I’ve written about the spectrum of medical and scientific opinion (not, unfortunately, always the same thing) over the use of opioids for treatment of chronic pain.  For those who missed the earlier discussion– one that produced a heated response from readers– I invite you to review those posts.

The essence of the issue is that over many years, there has been significant effort to increase patient access to potent opioids.  This effort has come in part from the pharmaceutical industry, but also from organizations that advocate for patients with a wide range of painful conditions, some with connections to pharma, and some without connections to pharma.

There has even been a push to increase opioid prescribing from Federal agencies.  Back in the 1990′s, when I chaired my local hospital’s Department of Anesthesia, we were warned by agencies hired by the hospital that the Joint Commision on Accreditation was focusing on pain control one particular year, and that some hospitals had been cited for insufficient prescribing of pain medications.

26 Comments to
Opioids for Chronic Pain (?)

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  1. First of all, the CDC has not shown a valid statistical relationship to establish cause-effect between increases in opioid prescribing, addiction treatment admissions, and opioid-related deaths during the past decade. The science is not there.

    Of equal concern in terms of an “epidemic” might be the 36,547 suicides in 2008-2009, compared with 15,000 opioid-related deaths. How many of those suicides were among persons with unrelieved chronic pain? The biased focus on opioids may be missing problems of even greater concern among the 116 million persons with chronic pain in America.

    Finally, the PROP-group videos are very interesting and the presenters are highly respected professionals in the pain field. However, some of the opinions expressed are not supported by a preponderance of high quality evidence. In fact, overall, the newly emerging anti-opioid bias is not really supported by good and valid evidence. The presenters might be correct in their clinical observations, but are we to be guided by opinion based on limited observation or by validated scientific evidence? A great deal of the research evidence relating to long-term opioids is of very poor quality and driven by the hidden agendas of the researchers.

  2. I have gone to a chiropractor, bought to hot tub, bought to zero-gravity chair, taken opioids. The meds use to work but now been on them over a year, but my body has now become immune to my meds that I currently take. Indicates Chronicpainkillers.com that this is due to the amount of opiate that I take and that I must be careful with the side effects. Even though my blood pressure is always elevated, I have yet to find a pain doctor to switch me to a different long acting opioid and breakthrough or raise my dose. Where are the real pain management doctors that can tell the difference between a head and an current pain patient pill?

    • I’ve BEEN a chronic paid doctor, back when I was an anesthesiologist– and frankly, I’ve always believed that the ‘pain clinic’ is more of a marketing idea than specialty that offers a significant advance in treatment of pain.

      I think you are referring to ‘tolerance’ when you say you have become ‘immune’. Understand that there is ‘cross-tolerance- between all opioids that act at the mu receptor– the receptor where most of pain relief is derived. So if you are tolerant to morphine, you are also tolerant to extended release oxycodone, hydromorphone, oxymorphone, etc.

      If you find a doc to increase your dose, your body will become ‘immune’ or tolerant to that new dose within a period of weeks. That is the dreadful pattern that often ends up trapping people, and they end up unable to reduce their dose without withdrawal symptoms, yet unable to continue to push it higher and higher– as good doctors know that the sky is literally the limit, in such cases.

      There is no simple answer; anyone who provides one is simply incorrect. I do believe that the future holds benefits for people in your position– but we are not there yet. I’m sorry that I am not able to be of more help– and I hope that whoever is treating you is aware of the concept of first, doing no greater harm to you than has already been done.

  3. I find need to comment regarding first comment posted by Stewart Leavitt:

    In the first paragraph it is stated that, “the CDC has not shown a valid statistical relationship to establish cause-effect between increases in opioid prescribing, addiction treatment admissions, and opioid-related deaths during the past decade. The science is not there.” This is most reminiscent of the 50′s and 60′s when we heard the same comments about tobacco and its relationship to COPD, heart disease and lung cancer. I think the response is that “the statistics are there”. I am more concerned that the science is not there to support chronic opioid therapy in non-cancer pain.

    With regard to the conjecture re suicide rates and that a significant proportion of suicides may be chronic pain patients. Given the marked escalation in use of opioids to treat chronic pain in the last 15 or so years the suicide rate should be down (if even as partially effective as implied). I am reminded that we tell our patients “do not use drive, use machinery or make any serious decisions when you are under the influence of opioid pain medications”. I am thus more worried about the reverse situation, that the abundance of opiates in increasing the suicide rate. (And I wonder how many tolerance-related dose escalation overdoses are classified as suicides? If we are to speculate I think the overdose rate is underestimated.)

    The current US population is now roughly 312 million. I find it hard to believe that over one third of the US (116 million stated) have chronic pain and by implication might need opioid therapy. According to recent data the US (4.5% world population) consumes roughly 80% of the worlds entire opiate supply. God Bless America.

    The final comments stating that the PROP information may be based on limited evidence well sums up the reasons we should be skeptical of high dose opioid therapy in non-cancer pain. “The presenters might be correct in their clinical observations, but are we to be guided by opinion based on limited observation or by validated scientific evidence? A great deal of the research evidence relating to long-term opioids is of very poor quality and driven by the hidden agendas of the researchers.” I think that is entirely correct. And we are now aware that many of the researchers and proponents of opioid therapy have been supported by the pharmaceutical industry (such as Purdue). Thus, based on the limited (and perhaps biased) data, should we be so enthusiastic in our endorsement of high dose or long term opioid therapy? The downsides are clear.

  4. If “the statistics are there,” as Dr. Carlisle says to support a cause-effect relationship in the CDC data, he should certainly educate the CDC because they have not produced such data (other than rather deceptive graphics showing parallel trends). There are other observations of their data to be made, which I’ve done in a Pain-Topics UPDATE here.

    Comparing the CDC’s assertions with tobacco is interesting. A more recent example might be those who were certain, based on the research, that hormone replacement therapy reduced cardiac morbidity and mortality in women. When better-designed, less biased research was conducted it was determined that just the opposite is true.

    Also, saying, “I am more concerned that the science is not there to support chronic opioid therapy in non-cancer pain,” is the argumentum ad ignoratum that is becoming so fashionable these days. That is, long-term opioids are of little benefit because they have not been sufficiently proven otherwise; or, the absence of evidence is evidence of absence. It also could be countered that a great deal of the evidence against long-term opioids has relied upon biased data-mining studies, confounded by un-assessed variables, and often finding effect sizes of statistical significance that are of trivial clinical significance.

    The 116-million adults with chronic pain is from the recent report on “Pain in America” from the Institute of Medicine. Sounds fantastic to me, too, but it is not saying that all of those persons need opioid analgesics.

    Finally, I think we’ve had a lot of biased research and commentary coming from both sides — industry supported groups and a cadre of anti-long-term-opioid folks. Add to that the interventional pain management specialists who favor approaches other than medications. Probably… there is some truth in what each group has to say; however, in my opinion, there has yet to be a truly independent, unbiased, and fair-balanced assessment of all the evidence.

    Long-term opioids for chronic noncancer pain are NOT the solution for all patients; but neither are they inherently evil as some would make them out to be. Meanwhile, many patients with chronic pain suffer needlessly.

  5. I appreciate the reply to my comments. But I protest, you put words in my mouth. The statistics that are there show a clear association. Cause and effect often takes much longer to prove. But given the clear association between the increased availability (prescription rate) and addiction, overdose and death (and I do not buy that it has to be one to one or similar as you imply on your site) it seems the burden of showing proof of real benefit is on the pro side of long term and high dose prescribing. Your arguments again mirror those so well described in the tobacco fight and the ultimate demand by industry that we “show cause and effect”. It took a long, long time and a lot of good people went down waiting for the proof.

    The HRT argument is not comparable and the magnitude of change is not comparable.

    Again in your words there is not good evidence and you say for either side. So we have two opposing sides, one supported by industry with dollars at stake, the other just trying to do the right thing as they see problems associated with change led by the pharmaceutical industry in the ’90′s that were not there pre-liberalization of drug prescribing practices. Seems that the burden is to show true benefit for use of such potentially dangerous medications. I can say in my emergency medicine practice I see the many complications of opioid therapy and I have seen an ever increasing burden of (“no I am not addicted”) patients begging me to renew their pain medications while they have an awful quality of life, often abandoned by the very doctors who put them on chronic therapy; not to mention the indirect consequences I see such as multiple young and middle aged heroin addicts who got there from oxycodone use. I don’t see the dead ones, they go to the morgue, but I do hear about them in my community, and do not remember this 15 to 20 years ago.

    The IOM report is nuts. If you are to believe their statistics there must be a whole city of pain somewhere to make up for all the pain free people in my neighborhood, community and practice. It is embarrassing they try to foist such numbers on us unless they are talking about the routine and recurring but intermittent pains that most of us learn to live with.

    I am not against prescribing opioids but over my 30 years in medicine I must say we have recently really gone overboard and in the wrong direction. To me it seems we have become awash in a sea of opioids and the statistics do show that. We owe patients the best pain relief we can give . . . but without addiction, dependency and opioid deaths, both for them and the community.

  6. Interesting exchange, Dr. Carlisle. Yes, the IOM data seem off kilter; however, before that report came out the prevalence of chronic pain was set at 78 million adult Americans (still outrageously large). Perhaps, the definitions are skewed (much like other government data are distorted, such as regarding opioid misuse, abuse, etc.). Question is, where did all that pain “suddenly” come from in the last decade or so? Surely, not everyone is merely faking it and seeking drugs.

    As for the CDC… curiously, they do not offer any statistical measures, of correlation or otherwise, to support a mutually dependent relationship of opioid distribution, deaths, and treatment admissions. One is just supposed to eyeball the graphs and leap to conclusions. This is not science.

    To finish this interesting exchange, I’d like to quote from one of our UPDATES articles, which I believe expressed our perspective fairly well….

    “Our own bias is that it is time to shift the dialog regarding opioid analgesics. While these medications may not be curative of a chronic pain condition, they can be a means to an end in providing essential relief from pain so that a patient might pursue additional therapeutic modalities to help promote enduring functionality and facilitate a better quality of life — albeit, a life that may not always be completely pain free. For many patients, opioids are a temporary measure — at whatever dose and period of time that are necessary — but, for some, these drugs may be a vital and relatively safe lifelong therapy for maintaining a more normal, comfortable existence; much like insulin, antihypertensives, antidepressants, or other medications are necessary in some patients. Rarely, if ever, would patients choose opioids (or any medication) over nonpharmacologic approaches, if the latter were readily accessible, affordable, and could provide comparable, lasting relief from pain and suffering.”

    “We agree with others that the greatest problem facing healthcare providers and society today is not too much pain medication or its misuse by a small minority of individuals; rather, the problem is too little pain relief for the millions of patients in need.”

    Ciao… SBL

  7. Dr. Leavitt, If you believe the sharp increases in opioid OD deaths, opioid addiction tretament admissions, ED visits involving opioid analgesics, etc, are unrelated to the exponential increase in opioid consumption over the past 15 years… then how what do you believe is causing the epidemic?

  8. Leave aside the issue of opioid risks. What is the evidence for efficacy of chronic opioids for pain? Epidemiological studies show that chronic pain patients on opioids do much worse in terms of pain and disability. Basic science studies show that daily opioids stimulate cellular synthsis of dynorphin, cholecystokinin, cytokines, and other neuropeptides all of which increase sensitivity to pain (hyperalgesia). Methadone maintenance patients on high doses of this powerful analgesic are more sensitive to experimental pain and complain of significant chronic pain, the more so the longer they have been on methadone. Imaging studies show anatomic changes in the brain after a month of opioids. Reports document decreased pain after detoxing from opioids in series of patients. Anecdotal reports abound of patients who believed they needed opioids for pain until they were detoxed and then felt better. When patients seem to do well maintained on opioids thiscould be office-based opioid maintenance for opioid dependence rather than pain management. The evidence on the other side that opioids esp. in high doses remain effective for pain is weak at best, and seems more like an unexamined belief that opioids are effective for chronic pain in some patients and therefore worth a try.

  9. As one who’s occupied both sides of the consulting room — as both a pain therapist and chronic pain patient — there are times when pain needs aggressive treatment, in spite of the risks of opiate therapy. However, that therapy should not be a steady state, chronic treatment. Changes to the clinical picture occur as a natural part of the a patient’s aging process, their activity level, their attitudes about themselves and their jobs and families, the state of current therapy, (and even the weather!) To generalize about the benefits and risks of opiate therapy does not further the comfort and well-being of the patient. Neither does it further current theraputical choices. A trained pain practitioner deals with each patient’s clinical picture as a unique instance. Opiates may or may not be indicated. Likewise, in a family-based practice, antibiotics may or may not be indicated, and also carry risks and benefits. Just as there are cases where a type-II diabetic needs insulin, there are cases when a chronic pain patient needs long-term opiate therapy. The opiophobia that is still perpetuated in medical schools is not based on the experience a practitioner gains in the examining room, nor is it based on laboratory evidence — skilled long-term opiate care for the non-terminal patient is still a relatively new practice. Yet, debate is healthy, so I will put in my 2 cents worth — IMHO, a practitioner’s opiophobia is based on fear, both for the patient’s welfare and for the maintenance of a practitioner’s DEA number. We may be taught to first do no harm, but we are also taught that a patient has a right to a certain quality of life. In about 40 states, this is now the law of the land. Pain is a vital sign, and sometimes, strong pain medicine therapy is the only answer for persistent pain, always based within the spectrum of an individual’s complete clinical picture (including their psycho-social profile). Yes, the choices may be difficult, but this is why we have training, and possess a brain to assimilate our experience. I must entreat the practitioners in the group to consider your patient’s holistic welfare, to use palliative treatments with both your head and your heart, and to refer to a board certified pain manager when you feel out of your comfort zone in prescribing.

  10. let some of these people have some real pain & then maybe they will shutup

  11. Opioid misuse reflects the longstanding neglect of pain in medicine. If medicine took pain seriously 50 years ago- there would b no need for this discussion as opioids, at best would be considered obsolete and superioir treatments would be commonly used. Lets face the facts doctors in only a few states receive education in pain care moreover doctors opposed the fdas efforts to require them to have education on opioids and the actively oppose state legislation on requring them to have education in paion care. In a recent study 70% of doctors failed a basic test of musculoskeletal knowledge- 80% of pain conditions are musculoskeletal. On average doctors know of three medications for pain- how many use ESWT, dry needling or refer to a chiropractor. The real problem with opioids has nothing to do with opioids- and everything to do with a medical profession that continues to neglect 116 million Americans in pain-Lets have some honesty for a change when it comes to the issue of opioids.

  12. Dry needling and chiropracty are quackery, that’s why no doctor uses them. It’s like recommending homeopathy. The best that can happen is the placebo effect; the worst is actual harm.

  13. As a person with chronic pain, I would like to observe that there really aren’t lots of good choices for the medical treatment of pain. Anticonvulsants and antidepressants carry significant risks and unpleasant side effects, and can have their own withdrawl problems. Opiates can lead to tolerance, escalating dosages, and hyperalgesia. Antiinflammatories can lead to gastric hemmorhage, heart attacks, and stroke. And all of these medications carry with them a risk of fatality that isn’t zero.

    We need more research, because not treating pain carries significant medical risks as well as psychological ones. I would personally appreciate something more useful than arguing over whether we’ll use medication that’s dangerous and ineffective, or nothing.

  14. Chrysostom- perhaps you could cite sources for your beliefs? Dry needling has been the subject of many studies as has chiropractic-perhaps people like yourself should exercise more caution when making blanket statements for anyone can go to pubmed and see for themselves Oh and by the way orthopedists do sometimes use dry needling- i assume you’re not familiar with specific mechanotransduction treatment or collateral accupressure meridian therapy or activating the transsynovial pump or mechanoreceptor myomanipulation, either. Anesthesiologists have already published studies on the aforementioned.
    Unfortunately too many people are conditioned not to explore alterantives beyond medications-they are victims of the moral and mental laziness in medicine and government when it comes to pain care.

  15. http://www.ncbi.nlm.nih.gov/pubmed/20823359 This article shows the effectiveness of dry needling- its unfortunate there are those who wont bother to do research before trying to spread their prejudices toward treatments for pain.

  16. What’s interesting to me, as someone who has lived with persistent pain for 30+ years, is that this forum is taking place in a psychiatric environment. Of course, psychiatrists are more likely to see patients with more problems related to any kind of substance issue. Through all my years of various treatment attempts, the psychiatric approach has been the least helpful. My body hurts. My spine is damaged complicated by lasting side effects from cancer treatment. I can reframe my thoughts, but that doesn’t take the offending physical cause away. Without the medications I take (long-acting and rescue meds.), I would be without the little control I have over the quality of my life. Regardless of counseling, before appropriate pain treatment, I was at times suicidal. I could have added to the statistics of folks who simply wanted to give up due to under-treated pain.

    Sure, every few years my doc and I have to look at the effectiveness of my regimen and decide on the right course of action. I trust her to advise me based on symptoms and lifestyle, research and current trends; and she trusts my pain reporting and engagement in non-medical coping strategies. As my condition is not “fixable,” I have to accept the fact that there is no one magic bullet that will cure me, and at 55, and in remission from cancer, I feel that my treatment is palliative. Why should one have to wait until ridden with cancer or at end of life to receive appropriate pain care? I know that I have to be an active part of my own multi-D care, and like the majority of people with significant pain, I look on my opioid medication as a serious commitment. That said, the back and forth arguing over withholding effective pain relievers from those who need them just makes me want to howl. The negative publicity towards opiates has gotten to the point that even some people I work with who are experiencing painful cancer complications are afraid to take their prescription painkillers because they (or their families) are afraid of addiction. Some of these folks have stage IV disease, who are in constant discomfort, disrupting the small amount of quality of life they have left. Of course, I am, like most patient advocates, abjectly opposed to recreational abuse and distribution of opioids and resent the burden such use has placed on legitimate patients who follow every rule. I, like most other people with significant pain, do not experience euphoria or get “high” which is one of the myths surrounding opiate use. I can just cope better. Get out of the house despite my pain and do the world some good.

    Let’s stop squabbling and put our collective energies into finding new therapies for pain. Come on! We have not come much further than morphine, and how old is that? Working as a volunteer in the oncology field, I see new targeted treatments go to trial all the time. Where are the targeted therapies for pain? Many jumped on the anti-convulsant and NSRI bandwagon, but I think it’s a bandaid. We need to better understand how to cut off that pain signal from the brain. Let’s put our best scientific minds to better use to find better therapies, instead of butting them together over the pros and cons of opioid use.

    • I should mention that my approach, treatment perspectives, etc are unique, because of my unusual background. I worked for ten years as an anesthesiologist, including in pain clinics. I am lifetime-board-certified in anesthesiology. I did a psychiatry residency–the typical 3- yr program–
      -after developing opioid dependence that began with appropipriate use of cough medicine that contained codeine– and crossed over to OR medications during a relapse, after seven yrs of handling potent opioids every day without a thought of using them. But once I used them, the genie was (permanently) out of the bottle–leading me to change specialties.

      I can’t speak to the effectiveness of the ‘traditional psychiatric approach’ to chronic pain, because I’ve never been a ‘traditional psychiatrist’. But I DO hear from literally hundreds of people each year– a statement based on receiving 1-5 messages daily– from people begging for help escaping from the trap of opioids. Most of those writers describe stories that began with legitimate trips to see a doctor, to find relief for sin the found, at the time, unbearable. At some point their dependence on opioids became much more unbearable than their initial pain complaints.

  17. Morphine? I think it’s been used since about the 17th Dynasty, that is, around 1550 BC, or the time of Moses.

  18. Thanks Hollicoop for telling it like it is. Just wondering how many of the docs who commented have lived with chronic, debilitating pain every day of their life. I too have had cancer that is in remission. We don’t know how long we will live. We could go in an accident tomorrow or from cancer recurrence in a year or naturally in 10 years. Right, no one knows. If I die in the shorter amount of time it will be a crime if I am refused the only pain relief I have found. So what if it comes in the form of opiates. It’s my body and my life and I should have the right to choose whether I want to live in pain or get some relief. Yes, there are many people out there abusing narcotics. Are they all such great actors that doctors can’t tell they are faking? Just curious. Sometimes just sitting in a waiting room I can tell who may be phony, like the person who asks “what happens if you fail the swab drug test”? I know changes have to be made to prevent the overuse epidemic and I know that my state is making changes as I type. But don’t withdraw the ability for the true sufferers to get some relief. I honestly believe that it is not a doctor’s or government agency’s right to condemn us to live in excruciating pain. As for the great actors who obtain the narcotics, docs should actually make everyone aware that taking the meds in a way other than prescribed could cause overdose or death. Amen!

  19. I find it interesting that you believe that it’s unethical to withhold opiates (bupe) from addicts simply due to the fear of diversion but you think it’s okay to withhold opiates from people with severe, unbearable pain because of the risk of addiction for some people. Maybe the risk of addiction would not be worth taking if there were any real options to treating chronic pain but as it is there isn’t. Like with many medications one has to weigh the risks with the benefits and I believe the risk of addiction is worth taking rather than leaving someone in excruciating pain which robs them of all quality of life and maybe of life alltogether due to suicide.
    My aunt has scoliosis that has gotten worse and worse over the years. Over ten years ago she had to quit her job as a nurse and could not function at all due to her pain. She was finally put on methadone some ten years ago and thanks to the relief it gives her she can have some kind of life and take an active role in her kids’ lives. Without it she would have killed herself a long time ago. Don’t you think it would be cruel to deny her that relief?

    • I guess the difference comes down to efficacy. I KNOW that buprenorphine saves lives. I do NOT knoe if opioids improve chronic pain. I know that people with chronic pain believes that it does– and I’m sorry to sound patronizing here– but studies suggest that those people grossly over-estimate the degree of relief that they get from pain meds. Moreover, they tend to disregard ‘function’, and place a higher priority on ‘relief’. Is your aunt better off attending family functions and knowing her grandchildren, while wincing in pain– or laying in bed, in a comfortable haze? Or should that decision be entirely up to the individual to decide? The questions become similar to the issues faced when discussing euthanasia, and are deeper than I am prepared to discuss at this moment… But I posted the PROP videos to show some of the evidence against the use of opioids. Please look at the evidence; it is compelling. But THAT is the difference in my positions; Plus I believe the fear of diversion of buprenorphine is somewhat overblown, and far less than the risk of diversion of true agonists.

  20. My aunt can attend family functions and be active in her childrens’ lives WITH the medication. Before she was put on methadone she couldn’t function at all and just lied in bed wanting to commit suicide. The difference is obvious for anyone who knows her. She still has some pain but it’s manageable. Based on what I know about her and other pain patients I definitely don’t think function is improved by withholding pain medication. It’s the opposite. I’m not a pain patient but like most people I have experienced pain and I just have to go to myself to know that when I’m in pain I don’t function well but if I take something for that pain I do. I had a bad headache earlier today and all I wanted to do was to lay on the couch. I couldn’t imagine having to feel that kind of pain every day of my life and I think it would be extremely cruel for a doctor to not give me medication that would relieve that pain. Pain hurts. A lot. That’s the reason why the suicide rates of people with chronic pain conditions is so high. Isn’t it as much worth to give opiates to pain patients to save their lives as it is to give them to addicts to save theirs?

    I don’t think there is any doubt that opiates relieve pain. Anyone who has ever taken opiates for pain knows that.

    • I was in the midst of responding, and my comment got so long that I decided to move it to a new post. Feel free to respond here, or there– and thank you all for your ongoing comments!

  21. I am interested in the answer to J miller’s last comment so I am joining the conversation.
    I my honest opinion. I think it is very inhumane to with hold pain relieving medications from anyone that gets relief with them. As for all these people in pain, I do know Lyme is an epidemic that wasn’t around when I was young but that causes terrible pain also. So here you go another disease that causes pain. More people, more disease, more need relief.

  22. Wow….. To say that the PROP videos are “evidence” that is compelling is a bit of an exaggeration! Thank you, Stewart Leavitt. I’m so grateful to Pain-Topics, and all of the excellent, unbiased reporting, information, and “evidence” based studies….or, if they aren’t….. We know! Thanks for being the voice of reason, when there aren’t many around. Also, thank you to the chronic pain patients who have responded, and aren’t laying in bed, “in a haze” from your opioid medication. So….I’m confused, are we to believe that all non cancer chronic pain patients who are on liongterm opioid therapy, are addicted, and not “dependent”? And, wait…..we don’t know whether or not opioids help our pain? And increase function? Let’s remember that for some of us who have intractable pain, there aren’t many options. I could do what I used to do….. Spend all my money on PT, acupuncture, massage, injections, therapy, chiropractors, while still in AGONY, no quality of life, no hope, no sleep, no social life, no sex, no RELIEF from unrelenting, severe pain. OR…I could do what I do now…. Fill my RX monthly, store and take it responsibly, see my prescriber monthly, sleep well, eat, play with my kids, fulfill my responsibilities at home, have sex with my husband, see friends, read books, & concentrate on things other than my PAIN. If that is NOT functioning, when before this (in between all my expensive, useless, appointments) I CRIED from pain all the time, stopped socializing, lost a ton of weight, didn’t sleep, and had thoughts of suicide. NOW that I have some semblance of a live, even with some unrelieved pain, don’t want to kill myself and escape my daily, debilitating pain, and don’t DREAD waking up everyday to the reality of severe, untreated pain….. You “EXPERTS” want to take opioids away from people like me? Because they don’t work, cause “hyperalgesia” and don’t increase my function? Says who? The patients you interviewed, who had UNDER treated pain, and complained of high pain scores, and lack of functioning? Oops….almost forgot….where is the compassion for people who DO benefit from opioids? The marginalization of chronic pain patients (particularly those on longterm opioid therapy) is a disgrace. We have been removed from the conversation, and when we are included, you don’t believe us? drug addiction is a disease, and needs to be treated as such. Don’t confuse all of the chronic pain patients with drug addicts. There may be some overlap, I agree. The majority of us who are benefitting from opioids, are engaging more in our lives because our pain is reduced. The people who are addicted, are avoiding life. They will find what they need…..no matter WHAT you do….until they are ready to surrender and ask for help…… They are the lucky ones in a way. When they are taken off opioids, or put on meds to help with dependence….. They get to move on with their lives…if they do what it takes, and really want sobriety, they WILL achieve it! US? You take opioids away from US…..we have no lives. So, until you all come up with something that works as well as opioids for intractable pain…. PLEASE, if we are being responsible with our medication, and getting relief, and YES….don’t worry, function, too! PLEASE?????? LEAVE US ALONE & stop blaming us for a problem we didn’t cause. We are human beings who have suffered tremendously with severe pain….don’t take away the only thing that has ever really helped us! Oh, and ask Forest Tennant, M.D. how HIS patients on longterm opioid therapy (even at high doses) are doing! He will tell you! They are doing quite well!

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