RSD Puzzle #063

H. Hooshmand, M. D.

DIPLOMATE AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY

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INTRACTABLE NEUROLOGY

EPILEPSY, PAIN, MS

An International Referral Center dedicated to Treatment, Education and Research

My doctor started me on Methadone treatment. Is there any problems with Methadone treatment?

Methadone treatment should not be applied to RSD patients. There are three different kinds of pain.

1. Acute pain such as a recent heart attack or car accident of a few weeks duration or a fracture of bone.

The treatment of choice for the acute pain is treatment with narcotics as well as correcting the damaged area by surgery or other methods which has originated the pain.

2. Cancer pain. In cancer pain the condition is called a "dynamic pain" which means there is a dynamic pathology ongoing damage in practically almost a continuous basis both acute and chronic due to the infiltration of cancer cells and or due to multiple operations, or radiotherapy. In treatment of cancer pain, anything goes. Methadone is no problem and should be used. Other strong narcotic such as Dilaudid, MS Contin or whatever treatment that relieves the patient's pain should be given. The patient has a short life expectancy and if sympathectomy relieves the pain, so be it. Even though sympathectomy is not indicated in RSD patients, it can be done in cancer patients who have diabetes or severe occlusive disease of the blood vessels in the extremity. In such diabetic or severe occlusive disease patients or cancer patients, the life expectancy is usually less than 5 years and sympathectomy can provide a few years of relief. On the other hand, truly chronic pain patients who are going to live several years or decades the sympathectomy is fraught with very high percentage of failure anywhere from a few weeks to 3 to 4 years after the sympathectomy is done.

3. The third type of pain is the chronic pain and complex chronic pain. In chronic pain, the original pathology has seized and has left scar and damage to the nerves. In some cases, the chronic pain has left the patient with no nerve damage but it is perpetuated because of the use of addicting (habituating and drug dependent) narcotics. On the other hand, in complex chronic pain either the patient suffers from neuropathic pain (a pain that is due to neurovascular damage such as diabetic neuropathy) or sympathetically maintained pain (SMP) or further scar formation and involvement of the adjacent nerves due to scarring such as in the case of arachnoiditis which is the scar formation in the meninges of the spinal canal.

The treatment for chronic and complex pain is quite different from acute pain.

In the complex chronic pain, the patient should definitely be treated with strong analgesics which are not addicting. The best non-addicting analgesics are Trazodone and Prozac followed by some of the tricyclic antidepressants such as Desipramine. These medications have a Naloxone reversible analgesic effect meaning that if they are taken along with Naloxone then they cannot control pain, otherwise they can. In this regard they mimic the strongest narcotics. They are not addicting. They raise the threshold of pain and they provide good analgesia along with more normal sleep and along with by-product or side effect of being an antidepressant even though the patient usually in over 1/4 of the cases is not even depressed.

In addition, such patients can be treated with Morphine antagonists such as Stadol and Ultram which by nature of being Morphine antagonist the do not suppress the cerebral endorphins and other hormones in the brain. The addicting narcotics are not indicated in these patients because they cause perpetuation of pain due to the withdrawal (rebound) and tolerance (more demand by the brain for more of the medicine). What can change the simplest acute or subacute pain to a permanently chronic pain by the generous use of addicting narcotics?

Historically, Methadone has been used as an alternative for Heroin among the Heroin addicts. It doesn't mean it cures the addiction, it just replaces the Heroin. It is preferable because Methadone has got a several times longer half life lasting in the system from 3 to 6 or 7 days. So the patient does not develop a sharp withdrawal (rebound) as the patient experiences with Heroin.

Then the patient is provided with increasing dosages of Methadone at first once every day or every 2 or 3 days, then 2 or 3 times a day. At first it usually 10 mg three times a day and then gradually creeps up on the patient. the overlapping of the dosage of narcotics prevent withdrawal symptoms of pain, headaches, etc.

All this is achieved at the expense of Methadone causing inactivity and forcing the patient to regress into the use of a wheelchair or other assistive devices. In addition, as the patient regresses into the use of a wheelchair, the pain becomes worse because of the principle recently reported by Doctor Koltzenburg. Doctor Koltzenburg noted that an inactive extremity undergoes the development of the hyperexcitability of deep pain sensors in the muscles and bones. He calls this type of phenomenon a " sleeping nociceptor". The reason for the name is because there is such deep pain centers in the muscles and bones are usually silent and only becomes symptomatic as the extremity becomes inactive (such as the application of cast, braces or wheelchair).

The chain of events are as followed:

Methadone with increasing doses results in the patient not being motivated to be active and to get up and around. Secondarily the inactivity of the extremities wakes up the" sleeping nociceptors" and causes aggravation of pain. As the result, the patients needs to have more and more Methadone. Eventually the dosage gets to the level 10 to 20 mg 3 times a day up to even 50 mg 3 times a day. In such doses in the long term basis, the Methadone causes intoxication of the brain such as seen among Opiate addicts. This is in the form of prolonged bed rest, prolonged inactivity, drowsiness, and most importantly intoxication of the limbic system (the emotional centers of the brain).

This last complication of intoxication of limbic system results in the patients becoming chronically depressed, developing poor judgment, becoming argumentative, and short fused.

Worst of all the problem of poor judgment to go to the toxic long term side effect of Methadone prompts the patient to beg his or her doctor to resort to any for of treatment. We are seeing an increased number of patients undergoing carpal tunnel surgery, thoracic outlet surgery, tarsal tunnel surgery, sympathectomy, spinal stimulator surgery, and other harmful operations among the Methadone users.

A similar problem also develops among other chronic habituating strong Morphine agonist pain medications These consist of patients who use MS Contin and similar slow release of strong narcotics. Such medications are duragesic and other skin patch treatments with strong pain medications a very similar effect as Methadone.

The use of Methadone, MS Contin and duragesic could be limited to cancer pain patient.

Unfortunately, in the past three years, there has been a major confusion mixing cancer pain treatment form of treatment and applying it to complex chronic pain patients.

Nobody can argue that cancer pain patients are not being treated with enough medication for pain. They are also not being treated with enough medication for nausea or for depression.

This obvious and pathetic fact does not justify crippling and practically maiming complex chronic pain patients who don't suffer from cancer.

The end results has been that the pain clinics and pain specialists are using MS Contin, duragesic and Methadone, generously on RSD patients with disastrous results. The same patients also undergo unnecessary operations which are quite dangerous such as lytic lesions, chemical sympathectomy, neurectomy, or cryosurgery. Cryosurgery refers to damaging the nerves by applying extreme cold in a focalized fashion. It's obvious that cold in the form of ice, cryosurgery or capsaicin destroys the small c fibers (small sensory sympathetic fibers), and cause more dysfunction of the sympathetic system. It is obvious that such procedure are harmful in RSD patients.

However, it's going to take a few years or decades to undo the damages that have been done with the use of such dangerous drugs to RSD patients. It's going to take a few decades for the doctors to rediscover, as has been discovered in the past three decades, that the use of strong addicting narcotic is going to cause more problems for chronic pain patients rather than helping them.

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.