RSD Puzzle #028

H. Hooshmand, M. D.

DIPLOMATE AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY

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EPILEPSY, PAIN, MS

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RSD PUZZLE #28
"THERE ARE CONTRADICTIONS IN REGARD TO THE USE OF NARCOTICS"

This is an excellent question. First of all no RSD patient will have a day of rest or any improvement unless the pain is effectively suppressed with the help of strong pain medications, nerve blocks, and large enough doses of antidepressants.

On the other hand, addiction is a handicap in long term treatment of RSD because addiction in itself aggravates RSD, causes stress and alarm in the sympathetic system resulting in more severe sympathetic dysfunction, and results in perpetual presence of rebound (withdrawal) pain.

To be able to understand the principles of narcotic use as well as the reason for non-addicting nature of Morphine pump, one has to understand the principles of addiction. The following may be helpful.

THE FOUR PRINCIPLES OF ADDICTION:

1. COMPETITION: Competition refers to the fact that if the brain is naturally providing chemicals to relieve pain, or anxiety, or to provide good rest and sleep, the extraneous intake of similar chemicals in the form of medications will compete with the brain's own natural chemicals (such as endorphines and endo BZs). If the patient takes Morphine by mouth, through skin patch, or by injection at the usual doses of 60-100mg a day, then the brain will cease the formation of the natural endorphines. This is only to protect the human body so that the combination of natural endorphines and the strong narcotics does not cause deep coma, arrest of breathing, and death.

On the other hand , if the pain medication is taken that does not compete with endorphines and is not complimentary or similar to the endorphines, then the body will continue forming endorphines without disruption.

In the first case when the brain does not form its own endorphines, 4-6 hours after the intake of Morphine the body is left with no protective effect of pain medication. As a result, the withdrawal (rebound) pain develops.

In the second case, when the brain does not stop the formation of endorphines there is no withdrawal effect and no rebound pain.

The patient to begin with may have taken the Morphine for an acute condition such as a recent trauma, heart attack, or surgical procedure. If after the original trauma has cleared up, the dosage of Morphine is continued, then the patient will have a perpetual pain due to the withdrawal effect of the strong addicting narcotics. What makes the narcotic addicting is the fact that it competes and forces the arrest of secretion of the body's natural endorphines.

2. REBOUND PHENOMENON: The rebound phenomenon has been discussed in detail in principle #1.

The rebound (withdrawal) pain is quite different than the original pain of the disease that requires pain medication. The disease may be nothing but a fracture of the ankle. The pain in this situation is quite excruciating and limited to the ankle. On the other hand, the rebound (withdrawal) phenomenon due to the use of strong addicting narcotics causes pain all over the body in the form of headache, neck pain, low back pain, pain in every bone and every extremity. It is a non-specific continuous pain and has nothing to do with the pain due to the original focalized injury. Long after the disease has been fixed and cured, the patient will continue to have rebound (withdrawal) pain which will continue indefinitely.

3. TOLERANCE: This refers to the fact that as the rebound pain becomes more disabling and severe due to long standing use of addicting narcotics, the brain learns to tolerate larger doses of narcotics and to control the vicious circle of the rebound pain adding to the original pain. As a result, the patient demands more and more of the pain medication, and even after taking large doses of pain medications, still has very poor and irregular sleep during the night.

4. INCREASING INTAKE OF THE MEDICATIONS DUE TO THE TOLERANCE:
It is true that any pain medication or tranquilizer even though non-addicting may be abused. This abuse is usually in a small number of patients who try to accelerate the frequency and dosage of the medication to get pleasure out of it.

However, in the case of abuse of non-addicting narcotics or BZs sudden discontinuation of the non-addicting medications will not cause the severe withdrawal and the stressful symptoms and signs of the rebound. These consist of excessive sweating, rapid heartbeat, rise in the blood pressure, tremor, and severe anxiety and practically psychotic reaction. Such a withdrawal phenomenon is limited to the withdrawal from addicting medications.

In the case of application of Morphine Pump, none of the above four principles of addiction are involved. The dosage of medication given to the patient is so small (a dosage of 1 day is given in prescription form in 1 month). That does not compete and stop the formation of endorphines. There is no withdrawal phenomenon (no rebound symptoms) because of the strict drip irrigation form of application of medication. There is no tolerance because of the fact that the patient has no control over the intake of medication, and the body is not being exposed to the rebound phenomenon.

The problem of addiction as outlined above directly effects the sympathetic nervous system by causing stress (with resultant severe pain, sweating, tremor, etc.) and aggravating RSD.

The Morphine Pump is not given to facilitate the intake of an addicting medication. It is given to prevent the above mentioned four principles of addiction and tends not to cause problems of withdrawal and tolerance. The dosage of medicine is too small to stop the formation of other biogenic ammens, endorphines, endoBZs, and other hormones in the brain.

On the other hand, the use of pain medication in long term pain narcotic patients should be limited to the non-addicting type of pain medications (such as Stadol or Ultram) or at least to the less addicting pain medications such as Nubane and Talacen. In the meantime, it should be understood that one cannot keep the patient on any narcotic for ever. Simultaneously, the antidepressant medications should be increased until the analgesic effect of the antidepressant makes it unnecessary for the patient to take long term doses of strong medications.

The stress of severe pain and the stress of the rebound pain are two major aggravators of RSD. With the above mentioned methods, one should eliminate such distressors.

Stadol and Ultram as well as to some extent Nubain are Morphine agonists antagonists meaning that they enhance the pain relief and drowsiness in the presence of endorphines or other non-narcotics. Yet, when they are given along with other narcotics which are addicting, the combination is so strong that it causes nausea, vomiting, excessive drowsiness, and even breathing problems.

It is foolish to ask the patient to simply "live with the pain" and not to take strong pain medications. However, the most effective strong pain medication is proper antidepressants.

H. Hooshmand, M.D.

The material on the Neurological Associates Pain Management Center Homepage and all it's associated, linked or reference pages is for informational and education purposes. It is not meant to take the place of your physician. Before starting, changing, or stopping any treatments or medicines consult your physician. H. Hooshmand, M.D., Neurological Associates Pain Management Center and Associates will not be held liable for any damage or loss as a result of information provided on this page or associated documentation. Again, this WEB SITE is simply published as an information source and should not be used to treat or make judgments on RSD/CRPS. All associated material on this web site may not be copied, reproduced or quoted without expressed written permission from the owner; Copyright © 1999-2006 H. Hooshmand, M.D.