Friday, February 22, 2013

Pain medications

I decided to write this post to get awareness out about the NEED for pain medications for chronic pain sufferers.  We are NOT drug addicts, drug seekers, or getting high!  I am very disheartened about the new regulations out for pain medications, it hurts those of us that fight a hard battle with dangerous, serious, painful illnesses.  We do not sell them, overuse them, or abuse these medications.  We are very ill just trying to deal with debilitating, excruciating pain.  We are judged harshly enough about not looking ill, or on a good day being able to do a few things, these new limitations are only adding insult to injury.  Why must we pay over and over again for having illnesses that we cannot control, have no cure for, and will last forever!  There is no magic pill, shot or supplement, but we need relief, and many of us only get a that small amount of comfort from these restricted pain medications.  I would not be able to ever leave my bed if I did not have the ability to obtain my medications.  We are not complainers, or hypochondriacs we have real diseases that are very painful.  No one wants to be sick everyday unable to function, feeling guilty about not playing with our children, going out with friends, or having fun with our significant others.  There are many people that have drug addiction and that is a very serious disease and should be addressed but we are not using these medications illegally and we NEED relief. 

FDA might tighten reins on Vicodin
Donna Leinwand Leger, @DonnaLeinwand, USA TODAY8:55a.m. EST January 10, 2013

(Photo: Roel Smart, Getty Images)

·         CDC calls prescription painkiller abuse an epidemic
·         DEA wants to elevate Vicodin to the most restrictive category
·         FDA will hold a hearing in January on it
The DEA for nearly a decade has pushed for tighter restrictions on Vicodin, the nation's most widely prescribed drug. The chronic abuse of such painkillers, and devastating toll associated with this abuse, has reached epidemic proportions in the United States.
The agency could get its wish later this month when the Food and Drug Administration considers the DEA's request to put Vicodin in the same category as OxyContin and other powerful narcotics.
A recommendation from the FDA has proven elusive and is far from certain, but such a reclassification would allow the Drug Enforcement Administration to elevate the powerful painkillers from Schedule III to Schedule II, the most restrictive category of medically accepted drugs.
For the millions of patients across the nation who rely on Vicodin for relief from severe pain, the new rules could sharply restrict the number of pills they can get and drastically increase the number of doctor visits necessary to get them. Many patients who can now get a six-month supply would need to visit their doctors every 30 days to renew a prescription.
The Centers for Disease Control and Prevention calls prescription painkiller abuse an epidemic. Opioid painkillers, such as Vicodin and OxyContin, cause 75% of prescription drug overdoses, the CDC says. In recent years, such overdoses have outpaced cocaine and heroin deaths combined, the CDC notes.
"This is a real problem for the country," said Lynn Webster, president-elect of the American Academy of Pain Medicine and a board-certified anesthesiologist. He will speak before the FDA committee that meets Jan. 24-25 to consider the DEA's request.
This is the DEA's second attempt to get the FDA to elevate the powerful painkillers from Schedule III to Schedule II. In 2008, the FDA rejected the DEA's initial request submitted in 2004. The reasoning: The hydrocodone combination drugs have less potential for abuse than the other drugs in Schedule II, including oxycodone.
The DEA counters that abuse, trafficking and diversion of the drug have grown since its first request, causing a "devastating effect" on public health.
"Schedule III controls are not adequate," DEA Deputy Assistant Administrator Joseph Rannazzisi wrote Feb. 13, 2009, in a letter to the FDA requesting a scientific and medical evaluation of the drug for rescheduling.
Emergency room visits involving hydrocodone jumped from 37,844 in 2004 to 57,550 in 2006, the DEA says. In 2010, the most recent year available, the number had doubled from just four years earlier: 115,739 people were treated.
The FDA committee will evaluate the DEA's evidence, hear comments from the public and vote on its recommendation to the FDA commissioner and the Department of Health and Human Services.
The vexing question during the last review, and surely this one, is whether changing the classification will stem the misuse of the drug, or simply inconvenience patients. An analysis completed last year and submitted by the Department of Health and Human Services in advance of the meeting concluded the painkillers are "widely abused," but found no evidence to support that rescheduling would curb abuse.
Vicodin is a combination of hydrocodone and acetaminophen, the medicine in Tylenol. As a Schedule III drug, doctors can authorize up to five refills on one 30-day prescription, giving patients a six-month supply before they must visit a doctor.
Doctors wrote nearly 131 million prescriptions for the combination hydrocodone painkillers for 47 million patients in 2011, the FDA found in its analysis. IMS Health, a consulting and research firm, put the number of prescriptions at 137 million.
If Vicodin and other hydrocodone combinations, such as Lortab and Vicoprofen, are elevated to Schedule II, doctors cannot prescribe refills of a 30-day supply or phone a prescription in to a pharmacy. Rescheduling the painkillers would add another layer of regulations for manufacturers and pharmacies, including more extensive record-keeping and tighter security.
"On the surface, it looks like it might be the right thing to do," Webster said. "With increasing availability, we've seen an increase in the amount of harm from the drug, but I'm not sure rescheduling is going to reduce that harm."
Webster predicts that a reclassification would change prescribing practices because the restrictions on such drugs place burdens on physicians who have to do more paperwork and see patients more frequently. Patients who need the drug could face higher costs and more co-pays with increased doctor visits, he said.
"If we're talking about the problem of abuse, it's not just about the drug," Webster says. "It's also about the person and the environment. Part of the solution is for us to not focus only on the drug but also on the risk factors that lead to a substance-abuse problem."
Ed Michna, an assistant professor at Harvard Medical School who is board-certified in anesthesia, pain and palliative care, says the hydrocodone combinations have the same abuse potential as oxycodone, so there's no medical or scientific reason why they are not in the same category.
"It's one of the most abused drugs in the country," Michna said.
But he points out that changing the classification won't end abuse and might cause other problems.
"The other side of it is there's going to be an impact on patient care," Michna said. "Certainly, there will be less Vicodin prescribed. What's going to happen is that patients who probably deserve to have this as a treatment option are going to suffer."
Doctors, the DEA and the FDA have wrestled with the drug since 1999 when a physician petitioned the DEA to change the classification, citing increasing reports of abuse. The DEA, after compiling abuse data, in 2004 asked the FDA's Center for Drug Evaluation and Research for a scientific and medical evaluation.
On March 6, 2008, the FDA recommended against changing the classification. A year later, on Feb. 13, 2009, the DEA resubmitted its request with new data.
The January hearing is the final step in the FDA's latest evaluation.
Last year, the Senate unanimously passed a measure offered by Sen. Joe Manchin, D-W.Va., to elevate the hydrocodone combinations to Schedule II as an amendment to the Food and Drug Administration Safety and Innovation Act, but the House did not include the measure in its bill.
The DEA's administrator could issue an emergency order that would reschedule the drugs for two years, as it did when drugs such as K2 and Spice, synthetic forms of marijuana, emerged as a problem. The DEA declined to say Wednesday why it had not issued such an order.
Though the DEA and experts concerned with painkiller abuse are urging quick action, FDA spokeswoman Morgan Liscinsky defends the pace, and method, of the deliberation.
"Because this issue would impact millions of people, it has to be handled carefully and we have to make sure we are evaluating all the available data we have and make a really informed evaluation."
Opioids for Chronic Pain
Controversial Narcotic Pain Medications
From Erica Jacques, former Guide
Updated September 24, 2009 Health's Disease and Condition content is reviewed by the Medical Review Board
Opioids are powerful pain-relieving substances that are used as analgesics, or pain medications. They come from one of three places -- some are derived from plants, some are manufactured in a lab and others, such as endorphins, occur naturally in the body.
Opioids are very effective in the treatment of severe pain. In fact, they are frequently used to treat acute pain, such as post-surgical pain, as well as severe pain caused by diseases such as cancer. While opioid use for the long-term treatment of chronic pain is still somewhat controversial, these drugs can be effective and safe when taken under close medical supervision.
Depending on your needs, you may take one a few types of opioids. Opioids can be formulated as long-acting or short-acting pain medicine. While they may be taken intravenously, most people with chronic pain who take opioids use the pill or patch form of the drug.
Some opioids, such as oxycodone and hydromorphone, are straight narcotics. Others, such ascodeine and hydrocodone, may be mixed with other analgesics such as acetaminophen. Another class of opioids, defined as agonist/antagonist, combine medications to decrease pain and to decrease the potential for dependence. These include buprenorphine and butorphanol.
Opioid Side Effects and Other Complications
Many people with chronic pain tolerate the same opioid dosage for years without building up drug tolerance, or without developing physical dependence on the drug. Like most things, the extreme cases are the ones that get all of the negative publicity.
Unfortunately, many chronic pain sufferers who take opioids may wrongly be labeled as addicts, even if they do not meet the actual criteria for addiction. There is sometimes a certain stigma associated with taking narcotic pain medication, which can be frustrating for the person with severe chronic pain.
In addition to tolerance and physical dependence, opioids do have a number of other potential side effects. These may include:
·         Drowsiness
·         Confusion
·         Nausea
·         Constipation
·         Urinary retention
·         Difficulty breathing
·         Sexual dysfunction
·         Low blood pressure
·         Itching sensations
Opioids tend to affect seniors and children more than adults, so these populations must be monitored even more carefully. Often physicians start opioid doses very low and slowly increase them until a therapeutic level is reached.
Certain drugs may interact negatively with opioids, so careful monitoring is required if you also take other prescriptions regularly. Be sure to inform your doctor of any other medications you take, including those purchased over the counter, to avoid potential complications such as a drug overdose.
Why Use Opioids at All?
With so much controversy surrounding their use in chronic pain conditions, you may wonder why doctors prescribe opioids at all. Simply put, opioids are very effective at reducing severe pain. Many people with chronic pain get relief only through opioid use. For these people, the benefits of opioids outweigh the risks. Side effects and potential for dependence do not happen in every case. For many people with chronic pain, opioids can help give them back their quality of life.
Before starting you on opioids, your doctor should perform a full assessment as well as schedule regular consultations to monitor your condition. Some doctors may trial you on opioids, gradually increasing your dose while you are watched for potential complications.
Opioids: Addiction vs. Dependence
by Karen Lee Richards, ChronicPainConnection Expert
One of the greatest obstacles chronic pain patients face in their quest for adequate pain relief is the widespread misunderstanding of the difference between physical dependence on a drug and addiction. Many patients, the general public, and sadly even some physicians fear that anyone taking opioid medications on a long-term basis will become addicted. As a result, pain patients are often labeled as “drug seekers” and stigmatized for their use of opioid medications. Worst of all, their pain frequently remains under-treated.
Understanding the Terminology
Before we can adequately discuss this topic, it is important to clearly define the terms we will be using.
Addiction is a neurobiological disease that has genetic, psychosocial, and environmental factors. It is characterized by one or more of the following behaviors:
  • Poor control over drug use
  • Compulsive drug use
  • Continued use of a drug despite physical, mental and/or social harm
  • A craving for the drug
Physical dependence is the body's adaptation to a particular drug. In other words, the individual's body gets used to receiving regular doses of a certain medication. When the medication is abruptly stopped or the dosage is reduced too quickly, the person will experience withdrawal symptoms. Although we tend to think of opioids when we talk about physical dependence and withdrawal, a number of other drugs not associated with addiction can also result in physical dependence (i.e., antidepressants, beta blockers, corticosteroids, etc.) and can trigger unpleasant withdrawal symptoms if stopped abruptly.
Tolerance is a condition that occurs when the body adapts or gets used to a particular medication, lessening its effectiveness. When that happens, it is necessary to either increase the dosage or switch to another type of medication in order to maintain pain relief.
Pseudoaddiction is a term used to describe patient behaviors that may occur when their pain is not being treated adequately. Patients who are desperate for pain relief may watch the clock until time for their next medication dose and do other things that would normally be considered “drug seeking” behaviors, such as taking medications not prescribed to them, taking illegal drugs, or using deception to obtain medications. The difference between pseudoaddiction and true addiction is that the behaviors stop when the patient's pain is effectively treated.

Can a chronic pain patient become addicted to opioid drugs?
Although most chronic pain patients who take opioids on a long-term basis will become physically dependent on them, very few will ever become addicted to them. The rare few who do develop a problem are often highly susceptible to addiction due to a genetic predisposition. In a review of 24,000 patients who were medically prescribed opioids, only seven could be found who got into trouble with them. So a chronic pain patient becoming addicted to opioid medications is definitely the exception rather than the rule.
How can you tell if someone is addicted to an opioid drug?
People who become addicted to opioid drugs usually report getting a feeling of euphoria or being “high.” They soon need increasing amounts of the drug to maintain that same high feeling. Unfortunately, this frequently leads to an ongoing and often desperate search for more of the drug through whatever means possible – legal or illegal.
Some behaviors that may be suggestive of possible addiction include:
  • Taking medications more frequently or at higher dosages than prescribed.
  • Ingesting drugs in ways other than directed, such as crushing, snorting, or injecting.
  • Frequent reports of lost or stolen prescriptions.
  • Doctor shopping.
  • Using multiple pharmacies.
Following are some of the key differences between addicts and pain patients:
Pain Patients
Addicts take drugs to get high and avoid life
Pain patients take drugs to function normally and get on with life.
Addicts isolate themselves and become lost to their families.
When pain patients get adequate relief, they become active members of their families.
Addicts are unable to interact appropriately with society.
When pain patients get adequate relief, they interact with and make positive contributions to society.
Addicts are eventually unable to hold down a job.
When pain patients get adequate relief, they are often able to go back to work.
The life on an addict is a continuous downward spiral.
When a pain patient gets adequate relief, their life progresses in a positive, upward direction.


The American Academy of Pain Medicine, The American Pain Society and the American Society ofAddiction Medicine. (2001). Definitions related to the use of opioids for the treatment of pain. Retrieved December 1, 2008, from American Pain Society Web site:
The National Institute on Drug Abuse. Addiction vs Dependence. Retrieved December 1, 2008 from OurChronic Pain Mission Web site:
© Karen Lee Richards 2008
Benefits and Risks of Opioids in Arthritis Management
by Michael Clark, M.D., M.P.H.
·         Introduction
·         Efficacy
·         Risks of Abuse and Dependency
·         Side Effects
·         Summary
·         References
Chronic pain is a significant public health problem and frustrating to everyone affected by it, especially the elderly who feel that healthcare has failed them but wish to remain in their own homes, live independently, and avoid becoming a burden to others. Psychiatrists offer skills with pharmacological and psychological treatments now recognized as effective in the management of chronic pain. Recent advances in the treatment of chronic pain include the diagnosis and treatment of psychiatric co-morbidity, the application of psychiatric treatments to chronic pain, and the development of interdisciplinary efforts to provide comprehensive health care to the patient suffering with chronic pain. The psychiatrist can provide expertise in the examination of mental life and behavior, an understanding of the individual person and the systems in which they interact, and facilitate the integration of the delivery of medical care with other health care professionals and medical specialists. However, not all patients with pain require psychiatric evaluation, which should be reserved for patients who have severe symptoms, multiple treatment failures, or problematic behaviors such as substance abuse or noncompliance. The majority of patients can be treated exclusively and successfully by their primary physician.
The use of opioids as a treatment for non-malignant chronic pain remains a subject of considerable debate. Until recently, opioids were reserved for use only in the treatment of acute pain and cancer pain syndromes. Non-malignant chronic pain was considered to be unresponsive to opioids, or the use of opioids was associated with too many risks. Fears of regulatory pressure, medication abuse and the development of tolerance create a reluctance to prescribe opioids and many studies have documented this “underutilization”. Fortunately, recent studies of physicians specializing in pain, as well as those who do not, have shown that prescription of long-term opioids is increasingly common. Surveys and open label clinical trials support the safety and effectiveness of opioids in patients with chronic non-malignant pain.(refs 1-6)
Recently, several controlled trials have documented the effectiveness of opioids in the treatment of chronic non-malignant pain such as low back pain, post-herpetic neuralgia, and painful peripheral neuropathy. These studies support the use of opioids to provide direct analgesic actions and not just to counteract the unpleasantness of pain. In the treatment of chronic low back pain, transdermal fentanyl significantly decreased pain and improved functional disability.(ref 7)
In a randomized, double-blind, placebo controlled trial, controlled-release oral opioids were more effective than tricyclic antidepressants in decreasing the pain of post-herpetic neuralgia.(ref 8) Other studies have documented the presence of opioid receptors in the peripheral tissues activated by inflammation. These findings suggest a role for opioids in the treatment of chronic inflammatory diseases such as rheumatoid arthritis and connective tissue disorders.
The use of opioids for the treatment of non-inflammatory musculoskeletal conditions is more confusing. A randomized double-blind, placebo-controlled crossover study of oral controlled release morphine was performed in patients with chronic regional, soft tissue musculosketal pain conditions that were resistant to codeine, anti-inflammatory agents and anti-depressants. Although patients experienced a decrease in pain, they did not experience significant psychological or functional improvement.(ref 3) In contrast, another randomized, placebo-controlled clinical trial in patients with chronic non-malignant pain found that treatment with controlled-release codeine reduced pain as well as pain-related disability.(ref 1)
Risks of Abuse and Dependency
·         studies found that all patients who developed problems with opioid use had a prior history of substance abuse
·         maladaptive behaviors such as stealing or forging prescriptions rarely occur in patients suspected of dependence
Terms such as addiction, misuse, overuse, abuse, and dependence have been used inconsistently to describe various behaviors, making interpretation of many research studies difficult. Nonetheless, studies investigating the risk of opioid abuse have been reassuring. In one study of 12,000 medical patients treated with opioids,(ref 9) only 4 patients without a history of substance abuse developed dependence on the medication. Dependence, in this article, was defined as a psychological rather than physical dependence involving a subjective sense of need for a specific psychoactive substance, either for its positive effects or to avoid negative effects associated with its abstinence. This now is the approved definition of the American Society of Addiction Medicine for psychological dependence.
Dependence used alone SHOULD be reserved for physiological dependence that leads to a stereotyped withdrawal syndrome upon discontinuation of the medication, particularly in the field of pain medicine. Unfortunately, psychological dependence is generally confused with many terms and therefore best avoided in my opinion. The psychiatric literature is somewhat inconsistent with the substance abuse literature, e.g., the Diagnostic and Statistical Manual, edition IV, (DSM-IV) defines substance dependence as a more serious form of substance abuse. This maladaptive pattern of substance use is characterized by tolerance, withdrawal, overuse, craving, inability to cut down, and excessive preoccupation with respect to obtaining the substance. Substance abuse is characterized in the DSM-IV by use leading to failure to fulfill roles/responsibilities, use in hazardous situations, legal problems resulting from use, and use despite negative consequences.
Other studies of chronic opioid therapy found that all patients who developed problems with opioid use had a prior history of substance abuse. Even when the diagnosis of dependence is suspected in patients taking opioids for chronic pain, maladaptive behaviors such as stealing or forging prescriptions rarely occur.
In a study of patients attending a clinic specializing in pain management, almost 90% of patients were taking medications.(ref 10) Opioid analgesics were prescribed to 70% while antidepressants and benzodiazepines were being taken by only 25% and 18%, respectively. In this population, 12% met DSM-III-R criteria for substance abuse or dependence, however, the misuse and abuse of medications was not limited to just psychoactive substances. In a review of 24 studies of drug and alcohol dependence in patients with chronic pain, only 7 studies used standard accepted criteria for dependence and addiction. The prevalence of dependence/addiction in these studies ranged from 3.2-18.9%.(ref 11) In a study of chronic low back pain patients, 34% developed a substance use disorder, and in all cases, a history of substance abuse was present before the onset of their chronic pain.(ref 12) In addition, individuals with a previous history of substance abuse prior to study entry were found to be at increased risk for recurrence during treatment for chronic pain. The mechanism of relapse back to substance abuse in these patients is not well understood and probably involves multiple factors; however, a cycle of pain followed by relief after taking medications is an example of operant reinforcement of their future use. Therefore, if the patient has unresolved pain and perceives a lack of commitment to treatment by the physician, they are at high risk for relapse into substance abuse. The best prevention of relapse comes from aggressive treatment of pain and close follow-up to monitor the patient for signs of relapse into dependence/addiction.
Abuse harmful use of a specific psychoactive substance
Addiction continued use of a specific psychoactive substance despite physical, psychological, or social harm
Misuse any use of a prescription drug that varies from accepted medical practice
Physical dependence physiological state of adaptation to a specific psychoactive substance characterized by the emergence of a withdrawal syndrome during abstinence, which may be relieved in total or in part by readministration of the substance
Psychological dependence subjective sense of need for a specific psychoactive substance, either for its positive effects or to avoid negative effects associated with its abstinence
Guidelines to Minimize Risks and Optimize Benefits
Type of Information
Agency for Health Care Policy and Research (1992);(ref 13)
Cancer Pain Management Guideline Panel 1994
guidelines for the treatment of acute pain and cancer pain
The Federation of State Medical Boards (1999)(ref 14)
guidelines for the treatment of chronic pain
The American Academy of Pain Medicine and the American Pain Society
a consensus statement: “The Use of Opioids for the Treatment of Chronic Pain”
American Geriatric Society (1998)
clinical practice guidelines for the management of chronic pain in older persons
Short Versus Long-Acting Opioids
Opioids with a short duration of analgesic activity generally create more problems than they solve. These medications must be taken multiple times a day often interfering with the patient’s daily activities including sleep. But more importantly, opioids with short duration result in serum levels of considerable variability. Analgesia is difficult to achieve and side effects are more likely to occur. Controlled release (CR) formulations of morphine, oxycodone, and fentanyl are now available with a hydromorphone preparation soon to be released. Multiple studies describe the more favorable pharmacokinetic and pharmacodynamic profiles of these medications. However, a recent study comparing CR oxycodone and CR morphine found comparable analgesia but more vomiting occurring with CR morphine and more constipation with CR oxycodone.(ref 15) Transdermal fentanyl is an effective analgesic with generally fewer side effects than oral medications and over 90% of patients choosing to continue the medication after completion of a study trial. Tolerance leading to dosage escalation is generally not a problem in the management of patients taking long-term opioids. Standard tables comparing the drugs are not very helpful in dose conversion, which really varies particularly because of variability with chronic administration versus use acute/post-operative settings. Street value of the various opioid drugs varies by region of the country and there is no consistent data. In general, most addicts like to use drugs that have high potency or fast onset of action. Therefore, the controlled release drugs like Transdermal fentanyl have the lowest abuse potential. Oral controlled release opioids like Oxycontin can be crushed to destroy the matrix and they become the equivalent to immediate release forms.
Side Effects
The most common side effect of chronic opioid therapy is constipation secondary to decreased gastrointestinal motility.
However, concerns about potential cognitive impairment are more often the reason opioids are not prescribed, particularly in the elderly. However, the available research has not demonstrated deleterious effects on cognition by neuropsychological testing or electroencephalography (EEG) except in patients prescribed multiple types of medications, especially sedatives and hypnotics. Elderly patients are more susceptible to delirium than younger patients. Although no studies have examined this risk of delirium in chronic pain syndromes treated with opioids, post-operative patients are less likely to develop cognitive impairment with fentanyl than morphine. A similar study found that cognitive performance was poorer in patients receiving hydromorphone compared to those receiving morphine.(ref 16) Many metabolites of opioids are excreted by the kidney increasing toxicity in the elderly. Creatinine clearance should be monitored to minimize potential toxicity.
Discontinuation of Opioid Treatment
No treatment should be continued without benefit. If treatment is unsuccessful, it should be discontinued and patients carefully monitored to minimize physiological withdrawal symptoms such as yawning, rhinorrhea, piloerection, perspiration, lacrimation, mydriasis, tremors, restlessness, vomiting, muscle twitches, abdominal cramps, and anxiety. The essential element for successful opioid detoxification is the gradual tapering of the dose. Opioid withdrawal is generally not dangerous except in patients at risk from increased sympathetic tone, such as those with increased intracranial pressure or unstable angina. However, opioid withdrawal is very uncomfortable and distressing to patients. Tapering opioids often results in exacerbation of the patient’s primary pain symptom (rebound pain). Increases in pain can occur even if the analgesic effects of opioid therapy had not been appreciable. Although it is generally not possible to avoid discomfort completely, the goal of detoxification is to ameliorate withdrawal.
Several non-opioid pharmacological agents are commonly used as adjunctive agents to provide patients additional relief from withdrawal symptoms. Clonidine, an alpha-2-adrenergic agonist that decreases adrenergic activity, is commonly prescribed. Clonidine can help relieve many of the autonomic symptoms of opioid withdrawal such as nausea, cramps, sweating, tachycardia, and hypertension, which result from the loss of opioid suppression of the locus ceruleus during the withdrawal syndrome. Other adjunctive agents include nonsteroidal anti-inflammatory drugs for muscle aches, Pepto-Bismol for diarrhea, anticholinergics for abdominal cramps, and antihistamines for insomnia and restlessness.
Opioids offer an appropriate and safe treatment for some but not all patients with non-malignant chronic pain. Experimental research and clinical experience are needed to define those patients most likely to receive specific benefits from treatment with opioids. The benefits of treatment are now being documented in controlled trials. Potential risks, including drug abuse and intolerable side effects mentioned above, appear to be manageable in most cases. Anyone with chronic pain who has failed traditional treatments should be considered for a trial of chronic long acting opioids. If they have neuropathic pain, then opioids are now worth considering as a first line choice, especially if the patient cannot tolerate antidepressants or anticonvulsants. A recommended approach is to start low and go slow with a willingness to increase the dose until the person becomes toxic or delirious, complains of intolerable side effects, or gets complete relief of pain. Because patients with chronic pain suffer many consequences of their illness, any treatment with the potential to improve their symptoms should be prescribed and the results carefully studied.
1.    Arkinstall W, Sandler A, Goughnour B, et al: Efficacy of controlled-release codeine in chronic non-malignant pain: a randomized, placebo-controlled clinical trial. Pain 62:169-178, 1995.
2.    Dellemijn PL, Vanneste JA: Randomised double-blind active-placebo-controlled crossover trial of intravenous fentanyl in neuropathic pain. Lancet 349:753-758, 1997.
3.    Moulin DE, Iezzi A, Amireh R, et al: Randomised trial of oral morphine for chronic non-cancer pain. Lancet347:143-147, 1996.
4.    Schug SA, Merry AF, Acland RH: Treatment principles for the use of opioids in pain of nonmalignant origin.Drugs 42:228-239, 1991.
5.    Turk DC, Brody MC, Okifuji EA: Physicians’ attitudes and practices regarding the long-term prescribing of opioids for non-cancer pain. Pain 59:201-208, 1994.
6.    Watt JW, Wiles JR, Bowsher DR: Epidural morphine for postherpetic neuralgia. Anaesthesia 51:647-651, 1996.
7.    Simpson RK Jr, Edmondson EA, Constant CF, et al: Transdermal fentanyl as treatment for chronic low back pain. J Pain Symptom Manage 14:218-224, 1997.
8.    Raja SN, Haythornthwaite JA, Pappagallo M, Clark MR, Travison TG, Sabeen S, Royall RM, Max MB. A Controlled Trial on the Analgesic and Cognitive Effects of Opioids and Tricyclic Antidepressants in the Management of Postherpetic Neuralgia. Pain (In review).
9.    Porter J, Jick H: Addiction rate in patients treated with narcotics. N Eng J Med 302:123, 1980.
10.              Kouyanou K, Pither CE, Wessely S: Medication misuse, abuse and dependence in chronic pain patients. J Psychosom Res 43:497-504, 1997.
11.              Fishbain DA, Rosomoff HL, Rosomoff RS: Detoxification of nonopiate drugs in the chronic pain setting and clonidine opiate detoxification. Clin J Pain 8:191-203, 1992.
12.              Polatin PB, Kinney RK, Gatchel RJ, et al: Psychiatric illness and chronic low back pain. Spine 18:66-71, 1993.
13.              U.S. Department of Health and Human Services, Agency for Health Care Policy and Research, Clinical Practice Guidelines for Acute Pain Management: Operative or Medical Procedures and Trauma, AHCPR Publication Number 92-0032. Rockville, MD. February 1992.
14.              The Federation of State Medical Boards of The United States, Inc. Model Guidelines for the use of controlled substances for the treatment of pain. S D J Med 52:25-7, 1999.
15.              Heiskamen T & Kalso E.: Controlled-release oxycodone and morphine in cancer related pain. Pain 73:37-45, 1997.
16.              Rapp SE, Egan KJ, Ross BK, et al: A multidimensional comparison of morphine and hydromorphone patient-controlled analgesia. Anesth Analg 82:1043-1048, 1996.
Updated: July 31, 2012
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Petitioning FDA reclassification of vicodin from a schedule III to schedule II drug. 

FDA reclassification of vicodin from a schedule III to schedule II drug.: Stop the prejudice against us that have illnesses, suffer from severe pain!

    1. Marissa Zumbrun
    3. Petition by


We are NOT drug addicts, drug seekers, or getting high! I am very disheartened about the new regulations out for pain medications, it hurts those of us that fight a hard battle with dangerous, serious, painful illnesses. We do not sell them, overuse them, or abuse these medications. We are very ill just trying to deal with debilitating, excruciating pain. We are judged harshly enough about not looking ill, or on a good day being able to do a few things, these new limitations are only adding insult to injury. Why must we pay over and over again for having illnesses that we cannot control, have no cure for, and will last forever! There is no magic pill, shot or supplement, but we need relief, and many of us only get a that small amount of comfort from these restricted pain medications. I would not be able to ever leave my bed if I did not have the ability to obtain my medications. We are not complainers, or hypochondriacs we have real diseases that are very painful. No one wants to be sick everyday unable to function, feeling guilty about not playing with our children, going out with friends, or having fun with our significant others. There are many people that have drug addiction and that is a very serious disease and should be addressed but we are not using these medications illegally and we NEED relief. The people using these medications to get high are not obtaining them legally, please stop the prejudice! Forcing us to have more doctors appointment only costs us and health insurance companies, medicare, and medicade more money! It is as waste of time, money are resources! Pharmacists can also decide if they want to fill our prescriptions!! STOP the prejudice!!

FDA reclassification of vicodin from a schedule III to schedule II drug., FDA 
Stop the prejudice against us that have illnesses, suffer from severe pain!
[Your name]


  1. Is there any chance that they will only considering those drugs that will pay a good amount of money to be approved? There are some supplement like saw palmetto which is currently used by my husband which I is effective on the way he lives and through our relationship. I think something is wrong with the current system.

  2. Thank you for being a voice for us all. I could not get through some of my days without pain meds. Your right about how others view us, I tried to get sponsors for Lupus walk this year. No one replied to any of my emails, Facebook or verbal request. I have had fewer flares in the last 7months and choose not to look and act sick. I think this effected that outcome because last year I was flared a lot in and out of hospital at doctors, more visibly affected and received a lot of support for that event.

    1. I am so sorry you haven't had support this year it makes me so sad. I wish everyone who doubts us had to have lupus for one full week. They would praise us always after that week. Thanks for the kind words gentle hugs. xo