[simplyfantast]

I'm curious about your experiences.

I'm an inpatient physician. Once you are dying of cancer, we almost dump opioids on you where I practice. Especially if you elect hospice or comfort care. If you don't, then it becomes somewhat more difficult because escalating opioid therapy is just assuming risk of causing hypotension or respiratory depression.

We definitely undertreat acute pain. But in my circle, I'm pretty frank with patients that we generally won't use opioids for chronic pain outside of cancer-pain. It's not because of regulatory issues, it's more because the vast majority of people with chronic pain that I see don't have an obvious organic cause. Yes, it means the few that do have a good indication for chronic opioid therapy will suffer.

Also, acute and chronic pain behave differently. People with acute pain have a certain appearance that is easily recognizable. People with chronic pain will be sitting there looking comfortable, normal HR, eating and walking and watching movies comfortably on their iPads. It feels so weird prescribing opioids to those people. All the while telling you they "10/10" pain.

We need better studies on who qualifies for chronic opioid therapy and how it should be managed. Drug-monitoring databases have certainly helped, but a lot more needs to be done.

[jnbiche]

> I'm curious about your experiences.

Well, let me tell you first my personal experiences with a non-terminal but severe and potentially life-threatening illness before I move on to my two relatives who died of cancer. I've had two excruciating episodes of acute pancreatitis that sent me to the ER this past 18 months. One was quite severe and left me in the hospital for a week. Pain control wasn't a problem in the hospital, but once I was discharged it become a huge problem. I got multiple other episodes of similar severe abdominal/back pain the past year but my amylase/lipase weren't elevated sky-high as they were during the two hospital stays. The whole situation lasted so long I'd assume I would be considered a chronic pain patient, and yet I can quite assure you I wasn't looking comfortable, I had elevated HR and BP, I was nauseated from either the pancreatitis or the pain (sometimes it was hard to tell). And yet the gastro I was seeing was loathe to prescribe me adequate pain relief, nor would he make a diagnosis of chronic pancreatitis all while farting around with tests like colonoscopy and gastric transit time testing. I got a months worth of pain killers from him after I was in the hospital for a week, then I was on my own though the pain was sometimes just as bad.

Finally, I fired him after getting nowhere for a year, went to a pancreas center of excellence a few hours away where they quickly ordered an EUS and found it was a bad gallbladder that was causing it (the old gastro had ordered a CAT scan and ultrasound but neither showed the sludge that my GB was packed with, although it should have shown some other issues with the gallbladder according to the pancreas expert). Had gallbladder removed a month ago and am feeling much better now, finally able to eat normally for first time in 18 months and out of severe pain.

Unfortunately, because of the pain and sickness, I've been unable to work for most of the last 18 months. Along with my considerable hospital bills (dozens of procedures, a surgery, two hospital stays), this has left my family in a precarious financial position. Luckily, so I'm now looking to return to work.

My story is not even what I was thinking about above, since I'm not 100% sure if I'd be considered a chronic or acute pain patient, but your attitude struck a nerve with me so I thought I'd share. Frankly, it pisses me off to hear you describe your patients thus, because my guess is that some of them are like me over the past 18 months.

By the way, although I certainly wasn't comfortable when I was in moderate-to-severe pain from the pancreatitis over the past 18 months, I would watch movies in a sometimes vain attempt to distract myself from the pain. I mention this just to clue you in as to what might be happening with your patients. And yes, some of your patients are malingering, I'm sure. But the fact that you make blanket generalizations about all your chronic pain patients tells me all I need to know about how many true cases of severe pain you're discounting.

On to my two relatives who passed away from cancer. One (my uncle, 45 of age, with lymphoma) wanted to die at home and so took home hospice care. Vastly under-treated for pain, with my aunts and uncles constantly reminding the doctors that he was terminal and pleading for more/better pain meds for him. The man was dying and his main goal, as explicitly explained to the doctors, was to die at home and do so as comfortably as possible, so I don't understand why concern over addiction, respiratory depression, or hypotension should have played a major role.

My other relative (grandfather) who passed away from cancer was a paragon of his community, retired fire chief, in-patient hospice care, 80 years old, and still struggled to get adequate pain relief for his terminal cancer pain. Luckily, after 3-4 weeks of unnecessary suffering, he had enough connections to influential people in the community that the situation was rectified, but what happens to other people without connections? Well, if they were at that hospice, then they probably suffered.

Honestly, this whole situation pisses me off so badly this will be my last comment on the matter. Think what you want, but tons of people, both acute and chronic pain patients, out there are suffering, and yet what's currently causing most opiate deaths are illegal drugs, not prescription pain killers. And many of the prescription pain killers are diverted from overseas, and not diverted from bona fide pain patients.

> But in my circle, I'm pretty frank with patients that we generally won't use opioids for chronic pain outside of cancer-pain [...] Yes, it means the few that do have a good indication for chronic opioid therapy will suffer.

Glad you recognize this. In addition to my verifiably organic condition, I have a friend with phantom limb pain (actually missing a arm, pretty fucking organic!) who is not helped much by the usual neuropathic pain drugs while opioids helped him tremendously. But he can't get them anymore, like yourself, all his doctors refuse, and so he suffers and is on disability when before he worked. Another casualty from our war on drugs, I suppose.

If you're like most doctors, I'm guessing that this won't make a damn bit of difference to your perspective, so I'm not sure why I spent the time writing it up. But I did, so I'll hit submit.

[gm-conspiracy]

I am not a doctor, but I do appreciate you sharing your perspective.

Thank you.

[hansthehorse]

I recently underwent surgery and radiation treatment for cancer at the base of my tongue (left side) which was noticed by me because it formed a lump on the left side of my neck. They took about half a golf ball out of the base of my tongue and scooped out a bunch of neck stuff but my neck never bothered me at all. Tongue surgery recovery plus 2 months of mouth and neck radiation treatment is something I wouldn't wish on anyone.

I was on morphine for 5 months and my only complaint is that they told me at refill time that I should be done with it now and they didn't want to renew my monthly prescription. I told them I agreed with them but I needed another month of pills to allow myself to wean off of them over time. They were very reluctant but after a few hours and a few different doctors talked to me they went along with it. I did a 4 one week reductions and that first week without was almost worse than the cancer recovery.

I fear the return of the cancer more because of the need to have to go through the morphine withdrawal week than the cancer itself.

This was at the West Palm Beach VA Medical Center where I received absolutely first class treatment throughout the entire experience.

[gm-conspiracy]

I was on morphine for 5 months and my only complaint is that they told me at refill time that I should be done with it now and they didn't want to renew my monthly prescription. I told them I agreed with them but I needed another month of pills to allow myself to wean off of them over time. They were very reluctant...

This makes me so mad.

You are just supposed to quit in one day, cold-turkey?

Ridiculous.

[klibertp]

> People with chronic pain will be sitting there looking comfortable, normal HR, eating and walking and watching movies comfortably on their iPads.

Are you really a doctor? It's hard to believe - if you were, you should know at least how the chronic pain works, how devastating it can be, how it destroys people's lives, all the while without (most of the time) making them scream and cry (or have elevated heart rate).

The chronic pain works not through how severe it is (although it can be really severe at times), but through it being chronic: it's with you non-stop, never leaving you, you can't forget it, you can't do anything about and - which is the worst - you know it won't end. It's easier to cope with the pain if you know it will subside at some point, in a week, in a month. It's incredibly devastating to know that there is really no point in you trying to bear the pain because all it gets you is more, not less, pain tomorrow.

It's incredibly hard to even imagine what the chronic pain feels like. Chances are you are mostly healthy, and the pain you experienced was temporary. You can't, at all, use such experiences to try to understand chronic pain patients. If you want to understand it, go break an arm. Wait for it to heal a bit, then break it again. Rinse and repeat, for years. Then, try to live a comfortable, fulfilling life and come back to tell us how it went.

Chronic pain patients can look alright on the outside. Especially if they are on a good painkiller, but even if not, they can look perfectly normal... for a time. They develop coping strategies and generally do their best not to show their pain when in public. You can limp for a while with a broken leg, too, before passing out. Yet, if you observe the same patients for a whole day or two, you'll see a lot of signs that they do, in fact, suffer a lot. Don't dismiss it just because some of them manage to look alright when waiting for an appointment.

---

Another thing is that I don't understand what is wrong with taking opiates, at all, other than the risk of overdose, which would be non-existent if they were legally available. From what I've read, very few overdoses are intentional, most happen because people are getting fentanyl when they expected oxycodone (actually, it's crazy that they use fentanyl to fake oxycodone - it's like trying to fake coffee with amphetamine...). The less-potent opiates and opioids (basically oxycodone and tramadol), which seem to be fuelling the crisis, have a lot fewer side-effects, including mood-altering high, than morphine or heroin. I don't see a reason for banning people - even healthy ones - from using them, other than some almost-religious conviction that people "should live clean". If there's something I'm missing here, I'm all ears.