Quote From: docdebbeeThanks to Steve and Jenoc (I hope that's correct) for your kind comments on my rather verbose post. I hoped it would shed some clinical research light on the subject along with some of my practical experience.
Those on-line Vicodin suppliers are quite upsetting to me. I don't even like writing 90-day prescriptions for mail-in. That's too much medication to have at one time. And the real risk, unbeknownst to most people, is not the hydrocodone amount but the tylenol! The maximum safe dose per day is 4000mg. Most Vicodin or Lortab dosages contain 500mg of tylenol, regardless of the hydrocodone dose. That means the maximum number of tablets a day you should take, whether you take 5, 7.5, or 10mg of hydrocodone in the pill, is 8 tablets if the pill contains 500 mg of tylenol. Common dosages are 5/500, 7.5/500, 10/500, 7.5/750, 10/325, and 10/650. Sometimes I will write a prescription for 10/500 with the instructions for 1/2 to 1 tablet every 4 hours rather than 5/500 with instructions for 1-2 every 4 hours if I feel the patient might need the stronger hydrocodone dose as opposed to the tylenol in it.
There is a very real problem called "Iatrogenic pseudoaddiction". This means the doctor is underprescribing pain meds for a legitimate painful condition, causing the patient to not quite get relief. The patient then tells the doctor he/she needs a higher dose or an additional dose to be able to function normally. An astute doctor well versed in pain management will understand this is NOT a plea to "get drugs". This is a legitimate update to the doctor as to how the pain management is going. The patient's daily functioning is not quite normal, which is what the patient desires.
In keeping good notes, I ask patients on a 1-10/10 scale, what is the worst pain without medication, the best relief with it, and at what level do they feel the need for additional medication. Also what activities can they not do because of pain. Sometimes it's not a pain medication but a muscle relaxer that is needed, so careful questioning is important. On follow-up, I ask what the patient can NOW DO given the current medication dose. If the patient says, "Doc, I'm so much better, but I'm just not quite there. I can't stand as long as I have to at work. The meds don't allow me to sleep through the night. Etc.," I'm going to take the patient at his/her word and make adjustments. Usually it means instituting a long-acting medication and filling in with a short-acting one for break-through pain, which hopefully will be only a couple of times a day when the person is most active. NOW if the person just NEVER seems to be satisfied and "that other medication" always seemed to have worked better now that we've switched, that's a red flag that the patient may be after more than just pain relief.
My point with the above is there are too many doctors who immediately presume a patient who complains about the current dose being inadequate is wrongly labeled a drug-seeker when the problem lies with inadequate treatment. And, quite frankly my dear patients, there are far too many doctors who just don't give a damn! I'm not one of them, which is why I have a lion's share of chronic pain patients.
I have 3 principles in my practice of medicine: Respect, Listen, and Believe. RESPECT the patient regardless of age, gender, economic station, or past history. You may be the first person to give this person a fresh start. LISTEN to what the patient (or representative if he/she is a child or quite elderly) with all your senses. It's not just the words spoken that convey the message and you might miss it if you aren't careful. BELIEVE what you are told unless you have a VERY compelling reason not to. Assure the patient that you will always be truthful AND you expect the same. Many patients have not had that experience in a doctor's office. If you haven't, tell your doctor and find someone who will follow these tenents.
A couple of people have made the statement "I'm addicted to my antidepressant." I've got news for you--so am I! I had a problem with depression in the winter for years. When I finally realized the pattern, I did make sure I had plenty of light around. I didn't start med school until I was 33 (with kids 4, 6, and 9--and a fantastic husband who is still with me!) and I was smart enough to arrange my 3rd year schedule to have surgery during December and January with the logic being I would spend several hours a day under those bright lights in surgery. It made the rotation tolerable. The next year I knew I had residency decisions to make, and even though I was rather sure of what I planned to do, I was concerned that I'd hit one of those down periods and I didn't want that to happen. Prozac was finally commonplace then. I was started on it the first week in December. Three weeks later I felt like it was the middle of July! It was the best thing I ever did in my life. That June, I made the stupid decision to try and stop taking it--only to start bursting into tears if someone started to criticize me. Interns MUST have thick skins and "there's no crying in internship." I restarted the medication.
The guidelines for antidepressant use are to take it for a MINIMUM of 9 MONTHS to a YEAR if this is your first episode. If this is your second or later episode of depression, you may need to take it longer, or you may even need to take it for life. This is not a sign of failure in your life. It's a neurochemical imbalance. Of course there are other possible problems you could have that might be wrong if your antidepressant doesn't seem to be working, but that's for another time.
For those of you with chronic pain and depression, Cymbalta has been found to be an excellent medication you may want to discuss with your doctor. It hits both serotonin and norepinephrine and may even allow you to get by on less pain medication than you needed before. This is where I'll make another personal confession. I have a severe case of fibromyalgia, one of the reasons I have a great interest in chronic pain management. I started on Cymbalta over a year ago when I was in the midst of a terrible fibro flair. I was able to decrease my pain medications tremendously after starting this. Of course not everybody responds in the same way, but it was a blessing to me.
As a family physician for the past 11 years, having come into the profession at a later age, I hope I have been helpful in passing along some practical knowledge in these subject areas. These are tough topics. I hate for those with legitimate pain problems to be made to feel as though taking their necessary medications makes them addicts when they are nothing of the sort. I don't like needing medication. I have no "craving" for medication. I take what I need on a schedule that allows me to be a normal person, as do the overwhelming majority of chronic pain patients. Needing to get that "extra buzz" by taking increasingly higher doses is NOT what the chronic pain patient does. THAT is what the ADDICT does--however "high functioning" he or she perceives him/herself to be. There's a preoccupation with "needing that higher dose" and NOT with "needing enough". MAJOR DIFFERENCE.
I wish you all well and I hope I have helped answer some of the questions that may have been eating at some of you.
Blessings for now and for always,
DocDebbee
Doc, interesting post, but how can the person living with someone who is constantly saying they are in pain and need medication know if it is legitimate pain or just wanting to be medicated? My husband has used some type of drug for over 25 years and it has effected everything in our life. Has been to many physicians who just keep giving him meds. As I write today he is in a rehab after a family intervention. My hope for him is he will finally get honest with these people who are can help him because I am done trying.
Child of both mom and dad alcoholics, wife of 33 years to (some type of addict) 3 kids, 2 grands who is just plain tired and worn out.
(Original Air Date: 10/28/05) Being a mom is hard enough, but imagine juggling soccer, PTA meetings, homework and carpools all while trying to cover up a secret life of drug addiction. Dr. Phil follows up with some moms who say they were junkies. Joani, a mother of two, couldn't get through a half hour without shooting up -- and she was a nurse in a drug rehabilitation center! It's been six months -- how is she now? Then, Stephanie was addicted to Vicodin and took 60 times the recommended dosage every day. She's been clean for four months, but now has a new problem. Plus, a viewer inspired by Stephanie checks herself into rehab. Join the discussion.
