Category: Endometriosis Information

Dealing with Chronic Pain

Endometriosis symptoms

Endometriosis is a condition that effects about 20% of women. It is a disease that causes chronic pain, emotional torment, and can also lead to infertility. There is no known cause or cure for endometriosis. Treatments are available that can temporarily provide relief, however, none are long term. With such limited resources, all that is left is coping.
When a woman is diagnosed with endo, she may find herself frustrated and angry. She begins to wonder what she did to cause this. The pain continues and she finds herself going through cycles of surgeries and medications. Meanwhile, she is becoming a mental and physical wreck- full of anger, frustration and chronic pain. This cycle keeps repeating and eventually leads to anxiety and depression. The body can only handle so much stress before it wears down the spirit causing depression. The cycle has to be stopped.

There are several ways women cope with endometriosis. You will find that some may work for you while others may not. Experiment and build a “get well” program for yourself.

– Stop feeling like a victim. Realize that you did nothing that caused you to acquire this disease and that you are not responsible for what it has done to your life. It is the endo, not you, causing it.

– Find an outlet to release all of your negative emotions and feelings. Write in a journal, talk to someone, create poetry or art. Find a way to turn bad energy into good.

– Surround yourself with inspirational thoughts. Hang up your favorite poem or quote and read it when you need encouragement.

– Search for support. Find others to talk to that have the same condition. This can be found in a support group, web-site, or official association.

– Learn to focus on you. Treat yourself to a massage, take a bubble bath, meditate- learn to try new things.

– Become an active participant in your health care. You will feel better emotionally when you realize that you are in charge of your health.

– Become an advocate. Educate others about endometriosis. The more awareness about the condition, the better.

– Be optimistic. Visualize good things and do not focus on the bad. Of course you should be realistic, but try reversing the focus of your thoughts.

– It is unhealthy to hold tension in. If you need a good cry, you need a good cry. It is better to let it all out than to allow it to build up.

There is no easy way or a prescription for coping. Each person is different and will deal with chronic pain and emotional distress in their own way. As with any condition, some days will be better than others will. If you start implementing some of the ideas above, you just may find that you are having more good days than bad.

Author’s name omitted by request

Title: Endometriosis symptoms
Description: Endometriosis symptoms:a disease that causes women chronic pain and sometimes infertility. With no cure, women must learn to cope.

ENDO 101

“ENDO 101:”
The Basics

You’re laying in the recovery room after having a laparoscopy and your head is spinning. Your world is a foggy place and all you know is, you hurt. In the midst of this confusion, your doctor pops in and says, “great news! We found the reason for your pain. You’ve got Endometriosis. See you next week at post-op!” When the groggy feeling lifts and you start to regain your strength, you wonder, “what on earth is Endometriosis?!”
The Basics
Endometriosis is a disease affecting an estimated 77 million women and teens worldwide(1). It is a leading cause of infertility, chronic pelvic pain and hysterectomy. With Endometriosis, tissue like the endometrium (the tissue inside the uterus which builds up and is shed each month during menses) is found outside the uterus, in other areas of the body. These implants respond to hormonal commands each month and break down and bleed….

However, unlike the endometrium, these tissue deposits have no way of leaving the body. The result is internal bleeding, degeneration of blood and tissue shed from the growths, inflammation of the surrounding areas, expression of irritating enzymes and formation of scar tissue. In addition, depending on the location of the growths, interference with the bowel, bladder, intestines and other areas of the pelvic cavity can occur. Endometriosis has even been found lodged in the skin and at other extrapelvic locations like the arm, leg and even brain.

The presence of disease can only be confirmed through surgery like the laparoscopy, but it can be suspected based on symptoms, physical findings and diagnostic tests.

Often, younger women and teens who present to their healthcare providers with symptoms are dismissed and told they have PID or that they are too young to have Endometriosis. This is not the case. Endometriosis has been found in autopsies of infants(2) and in menopausal women. Endometriosis has even been found in men!(3)

Contrary to common misconceptions about the disease, there is no cure. There are, however, several methods of treatment which may alleviate some of the pain and symptoms.

Symptoms include: chronic or intermittent pelvic pain
dysmenorrhea (painful menstruation is not normal!)
infertility/ miscarriage(s) / ectopic (tubal) pregnancy
dyspareunia (pain during intercourse) / pain after intercourse
backache
leg pain
painful intercourse
nausea / vomiting
abdominal cramping
diarrhea
rectal pain
constipation
painful bowel movements
blood in stool
rectal bleeding
sharp gas pains
bloating
tailbone pain
blood in urine
tenderness around the kidneys
painful or burning urination
flank pain radiating toward the groin
urinary frequency, retention, or urgency
hypertension
coughing up of blood or bloody sputum, particularly coinciding with menses
accumulation of air or gas in the chest cavity
constricting chest pain and/or shoulder pain
shoulder pain associated with menses
shortness of breath
collection of blood and/or pulmonary nodule in chest cavity
deep chest pain
pain in the leg and/or hip which radiates down the leg
painful nodules, often visible to the naked eye, at the skin’s surface…can bleed during menses and/or appear blue upon inspection
fatigue, chronic pain, allergies and other immune system-related problems are also commonly reported complaints of women who have Endo. Remember, it is quite possible to have some, all, or none of these symptoms with Endometriosis.
Because Endo symptoms are so inconsistent and non-specific, it can easily masquerade as several other conditions. These include:

adenomyosis (“Endometriosis Interna”)
appendicitis
ovarian cysts
bowel obstructions
colon cancer
diverticulitis
ectopic pregnancy
fibroid tumors
gonorrhea
inflammatory bowel disease
irritable bowel syndrome
ovarian cancer
PID (pelvic inflammatory disease)

What does it look like?
Endometriosis can present in almost any color, shape, size and location. This includes clear, microscopic papules that can lodge themselves on the underside of organs or beneath the skin. Unfortunately, physicians who are less trained to recognize all manifestations often miss diseased areas, instead searching for visible, common “powder-burn” type lesions on the reproductive organs. In reality, the lesions can be black, red, blue, brown, clear, and raspberry colored, and microscopic in size. The lesions can be spread throughout the entire abdominal region, bowels, bladder, and other areas, and may not be visible without proper magnifying equipment.

Is it Fatal?
The disease itself is classified as “benign.” However, recent studies indicate that women with Endometriosis may have a slightly greater risk of developing cancer of the breast or ovaries and a greater risk of cancers of the blood and lymph systems, including non-Hodgkin’s lymphoma. Researchers caution that the cause of the relationship is unclear. The association may be due to drugs or surgery used to treat the condition rather than Endometriosis itself, and only women with the most severe form of the disease may have the excess risk, according to a report in the American Journal of Obstetrics and Gynecology(4) .

According to lead study author, Dr. Louise Brinton of the Cancer Epidemiology and Genetics Division of the National Cancer Institute in Bethesda, Maryland, the results are “provocative in suggesting that women with Endometriosis may experience elevated risk of certain cancers.” In the study of 20,686 Swedish women hospitalized for Endometriosis, the women had a 20% greater risk of developing cancer overall, particularly of the breast, ovaries and the blood and lymph cells, during an 11-year period. The women actually had a lower risk of cancer of the cervix. “The Endometriotic tissue and its surroundings will be enriched in growth factors and cytokines that might have a deleterious effect on the growth regulation of other cells, some of which may be in distant organs – for example, breast tissue,” Brinton wrote. The growth factors might act as carcinogens, thus promoting cancer.(5)

There are other possible explanations as well. Women with Endometriosis are also more likely take certain drugs, such as Progestagens and are more likely to have had their ovaries or uterus removed, another factor that influences hormone levels, and possibly cancer risk. It is also possible that women with Endometriosis may be screened more often for breast cancer and therefore be more likely to be diagnosed with the disease. Endometriosis has also been linked to a lack of physical activity and to exposure to the environmental contaminant, dioxin. These two factors might be to blame for the cancer risk, rather than Endometriosis.

Findings of one of the largest surveys conducted of over 4,000 Endometriosis patients in the United States and Canada(6) have indicated possible links to other serious medical conditions, including a 9.8% incidence of melanoma, compared with 0.01% in the general population, a 26.9% incidence of breast cancer, compared with 0.1% in the general population; and an 8.5% incidence of ovarian cancer, compared with 0.04% in the general population. Women with Endometriosis who participated in the survey also had a greater incidence of auto immune conditions and Meniere’s disease.

What are “Stages?”
Your surgeon determines the extent and severity of your disease once confirmation of diagnosis is made through both sight of the lesions as well as biopsy results(7). Staging has been defined by the American Society for Reproductive Medicine (formerly the American Fertility Society), with criteria based on the location of the disease, amount, depth and size. These factors are all graded on a point system and classification is thus determined. The first classification scheme was developed in 1973, but since then it has been revised and refined 3 times for a more precise method of documentation. As of 1985, the stages are classified as 1 though 4; minimal, mild, moderate, and severe. Stage of the disease is not indicative of level of pain, infertility or symptoms. A woman in Stage 4 can be asymptomatic, while a Stage 1 patient might be in debilitating pain.

How is it Treated?
Endo can be treated in many different ways, both surgically and medically. Most commonly, surgery will be performed during which the disease will be excised, ablated, fulgarated, cauterized or otherwise removed, and adhesions will also be freed. When adhesions are present, a women’s organs are literally bound together.

It is extremely important that a woman with Endo obtain treatment from a highly trained Endo treatment provider. There are many inexperienced physicians out there, sadly enough, who will a.) miss the disease altogether and not perform biopsies on tissue samples to confirm the diagnosis; b.) will confirm the presence of disease but make no attempt to remove it during surgery; or c.) will make the diagnosis, but will remove it in an incomplete or ineffective manner (such as ablation, which has been shown to be relatively ineffective on deep lesions). Doing so will unfortunately (as has been my experience and that of other survivors of the disease) allow the disease to flare again in a relatively short time. This vicious cycle only requires more surgery thereafter to once again lyse adhesions and treat the disease. Starting disease management with an Endo expert in the beginning of treatment can prevent repeat surgeries and ineffective treatment measures.

Surgeries include but are certainly not limited to: the laparoscopy; the laparotomy; presacral and uterosacral neurectomies – primarily done to lessen pain associated with Endo, where the nerves transporting sensation to the uterus are cut; and various levels of hysterectomies, where some or all of the reproductive organs are removed. It should be stressed that this method will only relieve the symptoms associated with growths on the reproductive organs, not the bowels or kidneys and related areas where Endo can be present.

There are several drugs utilized either alone or in combination with surgery. These include contraceptives, GnRH agonists, and/or synthetic hormones. GnRH agonists are commonly used on women in all stages of the disease and may sometimes have serious side affects. Be sure to inform yourself about all aspects of any drug before undergoing therapy with it.

GnRH (gonadotropin releasing hormone) analogues are classified into 2 groups: agonists and antagonists. Agonists are commonly used in the treatment of Endo by suppressing the manufacture of FSH and LH, common hormones required in ovulation. When they are not secreted, the body will go into “pseudo-menopause,” stalling the growth of more implants. However, these are again only stop-gap measures that can be utilized only for short term intervals, and the key word here is suppression. Once the body returns to it’s normal state, the Endo will again begin to implant itself.

Commonly Prescribed medications include: Leuprolide Depot – “Lupron” (Leuprolide Acetate) – administered as subcutaneous injection
Synarel (naferalin acetate) – administered as a nasal spray

Zoladex (goserelin acetate) – a subcutaneous implant placed into the abdominal wall
Suprefact (buserelin acetate) – also administered as a nasal spray
Danazol, a synthetic male hormone commonly marketed as Danocrine or Cyclomen
Depo-Provera (medroxyprogesterone acetate)-injectable form of progestins
Provera (same as above; administered in pill form)
Any combination estrogen/progesterone oral contraceptive recommended by your doctor

For treatment updates, please see “Endometriosis 2000 & Beyond: the Future of Research & Treatment.”

Living with a Chronic Illness:
While it cannot currently be cured, it is important to understand that Endometriosis is a disease that can be managed. It does not have to own you. Finding the right surgeon and choosing the right approach to treat your disease is crucial. Whether it be excision surgery, medical therapy or alternative healing that appeals to you and works to relieve your symptoms, the answers are out there. And remember…you are not alone.

For more information and support, please visit the Endometriosis Research Center on the web or call the ERC toll free at 800/239-7280.
Copyright (c) by Heather C. Guidone. All Rights Reserved. Do not Reproduce Without Express Permission From Author.

Endo and the Bowel

BOWEL ANATOMY 101

The intestines (bowel) are made up of two basic parts, the small intestine and the large intestine. The small intestine is about 9 feet long and the large intestine is about 3.5 feet long. The small intestine connects the stomach to the large intestine. The small intestine fills the area from the from the bottom of the ribs to the top of the uterus. It has no set course and looks a bit like a bunch a spaghetti. The large intestine connects the small intestine to the anus. From the anus the large intestine follows a course behind the vagina, cervix and uterus, and makes an upside down “U”, up the left side of the body, across the upper abdomen just below the ribs and down the right side of the abdomen ending near the hip bone on the right. The appendix is a small worm like structure projecting off of the large intestine close to where the large and small bowel connect. The contents of the small bowel are primarily liquid while those of the large bowel are primarily solid. The bowel wall is made up of three basic layers; (1) the serosa, (2) the muscle wall and (3) the mucosa. The serosa is outside lining of the bowel wall. It is very thin, similar to saran wrap. Most of the bowel wall is made up of muscle. This is the middle layer. The inside lining of the bowel is called the mucosa and is also quite thin…


ENDOMETRIOSIS OF THE BOWEL

Endometriosis has been reported to grow in almost every organ in the body outside of the reproductive organs. The bowel is the most common non reproductive organ involved with endometriosis.

INVASION

The degree of invasion of the bowel wall by endometriosis is one factor that will determine the type of symptoms that the patient will experience. If the bowel endometriosis is superficial, involving only the outside serosal surface, the most common symptoms are bloating, nausea and loose stools with menses. At the other extreme, if the endometriosis has invaded all the way through the bowel wall including the inside mucosa, then the patient will usually experience rectal bleeding with her period. While it is common for the endometriosis to invade through the outside serosa and the middle muscle wall, it is unusual to invade through the inner mucosal layer. This probably accounts for the high failure rate of barium enemas and colonoscopsies in diagnosing bowel endometriosis. The location of the bowel will be the primary determining factor of the type of symptoms when the muscle wall of the bowel is involved with endometriosis.

LARGE BOWEL

The pelvic portion of the large bowel (the rectum and the sigmoid colon) is the most commonly involved part of the intestine. The close proximity of this portion of the bowel to the vagina and cervix often results in painful intercourse. Bowl movements can also be very painful since the bowel contents are solid in this portion of the bowel. The portion of the intestine where the large and small bowel connect is located in the area between the belly button and the right hip bone. This is in the same area as the appendix. Involvement of the bowel in this area or the appendix can result in right sided pain. Bowel endometriosis can also result in adhesions (scar tissue). These adhesions can involve other loops of bowel resulting in a partial obstruction (blockage), the ovary, fallopian tube or even the ureter. These adhesions can also result in pain. Endometriosis of the large bowel rarely results in obstruction of the bowel.

SMALL BOWEL

Endometriosis of the small bowel usually results in bloating and pain which is associated with eating. Often patients with small bowel endometriosis have restricted the amount and type of foods that they eat. The symptoms are slowly progressive over time and the patient may not even realize the extent to which she has altered her diet. Small bowel endometriosis often results in a partial bowel obstruction. As the bowel swells following a meal the bowel kinks, and like a kinked garden hose the contents do not get through until enough pressure builds up to push by the narrowed portion.

TREATMENT OF BOWEL ENDOMETRIOSIS

All patients undergoing surgery should have a preoperative bowel preparation. It is impossible to tell preoperatively if bowel endometriosis is present. The microscope and the laser are wonderful surgical instruments for treating bowel endometriosis. This combination provides the magnification and precision necessary for me to remove the endometriosis from the bowel, without having to perform a bowel resection in the vast majority of cases. Situations in which the crude electrosurgery would result in the need for bowel resection are easily handled by microscopic laser surgery. This is true for both the large and small bowel. In the rare cases that the endometriosis has completely replaced a section of bowel, the diseased segment of bowel is removed by one of the bowel surgeons of my team and the normal ends of the bowel are reconnected.

THE TEAM APPROACH TO THE TREATMENT OF ENDOMETRIOSIS

Endometriosis is a dreaded disease which has no respect for the boundaries of the various medical subspecialties. For example: The urologist may help if the endometriosis involves the bladder or the bowel surgeon may help if the bowel is involved or the thoracic surgeon may help if a thoracoscopy is needed to diagnose and treat endometriosis of the lung. Proper preoperative evaluation and preparation in conjunction with the team approach should result in the complete treatment of the individual with endometriosis.

NON SURGICAL TREATMENT OF BOWEL ENDOMETRIOSIS

At this point in time there is no non surgical treatment of bowel endometriosis. Lupron, birth control pills etc, may slow the growth of endometriosis, but they will not get rid of the endometriosis nor the associated fibrosis or adhesions. Invasive bowel endometriosis is a serious condition which can lead to an acute surgical emergency (bowel obstruction).

CONCLUSION

In summary, you probably are looking at another surgery to treat the endometriosis of your intestine. Using microsurgical laser treatment, the vast majority of bowel endometriosis can be treated without having to perform a bowel resection.

Author Unknown
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Pain Assessment

Pain Assessment & Management in the New Millennium
Understanding Pain

Pain, without question, is the most common reason individuals seek medical attention. It is estimated that nearly 50 million Americans are partially or totally disabled by pain, and 45% of all Americans seek assistance with pain at some point in their lives.(1) Some researchers are now even referring to chronic pain as a “disease unto itself.”(2)
Whether acute or chronic in nature, “pain” is defined by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage.” “Acute” refers to pain which has been caused by an injury, illness or surgery, responds well to pain management interventions and lasts less than 6 months. Acute pain generally disappears when the cause has been treated. Chronic pain, on the other hand, may last 6 months or more. It is a persistent state that is usually associated with a long term incurable or intractable medical condition or disease. Approximately 9% of the US adult population suffers from chronic, non-cancer related pain; the majority of which have been suffering an average of 6 days a week for over 5 years.(3)

Emotional and Physiological Effects

Pain may include a range of distressing emotional and physical sensations, including aching, tightness, stabbing, burning and/or numbness. Signs and symptoms of pain vary from each individual, based on the patient’s specific maladies.

Unrelieved pain has a wide spectrum of negative effects, including interference with mobility, sleep and daily routine; impairment of concentration and cognitive abilities; a loss of enjoyment of life; feelings of social isolation and inability to relate to others; conflicts in marriages or close relationships; and feelings of anger, fear, resentment, depression and anxiety. Physical effects include impaired mobility, GI and pulmonary functions; increased metabolic rate; decreased immune response; delayed wound healing; loss of appetite; nausea; and fatigue.

Pain can impair every aspect of an individual’s life.

Women Hurt Worse

According to scientific reports, women are more sensitive to pain and require stronger doses of pain medication. Scientists believe that these differences are linked to genetic factors.(4) Additional study into this area has shown that women respond differently to pain due to the activation of different brain circuits than male counterparts. Some researchers believe that “over time, men evolved with the ability to block pain of trauma, i.e. spear points and lion bites, while women, who were not traditionally exposed to hunting and fighting, have grown to become more attuned to visceral pain like childbirth.”(5)

Assessing Pain

The Joint Commission on Accreditation of Healthcare Organizations…

(the “Joint Commission”) standards assert that individuals “have the right to appropriate assessment and management of pain.”(6) Pain assessment is most often measured through the use of scales. Examples include the 0-10 Numeric Pain Intensity Scale, as designed by the Agency for Healthcare Policy and Research in 1992. This scale rates pain from 0=no pain up to 10=worst possible pain. Another scale used by some practitioners is a simple descriptive scale, with captions reading, “no pain, mild pain, moderate pain, severe pain, very severe pain, worst possible pain.” Still another, the Wong-Baker FACES Pain Rating Scale, uses descriptive cartoon faces to allow patients to pick the one they most relate their pain with. Faces range from happy to very sad.

Coping & Management

“Management” refers to a comprehensive approach to obtaining pain relief. The patient, in association with her physician and healthcare professionals, determines an effective management plan to keep her symptoms at a minimum and regain her quality of life.

Pain management can be achieved through varied methods, ranging from alternatives to opioids. Alternative techniques commonly used include relaxation, imagery, medical massage like shiatsu and reflexology, hydrotherapy, homeopathy, music therapy, touch healing, hypnotherapy, magnet therapy, herbalism, reiki, aromatherapy, diet/nutrition, supplements, ayurvedic medicine, acupuncture/acupressure, yoga, exercise regimens, TENS units and biofeedback. Psychological counseling is often incorporated into a patient’s pain management program to relieve anxiety, anger, fear and other emotional aspects of pain. Over-the-counter medications and non-narcotic prescriptions like NSAIDs (Non-Steroidal Anti-Inflammatory drugs) are also used for pain management and relief. Finally, narcotic prescriptions are used alone or in conjunction with other therapies to treat a patient’s pain.

According to the Joint Commission, the following levels of care should be adopted when treating pain patients:(7)

Level 1: Mild Pain
Initial choices for treating mild pain include NSAIDs, aspirin and acetaminophen.

Level 2: Mild to Moderate Pain
Choices range from non-opioid to combined non-opioid / opioid. Opioids may also be used alone as therapy for patients no longer responding to or tolerating non-opioids.

Level 3: Moderate to Severe Pain
Opioid analgesics are vital to the management of moderate to severe pain. Long-acting opioids are most advantageous for maintaining round-the-clock pain control while requiring fewer medication dosages.

Continued Lack of Relief

Unfortunately, in spite of medical advancements and a growing list of pain treatment options, pain management has improved little over the last several decades. Pain remains largely undertreated and seemingly ignored by the medical community, including at hospital level. One NY State study of pain control in surgical patients revealed that the majority of patients did not receive pain relief as recommended in federal standards issued in 1992 by the Department of Health and Human Services’ Agency for Health Care Policy Research.(8) Medical experts have even stated that the weakest and most severely ill patients, including children and the elderly, get inadequate relief for the intense pain of serious surgeries, injuries or prolonged/terminal illnesses. Additional reports show that during an office visit, physicians will frequently fail to treat, or even discuss, a patient’s pain.(9)

There are several reasons for the continued inadequate treatment of pain from both patient and practitioner standpoints, including:

Lack of Communication: patients who are not directly asked, and even some who are, often fail to speak up voluntarily about their pain for fear of appearing non-compliant or being viewed as “a bad patient,” having trepidation that they may be labeled a “drug-seeker,” and being concerned about having to take painkillers.

Physicians often fail to inquire about a patient’s pain level because of several deep-seated obstacles in the medical education process, including:

Lack of training: studies have shown that poor physician training, particularly in pain assessment as well as management, significantly impedes adequate treatment. Most medical schools typically offer their students little education in pain management. Indeed, in two studies, physicians delayed giving morphine to a dying patient until the prognosis narrowed to “6 months left.” This pain management “strategy” was practiced despite the physicians’ knowledge that morphine is required to treat severe cancer pain.(10)

Concern over adverse effects: fear that a patient will have a serious physical reaction to a substance has historically made physicians reluctant to administer and prescribe high doses of painkillers.(11)

Fear of scrutiny: in today’s polemical society, some physicians worry about being placed under investigation by State or Federal agencies – or even by a patient’s family – for writing alleged “excessive” prescriptions.

And then comes the Pandora’s Box of fear regarding opioids.

Tolerance, Dependency & Addiction

Opioids all work to relieve pain in the same fashion; by attaching to opioid receptors on nerve cells, thereby causing a decrease in the transmission of pain impulses to the brain. Opioid medications all differ in strength, duration of action and side effects. In addition, no two patients are alike and therefore differ in reactions to the same drug.

One of the biggest impediments to pain relief is fear of addiction. While some believe that addiction and dependence are problems in pain patients treated with opioids, substantiated facts show that these fears are greatly exaggerated. For instance, in a review of the records of 11,882 hospitalized patients treated with opioids, there were only 4 cases of addiction in patients with no addiction history. It is further believed that opioids “depress respiratory function and are too dangerous to be dosed safely.” Research has shown that in reality, while respiratory depression is indeed the chief hazard of opioid use, clinically significant respiratory depression rarely occurs in patients in pain for whom doses of opioids are appropriately prescribed.(12)

Tolerance: refers to “a decrease in the effect of a drug in response to repeat exposure. All opioid medications are capable of inducing tolerance.”(13)

Dependence: a “physiologic state in which abrupt cessation of the opioid results in a withdrawal syndrome. Dependency is an expected occurrence in all individuals using opioids for therapeutic and non-therapeutic purposes. It does not, in and of itself, imply addiction.”(14)

Addiction: addiction in the context of pain treatment with opioids is characterized by “a persistent pattern of dysfunctional opioid use that may involve any or all of the following: adverse consequences associated with the use of opioids; loss of control over the use of opioids; and preoccupation with obtaining opioids despite the presence of adequate analgesia.”(15)

It is further noted, “…individuals who have severe, unrelieved pain may become intensely focused on finding relief for their pain. Sometimes such patients may appear to observers to be preoccupied with obtaining opioids, but the preoccupation is with finding relief of pain rather than using opioids per se. This phenomenon has been termed ‘pseudo-addiction’ in the medical literature.”(16)

Risks & Side Effects of Opioid Maintenance Therapy

As with all medication, opioid therapy entails a number of risks including sedation, possible liver or kidney damage if taken chronically, constipation, insomnia, decreased libido, itching, depression, loss of menses, urinary frequency, urgency or retention, muscle spasms, fatigue, GI disturbances such as nausea or vomiting, edema, weight fluctuation, headaches and withdrawal syndrome.

The most common symptoms of withdrawal syndrome are an increase in pain, general aching, cold sweats, restlessness, tremors, dizziness, nausea, vomiting and diarrhea. The syndrome can be

stopped by resuming opioid medications. If you anticipate the discontinuation of any opioid, the dose should be gradually tapered to avoid or lessen this withdrawal syndrome.(17)

The Oxycontin Controversy

Originally met with international support the year of it’s launch,(18) Oxycontin is making the news again; this time with a reputation as the latest “street” drug.

Oxycontin is a unique form of oxycodone. It is extremely effective for time-released opioid pain control in both cancer and non-cancer pain patients. Oxycontin is the only oral oxycodone that acts for a full 12 hours to relieve pain, making it the longest-lasting form of oxycodone to date. It also contains no aspirin or acetaminophen like its competitor products, which may be potentially toxic in maximal daily doses. Analgesic onset occurs within 1 hour in most patients.(19)

Oxycontin has been hailed as a “miracle drug” by chronic and acute pain patients everywhere, in a society where pain has generally gone undertreated. Unfortunately, the drug has now been nicknamed “the poor man’s heroin” because of it’s cheap price on the streets. Some have even called the illegal distribution of Oxycontin an “epidemic.”

When Oxycontin is broken, crushed and inhaled or injected, as is the method of ingestion by abusers, it is potentially lethal. In two states alone, at least 90 people have died as a result of Oxycontin abuse.(20)

Despite success stories associated with the drug, the bad publicity is taking its toll. Some pharmacies are so afraid of being robbed that they won’t even carry the drug and an Alabama lawmaker is drafting legislation that would ban it altogether, except in cases of terminal cancer.(21)

To make matters worse, some physicians are even being accused of cashing in on this and other pain relievers. In one instance, investigators cracked a pain management clinic that was a front for one of the largest narcotic-selling operations in the Midwest. Oxycontin was prescribed in half the cases for which the physician who ran the clinic was charged. The physician pleaded guilty to engaging in a pattern of corrupt activity, forfeited his medical license and was sentenced to 3 years in prison. In exchange, prosecutors dropped 46 counts of drug trafficking against him.(22)

These unfortunate developments have resulted in patients with true, intractable pain being unable to receive Oxycontin. One State Department of Professional and Financial Regulations has even urged “extreme caution” and issued voluntary guidelines for physicians and pharmacists when prescribing or filling prescriptions for Oxycontin. Physicians have been recommended to use special prescription forms that cannot be copied; use numbers followed by words to describe the quantity and strength of medication; specify on the prescription the name of the pharmacy selected by the patient for controlled substance prescriptions, as well as the patient’s insurance plan; and to fax a copy of the prescription to the selected pharmacy, when feasible, for authentication.”(23)

Joining the War Against Pain

In order to overcome problems faced by patients and physicians alike in pain management, specialists are calling for enhanced pain management education in medical school, as well as implementing new reimbursement categories for pain among insurance companies. California is breaking ground in this area, addressing the needs of it’s residents by passing legislation to make pain the “5th vital sign” to be assessed and recorded along with temperature, pulse, respiration and blood pressure. California also makes medical license renewal contingent upon completion of education in pain management. It is hopeful that other states will soon follow suit.

If you or someone you love suffers from pain, chronic or acute, it is important that you become an educated patient. Understanding why you have pain is your first step to treating it. Finding a physician who allows you to be a partner in your healthcare is equally as important. Communicate what you are feeling: if your doctor doesn’t ask, volunteer the information. To assist you in your communication with your health professionals, keep a pain journal…when pain occurred, what you were doing at the time, how severe it was, what alleviated it and when it abated. Take your medications as prescribed. Finally, in appropriate instances, learn what definitive measures may be taken to alleviate your pain, i.e. surgery.

If you are a caregiver, educate yourself about your loved one’s condition and offer help in various ways, like helping them maintain their pain journal, running errands, picking up prescriptions, etc.

Certainly, pain management is possible. However, more attention to this matter is needed by both patients and physicians alike in order to provide significant relief to those in need, to afford patients freedom from disabling pain, to allow patients to become more physically active and socially productive, and most importantly, to allow those in pain to lead a more fulfilling life.

For more information:

To report a complaint about a Health Care Organization to the Joint Commission on Accreditation of Healthcare Organizations:
http://www.jcaho.org/compl.html

The National Foundation for the Treatment of Pain:

American Pain Foundation:
http://www.painfoundation.com/

American Chronic Pain Association:
http://www.theacpa.org/

American Society for Action on Pain:
http://www.widomaker.com/~skipb/skiphome.htm.html
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