Opiates can lose effectiveness

DEAR DR. ROACH: I just read your column regarding concerns about taking tramadol long term for arthritis pain. I am a 74-year-old female, and I take one or two 50-mg tablets a day, depending on my pain level. Most days, my pain is controlled on that dose.

I also take 1,300-mg acetaminophen twice daily. I have chronic atrial fibrillation, and take Coumadin daily. I have been taking tramadol for over a year. I have been on other pain medications in the past, but my doctor didn’t want me to stay on them long term. What are my options?

ANSWER: Opiates like tramadol are useful pain medications for acute pain, but they are not appropriate for many people with chronic pain. They have side effects and can be misused, and people tend to develop a tolerance for them, which means that they really don’t work very well; people report the same amount of pain despite long-term use, compared with when they weren’t taking them.

Given the large amount of overdose with these drugs, deliberate and accidental, it is entirely appropriate to limit opiate use to a few days in those with acute pain and to consider whether any patient needs them long term. So, I understand why you are asking about options.

There is another side to the story, however. Some people do well on opiates, taking reasonable doses that remain stable, and they get good relief from the medication. There also are people for whom there are no other good medication options, such as people with extremely painful facial nerve pain syndromes.

Policies that are intended to reduce harm from opiates need to consider the group of people for whom they are appropriate, and who may be harmed by restrictive policies.

In your situation, given the low dose of tramadol you have been taking for a year, and the (what sounds like) adequate control on this dose, I would not feel strongly that you needed to change.

DEAR DR. ROACH: My niece recently was diagnosed with breast cancer. Radiation was recommended. Her mother said that first she’d have to boost her immune system. Is it possible to actually do that?

ANSWER: Radiation is a common treatment after breast cancer surgery. It’s done to reduce the risk of recurrence, depending on the exact type of cancer.

Boosting the immune system is a new adjunct for many types of cancer. There are several ways to do this: One is to genetically modify the patient’s own immune T-cells, but many other techniques are in trials now.

However, if your niece’s mother is talking about supplements, I’d be cautious.

Supplements that are promoted to boost the immune system generally are ineffective at doing so.

Making sure your niece has proper nutrition, gets good sleep and experiences as little stress as is manageable are ways to prevent stress on the immune system. Everyone could benefit from those deceptively simple steps, but especially a person being treated for cancer.

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