Significant pain reduction in chronic pain patients after detoxification from high-dose opioids:

http://www.rsds.org/2/library/articl...n_McDonald.pdf

S

My wife took Ibuprofen for 4 years with her RSD. She began to lose her mind and lost her job and career. She then was put on a cocktail of nerve and narcotic meds by her doctors in which she became much more normal and was much better in dealing with her pain. That was three years ago, that has been my experience.

I notice too that the symptoms they list are those we get with RSD anyway, so alot of folks would assume they were just getting worse not becomming intollerant to their medicine.. And the detoxification would/should be either temporary or until something else satisfactory could be found to adiquitly controll the pain in this case I would think anyway.

RSD/CRPS is not included in their patient's ailments in this study, and they do imply that the symptoms of hyperalgesia and allodynia are not symptoms they are expecting in their study participants.
I find their thoughts/supositions on hyperalgesia very interesting.
I become intollerant of most drugs before too long it seems, a very few I have been on for the long haul, such as baclofen.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
JimKing, Hi there..

Yes the ibuprophen is not good for the stomach and heart after very long either, not to mention that it is usualy not enouph pain relief for us, though it helps with the achey pain.. it does nothing for the deep bone pain or the various other types of pain thet RSD folk get.. for that we need an assortment of meds for each symptom.. I too have found that is the best way to manage this beast.

Best wishes,
S

Sandel,

I'm very glad to hear you were successfully able to get off of the pain meds you were on. Congrats! Personally, I am on a TON of them and there's nothing I can do about this relentless pain from breaking my neck, severing my nerves in the neck & a brain trauma due to an auto-accident.

I'm just wondering if you'd share with me WHAT you were taking and for how long? More importantly, how did they detox you?

You see, I don't think I'll be off my meds anytime soon, but I wonder how painful the detox process was for you. I tried to reduce my meds, bit my bit with my docs help, and it was unsuccessful due to the unrelenting pain. My surgeon said it HAS TO BE at this high dose due to the severity of the injury. I would like to not be tied down by my dependence on pain medication but I don't have no other options now. 1) Live in dire agony or 2) Live on addictive medication. It's just a crappy situation!!

The injury was 3 & 1/2 years ago ... Really, when (I wonder) can the nerve pain stop punishing me and let up. My surgeon said it may be a lifelong struggle (like the brain trauma).

Have you, Sandel, been down this road for years like me? If anyone else has been ... I'd like to hear your comments, too.

Thanks,

Joe

I have been slowly lowering the amount of Morphine I take every 8 hrs over the last 2 months. I think my doctor read that study...............cause he sited the reason that maybe my pain levels would go down by doing this. And maybe the new symptom I have had since last Oct would go away or lessen. It has lessened.............the symptom that is. It was where burning started on my scalp & would eventually encompass my whole body along with bright red blotches the size of my hand & larger. The burning was/is atrocious. I hit it with extra morphine immediately & the burning & redness start to go away. One note hear. I have been on the same dose of morphine since 2005. It has not actually been increased since then at all. Luckily for me I have not grown tolerant to it at all.

I have gone down 25mg every 8 hrs & he has left it up to me if I want to lower it another 15mg over the next 2 months as I see him every 2 months. To be honest I can't tell a whole lot of difference between my pain levels now compared to 3 months ago before lowering them. I am leery of taking it down any further, but I might try it with my bedtime dose next week.

DebbyV

My PM doctor has been telling me this for about 6 years. During this period I have come off all meds. and it is true the pain does change. I would not say it completely goes away but it changes for the better. Am I off everything today, no, but reduced tremendously....I have had surgeries and procedures that require me to take meds. at this times....The least you take the better....

Thanks for the info...

Gabbycakes

According to all the studies I've read, less than 3% (and I read in one study where it was less than 1%) of all patients who take heavy hitting narcotics because of severe injury or pain ever become addicted, so why be scared of them?

After being on the hard stuff since 1999 I can't believe how much of a difference it makes. Between my 160 mg of OxyContin plus OxyIR's I take throughout the day for breakthrough pain plus my internal morphine pump, I guess you might say I'm really going full bore as far as the hard hitting stuff yet without it, I'm in total hell.

My doctor explained how I can take the amounts I'm on without becoming some sort of screwy nut-case. "Bob, with your damage the narcotics are simply burned off by the body. While your body does expect the narcotics, you're not an addict." It was after watching one to many shows such as Intervention that I became terrified I was perhaps ruining my life. "Bob, stop watching those shows!"

For those who find that they at some point can take less or get off the hard stuff altogether, I'm not only proud of you, I'm tickled to death that your suffering has eased up so you can. For the others like myself where the damage continues to spread, we don't really have much of a choice. In fact my pain doctor has told me many regularly that I should probably be taking higher dosages but that it's me who's learned how to live with more pain hence the reason we've been able to keep my dosage levels where they're at.

Never once have I ever felt a single bit of being mentally disconnected or unable to concentrate because of medications (other than some short term memory problems) so why be scared of something that helps? If you're suffering, then take it. If you're doing better and don't need the extra pain relief then happier days are here again. Please let me assure you that not everyone who's taking narcotics is really a dope-dead in disguise. I might be loony, batty, and eccentric as all get out, but I'm not a drug abuser and 99% of all who are badly injured or in severe pain are not either. Best of luck, Bob.

Hi Sandel,

That was a very interesting study. I have seen it before. And there may be an application for some of us, certainly for the chronic pain patients that were chosen for that study. I think that in general, for those that can reduce their opioid meds, reducing exposure to unwanted side effects is always a good thing. My only input on this is that unfortunately while this study has some merit, by design it really doesn't apply to RSD/CRPS patients. The patient cohort has no RSD/CRPS patients in it; all diagnosis are unrelated so there really is no conclusion, good or bad, that can be drawn for us on the basis of this study alone unless your chronic pain is as a result of one of the diagnosis listed in the study. It may well be valid for us, it is just that you can't use this particular study to say so. Great read, though!

As Dubious notes, this study has been around for a while, 2006 to be specific. I suspect it's making the rounds now because for some reason it was featured on the RSDSA homepage a week ago.*

However, we are well-served to have this raised again by Sandra, because it's an important facet of pain medications with which we all should be familiar, the concept that we can be on large enough doses of opioids that they not only become essentially useless but they ultimately reinforce and strengthen what is already CNS generated pain. For the quick treatment on Wikipedia, see, http://en.wikipedia.org/wiki/Opioid-...d_hyperalgesia

But just as importantly, there are a number of solutions other than "detoxification." In fact, there is evidence that a complete detox may well be "sub-optimal." See, Reduced cold pain tolerance in chronic pain patients following opioid detoxification, Younger J, Barelka P, Carroll I, Kaplan K, Chu L, Prasad R, Gaeta R, Mackey S., Pain Med. 2008 Nov;9(8):1158-63. Epub 2008 Jun 18, FREE FULL TEXT @ http://www.ncbi.nlm.nih.gov/pmc/arti...ihms140159.pdf

Abstract

OBJECTIVE: One potential consequence of chronic opioid analgesic administration is a paradoxical increase of pain sensitivity over time. Little scientific attention has been given to how cessation of opioid medication affects the hyperalgesic state. In this study, we examined the effects of opioid tapering on pain sensitivity in chronic pain patients.

DESIGN: Twelve chronic pain patients on long-term opioid analgesic treatment were observed in a 7- to 14-day inpatient pain rehabilitation program, with cold pain tolerance assessed at admission and discharge. The majority of participants were completely withdrawn from their opioids during their stay.

OUTCOME MEASURES: We hypothesized that those patients with the greatest reduction in daily opioid use would show the greatest increases in pain tolerance, as assessed by a cold pressor task.

RESULTS: A linear regression revealed that the amount of opioid medication withdrawn was a significant predictor of pain tolerance changes, but not in the direction hypothesized. Greater opioid reduction was associated with decreased pain tolerance. This reduction of pain tolerance was not associated with opioid withdrawal symptoms or changes in general pain.

CONCLUSIONS: These findings suggest that the withdrawal of opioids in a chronic pain sample leads to an acute increase in pain sensitivity. [Emphasis added.]

PMID: 18564998 [PubMed - indexed for MEDLINE] PMCID: PMC2751584

http://www.ncbi.nlm.nih.gov/pubmed/18564998

The good news is that there are a number of fixes for the problem, including not only that old favorite, opioid rotation, but now there are actual or potential options of adding to the opioid another compound, whether it’s (1) a so-called “NMDA receptor antagonist,” which could be as simple as the over-the-counter cough suppressant dextromethorphan, in order to block pain processing from the spinal column to the brain, or (2) the most minute amount (in millionths of a gram) of an opioid blocker which has the paradoxical effect of increasing (potentiating) the analgesic qualities of the narcotic while reducing the total amount taken, and therefore the side effects.

As to the use of NDMA receptor antagonists, see, generally, Ketamine blocks enhancement of spinal long-term potentiation in chronic opioid treated rats, Haugan F, Rygh LJ, Tjølsen A, Acta Anaesthesiol Scand. 2008 May;52(5):681-7:

Abstract

BACKGROUND: Long-term opioid treatment is associated with the development of hyperalgesia. In a rat model we wanted to study if chronic opioid treatment changed the induction and maintenance of spinal long-term potentiation (LTP), a form of hyperexcitability in the spinal cord. We also wanted to investigate if the clinically available NMDA receptor antagonist ketamine inhibited the effect of chronic opioid treatment on LTP.

METHODS: The animals were randomized into four groups (saline, morphine 20 mg/kg/day, ketamine 20 mg/kg/day, morphine 20 mg/kg/day and ketamine 20 mg/kg/day). Drugs were given as continuous subcutaneous infusions by means of osmotic minipumps. After 7 days of treatment and during ongoing treatment single unit extracellular recordings were made from the lumbar deep dorsal horn under urethane anesthesia. Single electrical stimuli were applied to the sciatic nerve, and the C-fiber evoked responses of WDR neurons were recorded before and during 3 h following low frequency (3 Hz) electrical conditioning stimulation.

RESULTS: The potentiation of C-fiber evoked responses by conditioning stimulation was significantly increased in the morphine-treated group compared to the saline group, while there was no significant difference between the saline, the ketamine and the morphine/ketamine groups. The potentiated responses in the morphine/ketamine group were significantly reduced compared to the morphine group (P=0.01).

CONCLUSION: Our results indicate that animals treated with long-term opioid show amplification of stimulus-induced central sensitisation compared to opioid naïve animals. Ketamine inhibited the morphine-induced enhancement of LTP, supporting the role of ketamine in prevention of opioid induced hyperalgesia.

PMID: 18419722 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/pubmed/18419722

And, with respect to the effect of NDMA receptor antagonists, it's not just ketamine, magnesium appears to have a similar effect. See, e.g., Magnesium modifies fentanyl-induced local antinociception and hyperalgesia, Mert T, Gunes Y, Ozcengiz D, Gunay I, Naunyn Schmiedebergs Arch Pharmacol. 2009 Nov;380(5):415-20. Epub 2009 Aug 21:

Abstract

Fentanyl-induced hyperalgesia and antinociception after systemic administration has been shown in previous clinical and experimental studies. However, there is very little evidence regarding the local possible effects of fentanyl. The purpose of this study was to assess whether local (intraplantar) fentanyl administration can produce antinociception and hyperalgesia. In addition, we examined the effects of magnesium, N-methyl-D-aspartate receptor antagonist, on possible changes produced by fentanyl. The paw withdrawal latencies to radiant heat stimuli were measured to assess the thermal nociceptive actions. Intraplantar administration of fentanyl caused time and dose-dependent increase in the paw withdrawal latencies (antinociception). Coinjection of magnesium with fentanyl markedly enhanced the antinociception. However, fentanyl also markedly decreased paw withdrawal latencies 24 h after intraplantar administration (hyperalgesia). In the presence of magnesium, hyperalgesia after fentanyl administration was not observed. Consequently, following the fentanyl administration, local hyperalgesia after antinociception is a negative effect in pain treatment. Magnesium may not only prevent the hyperalgesia but also enhance antinociceptive effect of fentanyl. [Emphasis added.]

PMID: 19697012 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/pubmed/19697012

Having said that, although the combination opioids with trace amounts of an opioid block is a proven concept in the lab, and drug companies are falling all over themselves to be the first to gain FDA approval of their particular combination, none have made the grade so far. And although a number of people on the forum have found that one such drug - marketed to assist in the withdrawal from narcotic dependency/addiction - has been of real help to them, my pain mngt. doc hasn’t found it helpful in treating pain patients and so doesn’t prescribe it. (Search the forum under "Suboxone" and stay tuned for further developments.)

The bottom line is that no one should be resigning themselves to a life of bearing up under the weight of chronic pain, unless and until you’ve fully explored the issue of hyperalgesia and your options for dealing with it, with a good pain physician.

I hope this is helpful.

Mike


* Why I'm not sure, but there are two more articles up there now that were published in 2004 and 2009, respectively, and in the case of one of them, Carroll I, Clark JD, Mackey S, Sympathetic Block with Botulinum Toxin to Treat Complex Regional Pain Syndrome, Ann Neurol. 2009;65:348-351, as recently as a couple of weeks ago, it wasn't on the RSDSA site and was only available through PubMed Central at http://www.ncbi.nlm.nih.gov/pmc/arti...8/?tool=pubmed

Hi there folks, glad to see the old posts are still being brought up, that was origionaly posted last November.
I am no longer on any narcotics myself either I just slowly weaned off hard meds after I started getting the subcutanious lidocaine infusions I guess 2 years ago, morphine always made me sick as I was intollerant. I do take other meds to treat each symptom of RSD though and they help emensly, I am also am a medical marijuana patient here in Canada (I break the no choclate rule) and I eat medicinal MJ brownies for pain relief.. my local club also has a medicinal tincture for under the toung that realy helps for breakthrough pain.. it works almost instantly and lasts for a few hours, clears up nausia too.

So yah I supose one med for another.. with far less side effects for me anyway.

~Sandra