The Case for Pain Medicine Flexibility; About an Itchy Spot
Dear Dr. Roach: I have gone to the veterans hospital for my medical needs for the past 25 years. I have had four major back operations and a total knee replacement; I also have peripheral neuropathy. They put me on hydrocodone/acetaminophen and gabapentin for the pain and neuropathy. These two combined have helped me tremendously for the pain that I have had constantly for the past 20 years. Now they are going to take away the pain medication because they say they will prescribe it only to people who have chronic pain from cancer. They are going to give me something called Baclofen, a muscle relaxer. Is it a narcotic?
If that doesn’t work, they will give me something else. I told them I do not want to be a guinea pig. Why change something that has worked for my pain for many years. They tell me that pain meds do not cure pain, so how do people with constant pain survive without some type of pain medicine? — L.P.
Answer: I have written before about the concerns of using narcotics (opiates is a better word for medications related to opium — such as morphine, oxycodone or hydrocodone) for chronic noncancer pain. However, your situation explains clearly how inflexible rules don’t make sense. Some people with chronic pain from arthritis, spine problems or other causes do not do well on opiates. Their pain isn’t well-treated, and they require higher and higher doses, with side effects ranging from constipation to confusion. It’s because of this that many guidelines now recommend against treating noncancer pain with opiates. However, guidelines are to help show what is good for most people. They aren’t meant to force your doctor into a certain course of action.
In your case, it sounds like the opiates have been working well. Changing to Baclofen, a powerful muscle relaxant and not an opiate, may not control the pain and may cause excess sedation. There are many times when it’s appropriate to make a change for someone using chronic opiates, but this isn’t one of them.
Just surviving isn’t the issue. It’s surviving with a reasonable quality of life.
Dear Dr. Roach: I have noticed that many people return from air travel with a cold or some type of respiratory problem, and it seems to me that it may be caused by the recirculated air in the airplane. Is that true? If so, would it improve one’s chance of staying healthy to wear a mask on the plane? — C.G.
Answer: Yes, there is pretty good evidence that being in a plane with recirculated air does increase risk of infection, if there is an infectious person on the plane. One study from the Centers for Disease Control and Prevention showed that wearing a face mask is protective. I would recommend it only during an outbreak of an airborne contagious disease, such as flu, or for people at high risk, such as people with COPD.
Dear Dr. Roach : Why do heart attacks occur mostly in the morning and on Mondays? — J.V.
Answer : Your statements are quite true. Heart attacks are three times more likely in the morning than in the evening, and 15 percent to 20 percent more likely on Mondays than on other days. Nobody knows exactly why. Mornings are thought to be more likely due to several factors: increased blood pressure, an increase in cortisone and having “stickier” platelets in the morning.
There are two main theories for the Monday phenomenon — the first is back-to-work stress, but recently there has been some evidence that it may be excess alcohol intake over the weekend. These are good arguments for stress reduction and avoiding excess alcohol in the first place.
Dr. Roach Writes: In the summer, I wrote about an itchy condition on the back, and warned my reader to see a dermatologist to make sure it wasn’t a skin cancer. Several readers and a dermatologist have written to suggest a condition called notalgia paresthetica, which is a benign and common skin condition causing itchy back that can last for years. Moisturizer and avoiding scratching are good treatments. An ice pack or anesthetic spray may be helpful for more-severe cases.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or write to P.O. Box 536475, Orlando, FL 32853-6475.