Chronic pain & opiates (part 1)

I wrote this last year but it is still so relevant and I hope helpful!  Part 2 tomorrow…

Pain, pain go away…..if only it were so easy.  A new facebook friend is suffering terribly at the moment, whilst trying to do what the hospital requires for a spinal cord stimulator trial.  Trying to offer some words of advice and encouragement has got me thinking and I thought I’d have a stab at talking about opiate use in chronic pain.

I don’t know what the policies of other pain centres are, but the consultants at St Thomas’ recognise that opiate substances – control drugs such as morphine, pethidine, tramadol, oxycodone etc – are not necessarily the right fit for every type of pain.  The majority of what I am going to write is from personal experience – both in my other life as a palliative care nurse, and from now living with chronic pain.  I’ll try not to become too medical and I may spread this over several posts as I really don’t want to bore you!  I have done a little medical reading to ensure that I am giving you the latest thinking and for those with medical minds I will list some of the articles that I’ve read – although I wouldn’t necessarily recommend them, bedtime reading they ain’t!!

In cancer care and particularly palliative care, opiates have long been the gold standard for pain relief.  Diamorphine, pure “medical” heroin, was the drug of choice when I started working in cancer care, but even then nerve or neuropathic pain was a nightmare for us to control.  Try to visualise your nervous system as a circuit board whose main branch is the spinal cord, which is supplied with its impulses to & from a source that is your brain. The channels of the circuit are made up of building blocks, cells called neurons, which transmit the messages to & from the brain. The unknown quantity is: in the circuit that processes and transmits pain, which neurons are those providing the output that drives the pain network within the brain where chronic pain is present.  Still with me?  In chronic pain the firing activity of the neurons is changed, but it is still unknown quite how it is altered.

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I have sat in some very complicated pain management sessions in my time when the descriptions of the different pain receptors almost went over my head.  All you need to know is that the building blocks contain different receptors which convey different sensations and so respond to different drugs.  Think of a lock and a key – a particular key (the drug) is needed to open a lock (the pain receptor).  When opiate drugs are used for pain control, the receptor that responds to morphine etc is Mu, but there is now known to be an optimum time period for use of these drugs – probably about 3 months.  After a while the opiates cause the down regulation of the Mu receptors, which means that fewer receptors need more opiate molecules to get the same feeling of relief.  Eventually the loss of these receptors means that our bodies cannot regulate the feeling of pain so well – and produces what the medics call “hyperalgesia”.  When your consultant tells you that the opiates may be increasing your pain rather than reducing it, this is what he is talking about!

But where does this leave me, the person with the chronic pain? To be continued….

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“Personalised Medicine & Opioid Analgesic Prescribing for Chronic Pain: Opportunities and challenges”  Stephen Bruehl et al, The Journal of Pain, Feb 2013, Vol 14

“Increased Pain Sensitivityin Chronic Pain Subjects on Opioid therapy….” Yi Zhang et al, American Academy of Pain Medicine, 2015, Oxford University Press

“Narcotic Drugs for treatment of Chronic Pain: a double edged sword” Peter Ullrich, Spine-health.com, 2012

“How Pain killers sometimes increase Chronic Pain” Stepahnie Burke, Spine-health.com, 2013

Think this is enough……I apologise if this is too medical, the next part won’t be!

 

Lest We Forget

First I must give a huge shout out for my in laws who gave me a fantastic week, in spite of the weather.  Thank you for the break, the opportunity to rest without feeling (too) guilty and for generally looking after me!  I really, really appreciate it.

We drove back home on Sunday, a damp, dreary drive.  By the time we reached the first services on the M4 motorway I was beside myself – pain, nausea, swearing I would never make another car journey.  I was grey – even I could see I looked awful, and whilst a fix of caffeine helped, getting back in the car took an enormous effort.  But then something happened that put things into perspective.

images (1) From out of nowhere, a stream of motorbikes appeared, rider after rider bedecked in red.  Their mixture of T shirts, scarves and even hats over cycle helmets formed a crimson river billowing out behind them.  Many carried flags, wreaths or giant poppies.  We left the M4 for the M25 and another fleet of riders was heading towards us on the opposite carriageway.  This was the “Ride of Respect” and I don’t know how many riders turned out on Sunday on small bikes, Harleys, huge modern Suzukis, trikes, but they paid their respects to our forces in the most poignant way I’ve ever seen.  Why was I complaining?

It’s funny, but the first time I “experienced” nerve pain was as a new student nurse caring for an old soldier.  He had served in WW2 and had a wicked sense of humour.  In other words he had great fun teasing us first years.  “Nurse, please help, I need to get up to have a pee” and then he would roar with laughter when he saw the young nurse’s face as the bed covers were pulled back and realization dawned that he had no lower legs.  He would never say what happened to leave him a double amputee, only that he was the lucky one.  Most of the time he was happy go lucky with a throaty guffaw of a laugh, but every couple of days he would change.  He would rock backwards and forwards, and weep as the pain in his feet became unbearable.  Yes, that’s right, his feet.  My first experience of phantom limb pain.  The worst time for him was during the night when he cried out in agony, but there was little that could be done to help ease it.  We cared for his stumps to the best of our ability, and helped him fit his prosthetic limbs when he could tolerate them, but it is only now that I can truly understand to a very small extent what this uncomplaining old soldier was going through.

At one of my outpatient appointments with my last surgeon, Mr B, I asked why he couldn’t just “snip”the affected nerve and be done with it.  His response was that I knew better than that, as I would still feel pain after – exactly like phantom limb pain.  The actual problem is not in my foot or my leg or even my sciatic nerve, but rather right in the nerve root which then tells my brain that my foot has pain.  In the same way my patient’s brain was being fed false information that made him “feel” sensations in his non existent feet.  The nervous system is ever complex.

Today as we remember our war dead on armistice day, it is so important to remember our war living too – those wounded and in pain, physical and emotional.images (2)