Because We Are Hurting, Damnit!

By Katherine Keller
August 10, 2009

In the wake of Michael Jackson's death, there's been a lot of hysteria about the "dangers" of prescription drugs lurking in medicine cabinets, and calls for tighter restrictions on prescriptions.

Frankly, I fear a backlash that will deny people the pain relief they need and lead to deaths from the over use of "safe" drugs.

Note: I say everything I'm about to say as a person with a recovering narcotics addict and an alcoholic in my family. The first person to mention addiction as a valid reason to not prescribe medications deserves to get face punched and then kicked in the head.

In the United States, the Food and Drug Administration (FDA) is looking to increase the warnings and decrease the dosages of popular over the counter (OTC) pain relievers and combination fever reducer/cold-sinus medications and potentially ban the prescription pain relievers Percoset and Vicodin, both of which contain acetaminophen (aka "paracetamol"), the active ingredient in Tylenol.

The driving reason behind this is that in the United States, every year, there are 42,000 hospitalizations and 400 deaths related mostly to liver damage caused by the misuse of acetaminophen. That's right boys and girls, Tylenol, which is mixed in to a lot of other medications and prescribed because it has so few side effects, can destroy the liver.

While a good portion of that liver damage is caused by deliberate overdose (suicide) or by accidental overdoses (such as a person taking the maximum dose of Tylenol and then taking a maximum dose of a cold remedy without realizing that it contains a lot of acetaminophen), a statistically relevant portion of that liver damage has to do with people taking the maximum "safe" dose every day (whether prescribed or OTC) unsupervised, for extended periods of time because they can't get anything stronger. Or, damage occurs because people can't get a plain narcotic pill for pain, but can only get it mixed with acetaminophen or ibuprofen, and increasing the number of pills consumed to get needed pain relief leads to overdosing on the "safe" ingredients.

And that says everything about how we do, or rather, don't manage pain in the United States.

If a person is taking (or exceeding) the maximum dosage of a "safe" OTC pain medication every day for an extended period of time, then clearly, their pain is not being well managed.

In 1994 I herniated a disk in my back. (Eventually I had to have surgery.) I had constant sciatica down the back of my right leg and a constant sensation of pins and needles in my foot. For several months I took 800mg of ibuprofen every four hours just to function. I could not sit for more than two hours. I could not walk for more than 15 minutes without needing to sit down or lie down because of the pain. I did not sleep more than four hours at a stretch because as soon as the ibuprofen wore off, the slightest movement caused enough pain to wake me. My studies suffered because of my pain and lack of sleep, and I could not hold a job.

The maximum safe dosage of ibuprofen is 1200mg every 24 hours. I took 3600mg every 24 hours.

When I asked for something from my doctor for help with the pain, he told me that he didn't believe in giving out narcotics because he didn't "want to create addicts." Instead he told me I needed to cut back on the amount of ibuprofen I was taking because I was at risk of permanently damaging my kidneys.

I tried to tell him that the simple act of driving over the speed bump in the parking lot had caused me such a jolt of pain that I felt woozy.

But he wasn't hearing that, and told me I needed to "tough it out" and learn to "suck it up." He treated me like a junky trying to run a scam on him.

I'm no longer a frightened college sophomore hours from home and I know a lot more about pain management. I know that I should have been offered physical therapy, massage, possibly a muscle relaxant, and a course of steroids to help me with my pain. I also know that it is medically appropriate to give a person with a herniated disk narcotic pain relievers. (If nothing else, getting a longer night's sleep would've done me wonders; medically assisted sleep, while not as refreshing as natural sleep, is better than no sleep at all.)

Frankly, I view this doctor and medical professionals like him as little better than medieval torturers.

Contrast this with the experience I had last year when I tore my rotator cuff. After several days of increasing pain (not helped much by the maximum safe doses of ibuprofen or Doans Pills) I went to the Urgent Care, and in addition to being told to stay on the ibuprofen, I left with a prescription for Soma (a muscle relaxant) and instructions on using ice packs. Most importantly, the doctor told me to come back in seven days if I hadn't improved. The next Saturday, still in considerable pain, I went back, was told to continue the ibuprofen and ice packs, but also left with prescriptions for Prednisone (a steroid) and seven tablets of Vicoprofen (to be taken at night if needed for extra pain relief so I could fall asleep), and again, I was instructed to return in a week if these did not provide enough relief. I felt much better by the end of Sunday and had a much more productive week at work.

In both cases, both doctors understood that I was in pain and I never heard a word about "addiction" out of their mouths, just warnings about correct dosing and not to drive after I'd taken the Soma or Vicoprofen. The treatment started with a muscle relaxant (some of the pain was caused by swollen and clenched muscles pinching nerves), a standard treatment, and then escalated to the steroid and narcotic (also standard treatments), and each time, I was instructed to return if these did not provide enough relief from my pain. I was never told to "tough it out" or "suck it up."

Medicating for acute and/or chronic pain is a balancing act, for no pain medication is without a drawback.

NSAIDs (aspirin, ibuprofen, Celebrex, Piroxicam, etc.) are very irritating to the stomach, the aspirin related ones thin the blood, and ibuprofen can damage kidneys. (As an aside, the now banned NSAIDs Bextra and Vioxx were attempts to create a kind of super ibuprofen as strong as a narcotic and long acting, but they increased the chance of heart attack.)

Acetaminophen damages the liver.

Steroids weaken the immune system, weaken connective tissues (tendons, ligaments), and a person must be stepped off of even a short course. (Stopping a steroid "cold turkey" can have disastrous consequences.)

Cannabis impairs judgment and motor responses and is of questionable legality even when prescribed by a doctor.

Narcotics impair judgment and motor responses, cause constipation, have the potential for abuse, should not be combined except under medical supervision, and must be stepped off of carefully after a period of prolonged use.

Alcohol impairs judgment and motor responses, damages the liver, should not be combined with a narcotic, and has the potential for abuse.

Tricyclic antidepressants (used to treat neuropathic pain) have an incredibly long list of side effects, should not be combined with alcohol or barbiturates, and must be stepped off of carefully.

But, despite all of that, there is no excuse for telling a person that they need to "live" with intense chronic or acute pain while not exploring all the options for management, because that's not living, that's existing, and it profoundly impairs a person's ability to work, contribute to society and family, and it impacts their overall health in myriad ways (stress related illnesses, inability to exercise, etc.).

I am heartily sick and tired of hearing about the possibility of addiction being used to deny adequate pain medication. According to the National Pain Foundation, less than 4% of people prescribed narcotics for chronic pain become addicts, and less than 1% of the total population are narcotics addicts. This is a widely overblown fear, and the irrational response to it causes untold misery for millions. The solution is not to to have the DEA and the FDA treat doctors and patients like pushers and junkies and to clamp down super tight on narcotics prescriptions. Carefully monitored and properly used, narcotic pain killers do not create addicts. The correct dose of narcotics doesn't give a high, it simply kills the pain. It gives people their lives back and allows them to function. Moreover, narcotics themselves do very little damage to a person's vital organs. An addict can live to a ripe old age, provided they don't overdose.

Addiction is ugly, but even uglier is a bleeding ulcer and/or liver and kidney failure caused by improper pain management and the overuse of "safe" non-narcotic drugs.

We need more research into the mechanisms of pain, medical professionals who have a baseline education in appropriate pain management and who know how and when to refer a patient to a pain management specialist, and safer medical formulations (both prescription and OTC). We also need regulations that mandate insurance coverage for all forms of pain management (medication, physical therapy, massage, etc.) for any duration. The medical establishment needs to wake up and realize that pain management is essential, because condemning somebody to live in constant pain is not only inhumane, but when it leads to the misuse of "safe" medications, it's potentially a death sentence.

Pain Patient's Bill of Rights — The National Pain Foundation's statement on the right to proper pain relief
Redheads' Extra Pain — A scientific study shows that many redheads are more sensitive to pain and need extra medication.