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basis for viewpoint opioids are only effective long term for cancer pain, not noncanc

LucidSDreamr

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I've done enough research to know you can find plenty of recent scientific papers proving opioids work long term for non cancer pain.

But what i don't understand is the basis that i see in a lot of medical papers, that opioids are not effective long term for noncancer pain, but they are effective long term for cancer pain.

Since the perception of pain in the brain is how opioids work, i don't understand how the source of the pain extraneous to the brain matters. And even if it does, i don't understand why opioids continue to work for "cancer pain" but stop working for every other single type of pain that exists. The claim seems ludicrous

I'm thinking its just a bullshit argument that journals/funding agencies like to hear repeated, but i'm wondering if there is a scientific basis for this argument.
 
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There is something of a decent scientific basis for opioids worsening some types of neuropathic pain. Chronically dosing opioids is actually one animal model for producing a pain sensitized state.

Agonists at opioid receptors also tend to be agonists at Toll Like Receptors such as TLR4, located on immune cells like microglia that contribute to neuropathic pain, and the pain sensitized state. Some people may know the condition as reflex sympathetic dsytrophy, the new name being Complex Regional Pain Syndrome, sometimes the terms fibromyalgia and central spinal cord wind-up get thrown in here as well. For these conditions, practitioners tend to avoid prescribing opioids, as in the long term they can be unhelpful. Essentially, the opioids are capable of inflaming and sensitizing the CNS/peripheral nerves when given chronically.

On the other hand, Low Dose Naltrexone is a promising therapy for pain sensitized states, as naltrexone is an antagonist at Toll-Like Receptors. Dextro-naltrexone has negligible affinity for opioid receptors and still blocks toll-like receptors as well. See this paper from Stanford for example https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3962576/

For many musculoskeletal conditions, I think practitioners avoid using opioids long term for other reasons as well (hypogonadism). If a patient is in physical therapy long term, lowering anabolic hormones with opioids may not be ultimately in the patient's best health, even if the opioids do lower the patient's pain levels.

CY
 
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But why doesn't cancer pain suffer from these same drawback with opioids? Why is it ok to treat cancer pain long term with opioids?

Also you brought up something else related to something i've been pondering a lot lately but to scared to talk to my treating physicians about.

the hypogonadism caused by opioid use effect on prostatitis, see here: https://www.renalandurologynews.com...-hypogonadal-cpcpss-sufferers/article/415131/


My uro thinks this is what may be wrong with me (he doesn't have evidence, just a hunch). The only way i can cope right now is with opioids, but i'm scared I'm just making things worse.
 
I think cancer pain is treated differently from many other kinds of pain for two reasons:For one, the nerves carrying the pain signals in cancer patients may not have much sensitization compared to someone with e.g. fibromyalgia, therefore they could be less vulnerable to the unwanted pro-sensitization effects of MOR agonists. Number two, the downsides of opioids are overlooked due to the typically terminal aspect of cancer, and dosage can be escalated indefinitely as they're not likely to be two decade patients. RE: bladder issues, is that sort of explanation (prostatitis) really necessary if you're having bladder issues after dissos? Does ketamine cystitis and such not fully explain your symptoms or something? All the best, CY
 
Saying that opioids can't be useful for treating non-cancerous chronic pain is horse shit. Yes, there are issues such as neurological sensitization, and they
are ill-suited for treating pain of neuropathic origin, but for ordinary, yet long-term pain, opioids can indeed be effective.

I'd be totally buggered without them, I'm a chronic pain patient myself, and I'm on a combination of morphine and oxycodone. Most of the pain is of musculo-skeletal origin, although I also have a region affected by neuropathic pain. The pain meds are quite effective for the former, although not for the latter. I've been on them for years, and I can attest to the fact that they work. If they didn't, I'd probably not be able to leave the house. Or at best,
I'd not be able to get very far. And I'd also be at risk of getting stuck somewhere and ending up unable to return home.

As it is, the morphine/oxy are absolute lifesavers.
 
I think cancer pain is treated differently from many other kinds of pain for two reasons:For one, the nerves carrying the pain signals in cancer patients may not have much sensitization compared to someone with e.g. fibromyalgia, therefore they could be less vulnerable to the unwanted pro-sensitization effects of MOR agonists. Number two, the downsides of opioids are overlooked due to the typically terminal aspect of cancer, and dosage can be escalated indefinitely as they're not likely to be two decade patients. RE: bladder issues, is that sort of explanation (prostatitis) really necessary if you're having bladder issues after dissos? Does ketamine cystitis and such not fully explain your symptoms or something? All the best, CY

The doctor doesn't know about my drug use. The problem is that if I get diagnosed with ket cystitis. I will be banned from pain treatment forever which will mean heroin for ever. Something I'd like to avoid due to fent.

I'm not really sure how to do this I guess I will let the doctor know then switch to heroin when I lose my pain script.

Because I definitely want the right non opioid treatments available for what I have.
 
I cannot speak of any other country but here, if someone is in palliative care, there is no upper limit to the dosing. In fact, the BNF clearly states that opioids are used to treat unacceptable distress but patient morbidity should not influence use of the class. In English they are more or less saying 'keep the pain away and if the dose needed to do that could kill them, don't let it stop you giving that dose'. Kind of mealy mouthed but frankly, we let humans suffer to an extent that if it were an animal, we would be breaking the cruelty laws.

Opiates can be a good servant but they make a terrible master.
 
They don't mind giving to people with cancer because most likely there is no long term cancer pain. The people die so no addiction no long term anything .
 
I couldn't agree more, opioids as they currently stand are a great servant, but the servant has too much of a tendency to rebel and render the master the slave. And with the NHS (and other health services) as they are, you are fucked. For want of a better word, the moment tolerance even slightly exceeds demand, everybody in the medical profession turns hostile.

I've been suffering from knee pain, since childhood, after first having a long shard of glass go right though my patellar tendon and into the joint, that much has been proven, given I had to have it surgically removed, and later, bits of glass and shattered bone removed from my knee, and not long after, got royally fucked up by a pack of pikey trash, something like 20/1 and I narrowly got away alive, and was battered senseless as a kid, left in the street for dead, after having my head stamped on.

The change in walking gait the knee damage forced on me, left me with bilateral trochanteric bursitis, and without pain meds, I'd not be able to walk much further than the bounds of the house, its left me more or less bedbound (or sofa-bound at least) and its ONLY because of morphine and oxy shots that I can even go to the shop to buy food, yet the docs still are so close to kicking me out of the surgery that I dare not even make an appointment to get rescue-pack seizure meds and have to make the seizure meds (chlormethiazole) myself)

Its fucked up. Cancer would almost be preferable. I've more than once considered going away to where nobody could be harmed and blowing myself to pieces. I'm not about to, so don't worry about me, I *cannot* commit suicide owing to a sworn oath to someone I respect and love above anyone, barring alzheimers or similar, I'm here for the duration, but still, forced to depend on opioids and of course the drs aren't willing to rx suffient to avoid WD every week. Not bar buying H and methadone.
 
In the late 60s a psychiatrist gave someone with severe refractive depression Diconal. It appeared to work but 6 months on the patient killed themselves with an overdose and said psychiatrist wound up in jail. I honestly can't remember where I read that but it was in the 80s, I'm pretty sure.

I get clobazam for epilepsy and strong opioids for pain but when and what dose are to some extent my choice. You have to think ahead 'I need to go to the bank tomorrow so I can't afford to take any today'. It's hard to measure pain.
 
I never thought it was that they were only effective long term for cancer pain, just that cancer was the only thing that warranted prescribing them long term.
 
Whilst I am of course physically dependent, having taken them for so long, I still take the opioids, and they are, years later, still effective for pain.
 
my mom has breast cancer, before her cancer, she was on 8 roxy 30s, 3 8mg dilaudids, 3 soma, 3 bars, 2 OC80s, and 2 opana 40mg. NOw that she has cancer and had to switch docs, they took almost all her pain meds away. shes on 7 30s, and 2 morph 100s now. she also has really messed up back, nerve disease, and countless others. its sad cause her doctor says what she on now, exceeds even what a cancer patient should be on
 
Whilst I am of course physically dependent, having taken them for so long, I still take the opioids, and they are, years later, still effective for pain.

But how much of the pain is due to hyperalgesia? That's the kicker. If you have a terminal illness, just keep taking the pills (or whatever) but for other chronic pain, it's hard to tell. I certainly remember being amazed by a large study on patients taking methadone and the vast increase in pain perception. I've been shocked by my own pain perception. I am in the position where I can certainly get strong opioids... but I don't relish that invisible cardboard box on my back. It isn't heavy but it limits me because I cannot easily travel or even do everyday things without KNOWING I have a supply... and that is bad.
 
I have both neuropathic pain, and nonneuropathic pain. The former affects the side of one leg, or a portion of it, after a botched knee surgery, the rest of it, and the overwhelming majority of it, is due partly to the knee issue (I fell on an upraised dirty great spike of glass as a little kid, went straight through the patellar tendon, and I had to break it off, and drag myself home for miles, not having a phone at that age, and not long after (most of) it was taken out in hospital, I was attacked in the street, got jumped by 20 odd chavscum thugs, stamped on my kneecaps, stamped on my face, if I hadn't pulled a knife, I've little doubt they'd have killed me, as it was, they fucked off, I collapsed, and they just left me for dead.

Got worse and worse as the years went by, and the change it forced on me in my walking gait caused trochanteric bursitis, bilaterally, and it hurts like the holy mother of all fuck. To say nothing of the way the nerve damage causes a permanent severe contraction of my calf muscle without the ability to properly relax it, although the otherwise unabating, fucking painful spasm is relieved by a hefty dose of tizanidine.

The difference on and off opioids is dramatic. I had to walk what would be 5-10 minutes to get a tram yesterday and another walk to my destination after getting off at my stop. It took me a couple of hours at least. And by the time (I was down to a few meager scraps of H, congealed from vapor in a pipette modified into a pipe, that stopped full-blown maximum hell withdrawals) I got home, I could barely stand, and had to spend the rest of the day stretched out on the sofa, even sleeping on the sofa, today, I picked up a few grams of good heroin, and I can walk about the house no problem, I could even do the journey on foot to where I went yesterday without near enough howling in the street with pain.

Went from agony, to just a bit sore, after the first few pipette-loads of the gear. Its either take the morphine and oxy (and when its available, boxes of physeptone (methadone tablets) and whenever the money is spare, I'll get myself an 8th of H, and of course, since I'm on morphine, it has a habit of mysteriously turning into dipropionylmorphine, plus there's a nifty little trick someone taught me about a high yielding demethylation and 6-monoacetylation from dihydrocodeine to 6-monoacetyldihydromorphine, a truly excellent opiate. (thanks, btw, you know who you are) using 30% anhydrous hydrogen bromide in glacial acetic acid. DHC (albeit shitty weak stuff that I'd need to CWE boxes of for a single dose) is OTC here, so those several boxes, or make that a shopping-bag full of 32 count boxes, can end up as something much, much more potent.

Either way, it does fuck all (excluding the methadone, which has some, albeit weak, NMDA antagonist effects, and which does actually relieve the neuropathic pain) for the neuropathy, but the rest of it, any of them, can allow me to sit down, lie down, and have a life, albeit with the ball and chain of physical dependency, as opposed to an existence which would limit my walking distance to more or less the house, or at very most, the local shops or nearby doctors clinic (ten minute walk for most, about twice that to 25-30 minutes for me, and after it, my joints would be down on their hands and knees, begging with all their might for some sort of opioid)
 
A recent article in the journal "Anesthesia & analgesia" that I read some time ago actually presented some evidence that morphine-like opioids can slow down the growth of certain types of malignant tumors, especially lung cancer. The effect is apparently based on the binding of classical opiates to opioid growth factor receptors (OGF), which are found in large numbers on cancer cells. However, in the case of some other cancers, the opiates can speed up the tumor growth instead of slowing it down, so don't take this as saying that being an opiate addict would be some kind of a prophylactic measure against cancer.
 
Neuropathic pain is really NOT well controlled with opioids. 25mg amitriptyline per day worked better than oxycodone. It takes months to work properly but it dulled the pain. That takes-your-breath-away shooting pain disappeared leaving chronic (grumbing) pain for which only occasional opioids were needed. Of course, that is just me but I was impressed. Gabapentin & pregabalin are also effective for may people and if you need morphine potency, nefopam works. It has it's own set of side-effects but it IS as potent as morphine and better for neuropathic pain. Use with tramadol is VERY effective in some people.

Opiates have their place - but taken daily for months or years only works if the doctor accepts that the dose will tend to keep increasing (as does dependence) and even with planning - running out is VERY bad news.
 
Nefopam is out for me, I react badly to it. I've been scripted gabapentin, and I know (most) opioids don't work well for neuropathic pain. I have both 'bog standard' pain and that of neuropathic origin. And I HATE tramadol (besides, I take cimetidine, so it would cause a buildup of tramadol and inhibit metabolism to O-desmethyltramadol, which would be a bad thing.)

Polymath-would that be the zeta opioid receptor?


For me, given the regular-issue pain is severe and that it seems unlikely that it will go away, I'll be on opioids longterm whether I like it or not, at least, if I want to walk without feeling that my leg has been ripped off and a lump of red hot tungsten grafted in its place for me to drag about. I can even hear myself stomping along when I walk, if I have shoes on, with the distinctive toe-heel-thump pattern forced on me by the neuropathy. Best solution is that I have found, as far as opioids go, methadone, doubtless due to the NMDA antagonist effect, although not strong save for very high dosages, contemplating asking my doc to switch me to methadone as the workhorse analgesic and use morphine as the breakthrough, rather than morphia as my main big guns and oxy as a sidearm for when all hell breaks loose (or rather, for times other than when all hell has broken loose. Because all hell did some time ago, and I figure hell is probably like a djinni, once it gets out of its bottle, it isn't going back in again.
 
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Among opioid there are still big differences. Methadone works better than morphine for me. Oxycodone, morphine, diamorphine, hydromorphone and all of that class are almost useless for me (even butorphanol).

The problem I found was hyperalgesia. I ended up with MORE pain. All of my joints, my muscles... no, careful choice of opioid is important. I may ask about ethoheptazine. I mean, DHCs I can get any number of but when it takes a dozen to work, it really limited how often I can use them. Tramadol is worse than useless but ethoheptazine looks promising. Swapping that quaternary ethyl to a propyl produces a full agonist. Replacing it with a methyl produces a pure antagonist.

Not in 'the morphine rule' but the time has come to produce a new rule.
 
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