Opioid use tricky to navigate today
DEAR DR. ROACH: I am an 82-year-old female. In 2002, I had a triple bypass. Something went wrong, and I have been in almost constant pain ever since. The pain is in my chest wall. I also have other health issues, including atrial fibrillation. My cardiologist recommended pain medicine doctors, who have prescribed many different medications over the years, including: physical therapy, chiropractors, over-the-counter pills, analgesic gels, and opiates, including fentanyl patches, oxycodone and morphine. Also, I had a neurostimulator embedded in my back, and then in my chest, which also did not relieve my pain.
The only medicine that seems to work is morphine. I have built up a very great tolerance over the years. I have been prescribed 90 mg every four hours for many years, but since the opioid scare, the pharmacist will not fill a prescription for that amount. On my own, I have cut down to 60 mg every four hours, which seems to be OK for now. This past month, I think I may have had minor withdrawal symptoms from lowering my dosage, but nothing too serious. I function quite well. I enjoy life and have no problem taking care of myself. So far, so good.
I have been referred to an addiction specialist, who says I should stop taking morphine almost immediately. He says I should be hospitalized for a week or so during withdrawal. He will prescribe Suboxone to alleviate any pain. I am concerned that this might interfere with other meds that I am taking, and I’m afraid of the nausea and other pains I might experience during withdrawal.
At this time of my life and being an addict, I want to continue taking my meds as is, and not go through major discomfort. Also, if I may be a little sarcastic, if Suboxone is so wonderful, why do so many people relapse? -- L.L.
ANSWER: The reasons for the current crisis in opiates are many, and physician overprescribing is a significant one. Solutions must include less inappropriate prescribing of opiates, which are not the best choice for long-term pain management.
However, there are people who do require opiates, people for whom there are no good substitutes. Criteria for continuing opiate prescription in the long term include: successful pain reduction, as measured by a clear and sustained improvement on pain scales; absence of serious side effects from opiates; and clear and ongoing communication about mitigating risks to the patient and family members, including the availability of naloxone for reversal in the case of overdose.
I am concerned that people like you, who are functioning well on a stable dose of opiates, are at risk for not having good pain control with alternative methods. That does not mean it may not be worth a trial of alternatives.