internet pharmacies so it wouldn’t lose money if police shut the sites down, the indictment says.
Scientists have known for many years that on-going pain in one part of the body is reduced when a new pain is inflicted to another part of the body. This pain blocking is a physiological reaction by the nervous system to help the body deal with a potentially more relevant novel threat.
To explore this “pain inhibits pain” phenomenon, painful electric pulses were first administered to a subject’s foot (first pain) and the resulting pain intensity was then measured. Then the subject was asked to put their hand in a bucket of ice water (novel stimulus causing pain reduction), and as they did so, a telephone ringtone sounded in headphones. After this procedure had been repeated several times, it was observed that the pain felt from the electrical stimulation was reduced simply when the ring tone sounded.
The brain had been conditioned to the ringtone being a signal to trigger the body’s physical pain blocking mechanism.
The people being tested not only felt significantly less pain, but there were also fewer objective signs of pain, such as activity in the muscles used in the facial expression of pain (frowning). In total, 32 people were tested.
is possible to relieve pain hypersensitivity using a new method that involves rekindling pain so that it can subsequently be erased
studies had revealed that when a memory is reactivated during recall, its neurochemical encoding is temporarily unlocked. Simultaneous administration of a drug that blocks neurochemical reconsolidation of the memory results in its erasure.
The investigators wanted to see whether a similar mechanism was at play during neurochemical encoding of pain sensitization.
Realizing no one could help me but myself, I went on a search for more ways to cope, and read about the powerful role of the brain in perceiving pain. I began to understand how something as simple as my own thinking could make a difference in my pain experience.
What if my approach could be used to help others who suffered with chronic pain?
I learned that people who seek to eliminate chronic pain have seen many doctors, tried numerous therapies, often spent time with mental health professionals, and sometimes go to a pain clinic. What they lack is ongoing support and motivation to make changes that will improve their experience with pain over the long haul. A high percentage of chronic pain patients give up and give in to a life filled with pain, low productivity, and isolation.
If a study published in this month’s Journal of Nutrition is any indication, the caffeine in coffee might offer not just a momentary mental boost but also longer-term effects on thinking skills.
Having an alcoholic drink a day might also benefit our mental performance, but the line between just right and too much is uncertain. An even better strategy for maintaining memory and thinking skills with age may be to eat a healthy diet.
Making the journey from patient to person takes time. The isolation and fear that can overwhelm a person with chronic pain grows over time. And the return to a fuller, more rewarding life also takes time.
It’s a journey with many phases. The ACPA describes these phases as Ten Steps.
STEP 1: Accept the Pain
Learn all you can about your physical condition. Understand that there may be no current cure and accept that you will need to deal with the fact of pain in your life.
STEP 2: Get Involved
Take an active role in your own recovery. Follow your doctor’s advice and ask what you can do to move from a passive role into one of partnership in your own health care.
I have been hearing the term “intractable pain” (IP) to refer to patients with chronic pain more often of late. To me, it’s about time, as it conveys a simple, needed message—is the pain curable or incurable. Now is a good time to review the history and origin of this term.
In contrast to most pain terms developed by academics that describe the type (or cause) of pain, such as neuropathic, nociceptive, visceral, myofascial, the term IP was used by the Federation of State Medical Boards in 1985 when they created guidelines for the treatment of chronic intractable pain. In 1990, Texas and California both passed Intractable Pain Acts(Table 1).
Pain patients are usually prescribed additional medications to reduce their need for opiates, despite the known toxicity of these adjuvant analgesics.
An adjuvant (or co-analgesic) is a drug that in its pharmacological characteristic is not necessarily primarily identified as an analgesic in nature but that has been found in clinical practice to have either an independent analgesic effect or additive analgesic properties when used with opioids.
The therapeutic role of adjuvant analgesics (AAs) is to increase the therapeutic index of opioids by a dose-sparing effect, add a unique analgesic action in opioid-resistant pain, or reduce opioid side effects.
A notable difference between opioids and AAs is that unlike opioids some AAs are associated with permanent organ toxicity, for example, nonsteroidal anti-inflammatory drugs (NSAIDs) and renal failure