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PostPosted: Sun Mar 23, 2008 7:18 pm 
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I received this letter today. I don't know if was asking my opinion or challenging me to a debate. In either case it is worth publishing, because the issues are important. There are no straight right or wrong answers for some of the questions. The writer's questions are in italics; my responses are not.


Why is it wrong to take pain medications for pain? Especially if you have INTRACTABLE CHRONIC PAIN, what is there because detox.


Medications for pain are not ‘evil’—the only way I approach the issue is from a quality of life position. There are many problems with pain meds as they are now. At some point I expect we will find a way to avoid tolerance to opiates—that will truly revolutionize pain treatment. But as things are now, tolerance is the basis for the problems with chronic use of narcotics for pain. Any person taking narcotics, either for pain or for ‘fun’ (although there is nothing fun about opiate dependence after the first few weeks), will become tolerant to the effects. The medication will become less and less effective, requiring increases in dose to get the same pain relief. The dose cannot be increased forever—eventually the patient would be chewing on pills every minute of the day—and so the doc must limit the pills. If I give enough medication to satisfy a person who is 40 yrs old, what will I do when the person is 42 years old? Tolerance develops very quickly—this leads to tension between doctor and patient, and eventually the patient takes too many and asks for early refills. This annoys, angers, or frightens the doc, who therefore eventually stops the narcotics or quits seeing the patient. The patient, meanwhile, thinks he is being deprived, and gets mad at the doc, mad at all docs, and mad at the world. Finally, pain meds get inside the head of everyone who takes them, whether they are being taken legitimately or not. The patient becomes more and more focused on the meds, getting the meds, the pain, and the withdrawal. Relationships suffer. Depression develops. The patient eventually becomes a one-dimensional shadow of who they once were, where the biggest relationship in the patient’s life is the relationship with the pain pills. I have seen this all happen many, many times, with every patient who takes narcotics. I do treat with opiates, but I do tell the patient all of this, so they understand what they are taking on. This is why opiates are always the last resort. Any good pain doc will tell you that they have seen patients who complain of terrible back pain, who ask for narcotics repeatedly and think they need them… who get detoxed for some reason and after getting past the withdrawal are surprised to find that the pain is gone, or very small. I have seen it many times, and I cannot explain it, other than the body trying to trick the person into thinking he needs pain pills as part of an addictive process.

For cancer pain, by the way, none of this is relevant—with a limited life span the doc should just give what is needed to control pain. But for non-malignant chronic pain, I have never seen opiates improve a person’s quality of life in the long term. And I have seen many lives destroyed. The patient may not see it—he may insist things are great on the pain pills, even as his marriage falls apart and his kids disappear.

Why would you want to withdraw, if the pain was being controlled and it lowered your blood pressure?

We have plenty of ways to lower blood pressure—narcotics should never be used for that purpose, except in the case of acute myocardial infarction, when morphine has a number of helpful effects including lowering blood pressure.

What if the patient was limited, and could not do alot of physical therapy to get the benefits of endorphins to work for them.

Patients can do much more than they think with physical therapy. They need to be taught patience, and they need to work at it every day at home—not only at the therapy center. Physical therapy is so valuable—but patients generally look for short term solutions. That is unfortunate. As far as endorphins go, I caution people against getting wrapped up in thinking about what their brain chemicals are doing. It is much more complicated than magazines suggest-- endorphins, for example, do many things besides pain control—including things that have nothing to do with pain. Yes, they have been shown to be released by exercise, but… so what? We don’t know if that release actually does anything helpful for people.

Like you said, there is a difference between dependency and addiction. My family members suffer from chronic pain due to chronic pain conditions, that we were either born with or developed.

There is a difference early on, but over time the differences go away. A person who I see for a congenital pain condition who takes loads of narcotics has very few differences with a person who started pain pills ‘for fun’ and who takes tons of narcotics. If anything, the addiction is worse in the pain patient, because they are convinced they need the pills, and cannot see the destruction they are causing. A person who starts ‘recreationally’ is more likely to truly hate the pills, and is often willing to go to greater lengths to get off of them. That person hates the pills, where the pain patient thinks he loves them.

So, intervention should come, if I am just lying around getting HIGH in a chair, like the rubbish I have been reading.


I don’t know what you mean by this sentence. If you are referring to addicts as ‘rubbish’, you are off base. Yes, some addicts have bad characters, just as some non-addicts have bad characters. It sounds like you see a difference between ‘good people’ on pain pills and ‘bad people’ on pain pills. That difference does not exist. Over time, any person on pain pills becomes a slave to them, and desperately wants to be free from them. For some people, it takes longer to seek freedom; some people never seek it. I can assure you, though, that opiate addicts are not sitting around enjoying themselves—not after they have been doing it for a few months. They are scrambling for money to get something to avoid being sick—stealing, prostituting, whatever.

OR should it be, I take the pain meds, and I can walk around in the house, function a little better than suffering in pain.

That is your decision. But it is more complicated than you would like to believe.

I wish you the best, and hope things work out.

Jeffrey T Junig MD PhD
Fond du Lac Psychiatry
Wisconsin Opiate Manaement Center


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 Post subject: Goading?
PostPosted: Mon Mar 24, 2008 2:09 pm 
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Sounds like it to me, and I think its the opposite though this is only my experience, I was placed on methadone for pain management, and it was the worst experience of my life. As I tried to do a slow taper, as it did nothing for my pain, I kept myself in withdrawal for so long it caused real permanent damage to my body. When I finally realized I was merely taking it to find moments of normalcy in the day that never came, I got on suboxone and was relieved immediately, now I'm healthy, though I have to remain on hydrocortisone for life,as I went into adrenal failure. Two weeks ago I returned to my neurologist, that saw me 4 years ago, when I first started methadone, I told him it wasn't helping. He said nothing because I couldn't afford the EMD he said he had to perform to assess for real pain. On my return I told him my nightmare on methadone and only wanted to see if he could do the test now and see if I could get more restoration in my arm. I did PT on my own and regained some use back. He did the EMD and said the damage is permanent and it is what it is. Then he offered me pain pills. I said no thank you. So I disagree with the person that says if you use them recreationally you end up hating pain pills. I found the exact opposite to be true. I would never go through that again. I worked in hospice and agree completely, when terminally ill you do what it takes to get them comfortable. Sounds like someone's mind was effected by their drug use.

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 Post subject: Apology
PostPosted: Sat Apr 05, 2008 4:23 am 
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It's been a while since I posted, when I looked at my answer under opiates and chronic pain, I thought to myself, that's a little harsh, as I am not in that person's shoes, and my last sentence was inappropriate. I just think both patients and doctors should be more informed when making medical decisions. I have recently read where people are taking methadone for headaches and toothaches. I admit, I posted this in another forum. Why would a Dr. put someone on a very addictive narcotic, that you can't hardly take anything else, without risking your life? Especially for acute pain. Believe it or not I believe in pain management. I know the benefits of not living in chronic pain. This is by no means a bash on the medical community. I know this is a suboxone forum, so from here on out I'll leave the methadone part out. If you've read my posts, you know my feelings on suboxone, and I think it is a great tool for recovery. I am still new to total recovery and am entering my 4th month. I am still learning everyday. Thanks :wink:

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 Post subject: Apology
PostPosted: Sat Apr 05, 2008 4:25 am 
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It's been a while since I posted, when I looked at my answer under opiates and chronic pain, I thought to myself, that's a little harsh, as I am not in that person's shoes, and my last sentence was inappropriate. I just think both patients and doctors should be more informed when making medical decisions. I have recently read where people are taking methadone for headaches and toothaches. I admit, I posted this in another forum. Why would a Dr. put someone on a very addictive narcotic, that you can't hardly take anything else, without risking your life? Especially for acute pain. Believe it or not I believe in pain management. I know the benefits of not living in chronic pain. This is by no means a bash on the medical community. I know this is a suboxone forum, so from here on out I'll leave the methadone part out. If you've read my posts, you know my feelings on suboxone, and I think it is a great tool for recovery. I am still new to total recovery and am entering my 4th month. I am still learning everyday. Thanks :wink:

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PostPosted: Fri Dec 12, 2008 2:59 pm 
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suboxdoc wrote:
I received this letter today. I don't know if was asking my opinion or challenging me to a debate. In either case it is worth publishing, because the issues are important. There are no straight right or wrong answers for some of the questions. The writer's questions are in italics; my responses are not.


Why is it wrong to take pain medications for pain? Especially if you have INTRACTABLE CHRONIC PAIN, what is there because detox.


Medications for pain are not ‘evil’—the only way I approach the issue is from a quality of life position. There are many problems with pain meds as they are now. At some point I expect we will find a way to avoid tolerance to opiates—that will truly revolutionize pain treatment. But as things are now, tolerance is the basis for the problems with chronic use of narcotics for pain. Any person taking narcotics, either for pain or for ‘fun’ (although there is nothing fun about opiate dependence after the first few weeks), will become tolerant to the effects. The medication will become less and less effective, requiring increases in dose to get the same pain relief. The dose cannot be increased forever—eventually the patient would be chewing on pills every minute of the day—and so the doc must limit the pills. If I give enough medication to satisfy a person who is 40 yrs old, what will I do when the person is 42 years old? Tolerance develops very quickly—this leads to tension between doctor and patient, and eventually the patient takes too many and asks for early refills. This annoys, angers, or frightens the doc, who therefore eventually stops the narcotics or quits seeing the patient. The patient, meanwhile, thinks he is being deprived, and gets mad at the doc, mad at all docs, and mad at the world. Finally, pain meds get inside the head of everyone who takes them, whether they are being taken legitimately or not. The patient becomes more and more focused on the meds, getting the meds, the pain, and the withdrawal. Relationships suffer. Depression develops. The patient eventually becomes a one-dimensional shadow of who they once were, where the biggest relationship in the patient’s life is the relationship with the pain pills. I have seen this all happen many, many times, with every patient who takes narcotics. I do treat with opiates, but I do tell the patient all of this, so they understand what they are taking on. This is why opiates are always the last resort. Any good pain doc will tell you that they have seen patients who complain of terrible back pain, who ask for narcotics repeatedly and think they need them… who get detoxed for some reason and after getting past the withdrawal are surprised to find that the pain is gone, or very small. I have seen it many times, and I cannot explain it, other than the body trying to trick the person into thinking he needs pain pills as part of an addictive process.

For cancer pain, by the way, none of this is relevant—with a limited life span the doc should just give what is needed to control pain. But for non-malignant chronic pain, I have never seen opiates improve a person’s quality of life in the long term. And I have seen many lives destroyed. The patient may not see it—he may insist things are great on the pain pills, even as his marriage falls apart and his kids disappear.

Dr. Junig, thank you so much for posting this. This is exactly what happened to me, and it's refreshing to see a doctor acknowledge that long-term opiate use (other than for cancer pain) is always a bad idea and that this happens to non-addicts like me who end up needing Suboxone to safely ween them off. I just wish that I could have read something like this before this all started or that my doctors could have as well and/or been more vigilant in finding the source of the pain instead of just doping it up.


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PostPosted: Thu May 07, 2009 10:02 pm 
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I really applaud you for writing that. I totally agree.


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PostPosted: Fri May 22, 2009 6:53 pm 
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I agree completely with the doctor's response. I started out on pain pills for chronic pain. Talk about fast tolerance! That road was long and ugly. I really wish my doctors would have been more up front with me. Anyone who relies on narcotics daily for pain management will eventually end up in a dark place, in my opinion. For me, the Suboxone saved my life and keeps my pain tolerable.


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PostPosted: Mon Aug 08, 2011 3:09 am 
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I am new to the forum and I was looking for a place to write my thoughts about chronic pain and meds and then saw this post by Dr. Junig. I am so grateful for his post, I just wish I would have seen this the first week I was put on meds. Here is what I want to add to this, my individual story of how tolerance/dependence develops. My pain started 4 years ago and it is a very debilitating neuropathic pain condition. I was an athlete my whole life, very active in many many activities- running, cycling, horses, skiing... total outdoors woman my whole life. I was also someone who just had no interest in drugs. I tried pot a few times, but I've never liked the way any medicine including opiates made me feel. I'm not saying this from a judgmental place, but just a clinical point- I don't get psychologically addicted to substances, but I sure did develop a physical dependence on opiates. When I started with my dr. he gave me vicodin and told me to use it sparingly and I did just that- about 1 1/2 pills a day for a long time, several months in addition to Cymbalta to help with the nerve pain. Since that low dose seemed to work, he was thrilled. Said it was totally safe. THey discouraged Neurontin or Lyrica and said that since this conservative program was woking so well, why rock the boat. I still go to PT as well. After a few months they switched me over to 10 mg of MS Contin 2x a day... still low dose. They wanted me on longer acting opiates for better blood levels. No doctor during this time ever had a talk with me about escalating doses. Never. THey applauded the fact that I never asked for Vicodin refills, that I managed to have pain controlled on low doses. However, the pain that emerged after a couple of years- the w/d at night, that was a huge puzzle that is now figured out, but it really trashed my quality of life. It has had me thinking how this very typical scenario has been very dangerous. I'm a nurse and I certainly know how doctors work. I think in my dr.'s effort to give me good care, he was pleased that the opiates worked so well and so he was not motivated to try anything else. WHen I went to 2 pain dr's... one didn't deal with the kind of neuropathy I have and the second one just said "You won't be able to tolerate the neurontn or Lyrica so given that you are on "low doses" this is all quite benign. So, Hmmm... I believed them. Now for 2 years they did give me quality of life, except I had 2 bouts of serious constipation, and the w/d symptoms started at night and I could not sleep, and I was in more and more pain. I approached my doctor several times about this and he denied that this could happen. You shouldn't be tolerant he'd say... you are on such a low dose.....( get me a bucket about right now ;) Anyway, I had him refer to a new pain dr. and she got it and agreed with my problem of tolerance/dependence. SO, she prescribed the methadone taper ( I was on 5 mg 3x a day for pain for about 5 weeks before I started the taper), tapered so fast I had bad withdrawal and now I'm here on Suboxone. So.. this story could have been resolved at many different points along the communications. First, my dr could have told me, or as I now believe, he should have be mandated to make me sign an informed consent form to be on long term opiates. Just think, if I had a form to sign that stated I could get seriously hooked, have to take another serious opiate to get off.. I sure as heck would have made a different choice. For almost 2 years I rarely slept at night cuz my bone pain would start, my sweating would start, my insomnia would start and last all night. I'd awaken exhausted and the cycle would start all night long and then make my primary pain much worse and I was not very functional during the day. I honestly don't think doctors who give out opiates understand what they are setting patients up for. I really truly thought that when it was time to taper, I'd taper it just like any other drug that needs a taper. I mean, I never took more than I needed, took less than I needed.. I just thought after that last dose, so be it... I'm done. Doctors mostly learn that alcohol withdrawal is bad and benzos are bad... but the word you hear over and over for opiates "uncomfortable". THat's all... "uncomfortable. Well, an ill fitting shoe is uncomfortable. An awkward first date is uncomfortable. Burning dinner is "uncomfortable". Opiate withdrawal- is hell and way way more than uncomfortable. So, here I am wondering how the heck this supposedly super educated, smart RN, with doctors in the family got into this position. I think it stems from ignorance and naivete on the part of doctors. I certainly think their intention is to help, but then as Dr. Junig writes... it really gets dicey. I think informed consent would be a good place to start in educating patients on long term use of opiates. He brought up the exception was a person with cancer pain and I agree. My brother died last year from cancer and while treated he quickly became dependent in a very short time at very low doses. He ended up losing his life to cancer, and when I feel sorry for myself, having to take suboxone, I remind myself that my brother would be quite thrilled to even have the opportunity to be on suboxone right now. So, that thought certainly puts things back in perspective for me. But still, this insidious path to dependency/addiction is that proverbial sliipery slope and my regret is that I did not understand that the rationalization of my low doses did not at all protect me from dependence. So, now with every chance I have, I will be educating doctors that care for me, doctors that I know socially. As others have already said "This is where I am now" but I'd like to prevent others from going down this path.
Anita

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PostPosted: Mon Aug 08, 2011 3:11 pm 
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I agree that opiates cause a tolerance. No arguement here, but I do have a question that I still do not understand the answer to and would be great if an MD could help answer. How is it that methadone tolerance doesn't seem to be a problem. I was at a clinic for 9 years w/out a need for a dose increase ever. For me, that was the best painkiller w/out feeling like I was on something. Same with all the people I knew there. Never did I hear about someones dose needing to be raised because their tolerance went up. I'm a talker, so I got to know most of the people there. Is it the long half-life? If so, maybe there should be more, long half-life opiate meds out there that can be prescribed as easy as Percs or Vics, etc. I agree, methadone detox is HELL, and IMO clinics should be made to help someone detox when they're ready. Maybe Clonidine and Phenergan to help, prescribed at the clinic. Also wondering if people who get relief from pain with Suboxone need their dose increased. Just curious.


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Fond Du Lac Psychiatry
Dr. Jeffrey Junig, M.D., Ph.D.

  • Board Certified Psychiatrist
  • Asst Clinical Professor, Medical College of Wisconsin

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