I am worried that I take too much vicodin.

February 6, 2006 11:29 PM

I am worried that I take too much vicodin.

I have two forms of degenerative arthritis for which I take vicodin for pain, DMARDs (Humira and azathioprine), an NSAID (diclofenac), and as of this weekend, prednisone.

Over the last few months, due to a combination of the stress of my mother's death and general bad health, my arthritis has flaired causing me to take up to six or seven 5/500 or 7.50/750 vicodins a day to reduce my pain. On the pain scale it takes me from a 9 to a 6 or 7. Basically, it allows me to walk or do what most would consider limited daily activities.

My concerns are threefold. First, I am very concerned about addiction. I tell my family and friends that at my level of pain, addicition is unlikely since it is for true pain and not recreational. Am I deluding myself?

Second, I have common opiate side effects. Zero energy, constipation, interruption of sleep patterns, and inability to concentrate. I cannot sleep well unmedicated due to the arthritis pain, but the vicodin affects my ability to sleep deeply. Any advice on how to mitigate these side effects?

Third, while my rheumatologist has been excellent in treating the arthritis, and sympathetic to my pain, she has been leery about stronger pain medicine. My thought is since she is a high profile doctor, she is worried about increased DEA attention for prescribing narcotics. She did take me from a 5/500 to a 7.5/750 prescription. I worry about how to be honest about my pain without seeming like I am just looking for a high. What is the best way to talk to my current or a new physician about my pain management?

I can deal with some chronic pain, but at this level, with this amount of pain killers, I worry that I will never feel normal again. I appreciate your help and advice.

posted by anonymous to health & fitness (19 comments total)

Your story is compelling, and to my medical ear it sounds like your case is very difficult for you and your doctor to manage together. I am fairly certain there are no easy answers to any of the questions you have.

Here are some of my suggestions:

Don't be afraid to speak to your doctor. Don't be afraid to question your doctor's decisions, especially if you would like to better understand her reasoning. She may have good reasons for not wanting to prescribe you stronger medicines, reasons of which you (and I) are not currently aware.

Don't be too afraid of becoming addicted. Addiction, if you like that term, is a three-sided process at least. To be considered are: physical habituation, which occurs at the level of receptor regulation and influences the effects and withdrawal effects of the drug; psychological dependence, which occurs at the level of influencing your voluntary behavior; and social stigma, which I predict you are going to learn quite a bit about in the responses to this thread.

I generally tell my patients that as long as they are "with me" - keeping me up to date on how they're doing, listening to my recommendations, being frank with me about their feelings and needs - in the process of using medication to treat pain, they need not consider themselves addicted.

Bear in mind that most physicians have not been trained to be skillful with or intellectually interested in pain control; and that all physicians have been repeatedly exposed to extremely hateful behavior on the part of people whose pursuit of drugs of abuse has eclipsed every other aspect of their personality and their lives. Be respectful of your physician's experience in this regard, and I mean that the same way I would mean "Be respectful of a child's innocence."

Your opiate side effects are treatable. Speak to the physician who prescribed the medicine.

Finally, dealing with chronic pain plus the death of a parent is too much for anyone to be expected to bear. If you are grieving or depressed about your mother, you will perceive your pain as more severe - this is just the way your brain is wired. If you're concerned that part of what you're medicating is your grief, you may want to consider speaking to a therapist about the issues going on in your life.
posted by ikkyu2 at 1:04 AM on February 7, 2006

what ikkyu2 said. I too am a physician. Consider consulting a pain management specialist. Also, there are other drugs out there besides Vicodin to manage pain. Oxycontin (long-acting)with Oxycodone (short acting) for breakthrough pain is a common regimen. Best to talk to your doctor about what's best for you, and perhaps ask about seeing a pain management specialist.

For constipation, do not be afraid of taking Senna-plus, and additional colace (ducosate), as much as needed, to have one soft bowel movement every 1-2 days.

I'm an oncologist, so I manage pain quite a bit. Feel free to email me with any other questions. Email's in the profile.
posted by cahlers at 4:46 AM on February 7, 2006

Strongly agree with the above.

Also, I tend to think your doctor has more patients on long term narcotics than you might imagine, so any "reservations" she may have expressed are likely more hypothetical than actual. That said, it will keep her in better standing medicolegally if there is documentation on the chart of something called a 'Material Risk Notice', which basically is an informed consent agreement for narcotic pain treatment, as well as a 'Pain Contract' spelling out the parameters of your usage, your obligation to receive medication from her only (or her designees), to always use the same pharmacy, etc. Those documents, in my opinion, tend to lend some external 'legitimacy' to your situation in the event that you ever are seeing one of your doctor's covering partners, etc. It may seem superfluous, but many states require them.

The reality is that there has and will continue to be overwhelming medical support for the use of narcotic analgesics for the treatment of chronic pain. Reconciling that evidence with the real world of patient and doctor unease is where things get sticky. Your situation, to me, sounds completely normal, and I would agree that looking at other narcotic options may be useful. You might also look at tramadol as another option, alongside or in place of some of your narcotics.

Good luck.
posted by docpops at 7:10 AM on February 7, 2006

Second, I have common opiate side effects. Zero energy, constipation, interruption of sleep patterns, and inability to concentrate. I cannot sleep well unmedicated due to the arthritis pain, but the vicodin affects my ability to sleep deeply. Any advice on how to mitigate these side effects?


It's hard to tell from your post whether these side effects are from your narcotics, or from depression, some other medication, etc. But it's widely agreed that any useful pain management strategy is undermined by poor sleep, so I would absolutely talk with your doctor about this. There are multiple strategies for this - including but not limited to treatment for depression, and several very safe medications that have proven benefits for combined pain/sleep issues.
posted by docpops at 7:14 AM on February 7, 2006

The docs all seem to be in agreement here. However, are narcotic pain killers really the way to go for life long pain treatment?
posted by caddis at 8:08 AM on February 7, 2006

I volunteer with a medical group that treats chronic patients. One of the very first things they taught us was that painkillers used to manage actual physical pain are not addictive. They taught us that because so many patients and families worry about it, so the question comes up a lot.

So.... painkillers used to manage actual physical pain are not addictive.

Obviously keep talking to your doctor if you're uncomfortable, but it seems that a lot of patients and families are uncomfortable with painkillers for that reason, and that people (you, your family and friends, strangers on the internet) being uncomfortable is *not* automatically a sign that you're addicted.
posted by occhiblu at 8:10 AM on February 7, 2006

So.... painkillers used to manage actual physical pain are not addictive.

I don't understand how this is possible. I mean that honestly, I'm not just being a dick. If something causes a physical dependence, certainly it would do that no matter what, wouldn't it?
posted by dagnyscott at 9:37 AM on February 7, 2006

So.... painkillers used to manage actual physical pain are not addictive.

I don't understand how this is possible. I mean that honestly, I'm not just being a dick. If something causes a physical dependence, certainly it would do that no matter what, wouldn't it?

You're correct. They are addictive, but perhaps not in the way we usually think of addiction occurring or behaving. A person on long term narcotic therapy will become addicted, in that they will have withdrawl symptoms if they discontinue the drug. However, it's quite unlikely that a person using narcotics for management of chronic non-malignant pain will become psychologically addicted - seeking a drug-induced effect requiring ever increasing amounts of the drug, exhibiting pathologic behaviors to obtain said drug, etc.
posted by docpops at 9:51 AM on February 7, 2006

If you're using medicine in the way it was intended, how is that an addiction? The pain exists first, and exists whether or not you use the medicine. So the pain you're in when you stop the medicine is not withdrawal or psychological dependence, it's the same pain that caused you to take the medicine. You're not using the medicine to get high, or solve psychological problems, you're using it to treat a medical condition.

I mean, you could claim that my father is "addicted" to his high-blood pressure medication, because he has to take it every day and because there are serious consequences if he stopped taking it, but ... that would be stupid, you know?
posted by occhiblu at 9:53 AM on February 7, 2006

(Well, OK, maybe it *is* partly withdrawal pain, then, but you know what I mean.)
posted by occhiblu at 9:54 AM on February 7, 2006

occhiblu - the two scenarios are nothing alike. If a person on chronic narcotics runs out or abruptly ceases taking them, they will experience withdrawl, which can range from something moderately unpleasant to horrific, but not, typically, life-threatening unless they were already significantly compromised by chronic illness. This is also why the level of informed consent necessary for initiating a narcotic is levels above what would be necessary for starting someone on blood pressure medication, to use your example.

It's disingenuous and misleading to state that narcotics are not addictive, and it's just as important to clarify and distinguish physical from psychological addiction. But patients and their families can understand and appreciate the vast difference in the two.
posted by docpops at 10:11 AM on February 7, 2006

occhiblu - perhaps it would be better to define one scenario as 'physical dependence' and the other as 'addiction'?
posted by docpops at 10:13 AM on February 7, 2006

docpops, I don't think I understand your objection. You seem to be saying that the effects of stopping narcotics are less than stopping blood-pressure medication, and that's why narcotics need a higher level of informed consent? I'm not following your argument there.

I was certainly oversimplifying, though. My main point was that medications of whatever kind taken under a doctor's care -- with, as ikkyu2 points out, honest discussion between patient and doctor -- are not "addictions" in the way that most people think about addiction. (Which I think is pretty much what you said, too.)

But fear of addiction can keep people from taking medicine that would benefit them, due to the stigma, and from what I've heard through my hospice group, there are a lot of patients refusing morphine and other drugs that could help them simply because they or their caregivers are worried about becoming addicted, no matter how often someone tries to differentiate physical and psychological dependence.
posted by occhiblu at 10:36 AM on February 7, 2006

occhiblu,

I think I'm not so much objecting as stating a clarification. In the interest of accuracy I think it's important for patients to understand more about addiction and dependence, as opposed to simply telling them narcotics are not addictive. Informed consent means discussing all potential risks and options of treatment, as you likely know.

I'm not sure what to say regarding the hypertension analogy, except that in the real world patients routinely stop medication for diabetes, hypertension, depression, heart failure, elevated lipids, etc. without telling us, until we see them a year later for a cold and see the results, or they wind up in the hospital months after. If a person on long term narcotic treatment did that, within a few days they would be in such distress that we would hear from them. We would be liable as well if we contributed to that abrupt cessation. And people who have experienced it often tell us it is nightmarishly awful.
posted by docpops at 10:53 AM on February 7, 2006

Ahhhh, I see. I wasn't following that on your earlier post.
posted by occhiblu at 11:05 AM on February 7, 2006

However, are narcotic pain killers really the way to go for life long pain treatment?

Sometimes, yes. Depends on the case. Some cases are more difficult, intractable, whatever you want to call it, than others.
posted by ikkyu2 at 2:24 PM on February 7, 2006

One more note, besides the wonderful things the MDs have noted so far--you are taking too much vicodin, as far as the acetaminophen dosage goes--4g is the maximum dosage per day, and it sounds like often you're above that. Acetaminophen can have nasty liver toxicity. You clearly need better pain control as well.
posted by gramcracker at 4:08 PM on February 7, 2006

Check out Cold Water Filtration
posted by FearAndLoathingInLJ at 5:33 PM on February 7, 2006

Thanks ikkyu2, I learn something interesting here every day.
posted by caddis at 5:57 PM on February 7, 2006