Is there a place for narcotics, (Vicodin, Fioricet, Oxycontin, Hydrocodone, Codeine) or Fioricet (butalbital) in headache treatment?
A myth, which often permeates the halls of emergency rooms and other clinics, is that headache sufferers are nothing more than”drug seekers.” This of course implies that the headaches are made up, or at least exaggerated, just as a means to get narcotics. Then you can carry the logic a little further to conclude that the so-called sufferer is a bad person who takes drugs to get high.
Well, nothing can be further from the truth. The vast majority of headache sufferers, who go the emergency room or other clinics for immediate care, are in severe pain. For most patients, going to the emergency room is their very last resort.
With that said, there is a black hole in the midst of chronic headaches, as if the headaches themselves wasn’t curse enough. That entrapment is narcotic addition. In this case, the patient doesn’t start popping narcotics to “get high,” but they take them as a humane respite from the nightmare of constant pain.
In most cases, the use of narcotics starts with a few pills a month. But over time the use goes up and up until it is inevitable that an addiction develops. Addiction is a horrible labyrinth that steals away life in a way that a hope of escaping it seems mute. In the end, the addiction itself is what ruins their life, far more than the pain itself.
This is a very poignant issue for me right now as I had to deal with three different patients last week who were entrapped in this web. What is typical for the disease of addiction is denial. Even though there is absolutely no question that these patients are now addicted, they all three denied it. It breaks my heart. As part of their addiction is the related behavior of being dishonest. The dishonesty will severe our ties. I offer them help from the bottom of my heart . . . yet that help is rejected.
There is a behavior pattern that accompanies addiction. The person dependent on the narcotics, even though they might have always been a good person, starts to behave in ways, which are out of character for them. For one is lying to their providers and family. They start to grossly under-report the amount of narcotics they use. They start to visit multiple providers to get narcotic prescriptions for a whole variety of pain syndromes. They get Vicodin from their headache provider, and a few days later, more Vicodin from their primary care provider for an hurt back, then a few days later, Tylenol with Codeine from their dentist. To avoid getting caught, they then chose multiple pharmacies, thinking that they would avoid getting caught. The charade goes on and they start to borrow them from their friends and family. Then they start to buy them from the street, often their family doesn’t even know. This has now changed. As of January 1st (or thereabouts) the state of Washington adopted the PMP (Prescription Monitoring Program). In this program, the state keeps records of all controlled substances prescribed for one individual, including all providers and pharmacies.
The other strategy that someone will use, in order to get more narcotics, is to try and create chaos. They call the provider after hours to ask for refills. They miss their scheduled appointment but then show up on days that they didn’t have an appointment and pretend that they were confused. In this plan, they think that they can create enough confusion that they can get the refills they want without getting caught.
The patient often starts to rationalize that they deserve or must use narcotics because nothing else works. But it is certainly a vicious cycle because nothing else works BECAUSE they are taking too many narcotics.
This is not a moral problem. I will emphasize this over and over again. It is about quality of life.
I have a discussion with patients about once a day. They come to me taking daily, or nearly daily, narcotics. They ask why can’t I just continue them on pain killers? It isn’t because we don’t care, it is because we do. I will explain.
Headache is a treatable disease in the same way that diabetes is a treatable disease. It makes no sense to ignore the root cause of the disease, but instead give pills that numb up the head so you don’t feel it. It is the same philosophy as dismantling the smoke detectors in a burning home.
The other problem is that pain killers make the underlying disease worse. I will explain how.
The way that narcotics work is that they mimic natural chemicals (endorphin), which the brain makes to kill pain and to increase the feeling of well-being. There is a place for those natural brain chemicals. If you break your arm it hurts like the devil at first. Then in a few minutes, the pain diminishes a bit. The reason that it diminishes is the endorphin kicks in. This is a good thing and it is the way our body gives us enough pain to warn us, but not more pain than we can bare.
The human body is very efficient. If you give the body an artificial endorphin, it stops making its own. Then, in the absence of the narcotics, the brain is deficient of endorphin and the person feels horrible, emotionally and physically. As part of this complex response to endorphin deficiency, headaches are provoked and exacerbated. Therefore, in summary, narcotics make you more prone to headaches, makes the headaches last longer, and more resistant to treatment. This is officially called the Medication Overuse Headache syndrome.
So then, why do we ever prescribe narcotics? I believe that there is a limited role for them. We do it out of compassion for patients which have no other effective treatment. However, they are not the first step, but the last . . . or what we call rescue medication.
In conclusion I’m going to list some valuable resources for patients who think they may be addicted. It is a very hard step to admit that you have a problem. But the only other option is a total personal disaster. If you are my patient, tell me and I will help you get the help you need.
Anacortes meetings at the Burton Building Sundays at 4:30 and at Christ the King Community Church Fridays at 8 PM. NA hotline: (206) 790 888. Mount Vernon hotline: (360) 647-3234
Phoenix Recovery Services (855) 786 7378
Drug Strategies: (800) 599 9503
Drug Rehabs (855) 378 4734