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Maintenance Narcotics - Usually Not a Good Practice

Many patients receive maintenance narcotics (MN). (See Table 1 for a list of commonly prescribed narcotics.) For most of them, this is NOT consistent with ideal medical practice. (We define MN use as length of use that exceeds several months or that is indefinite.) For example, medical science and practice guidelines do NOT recommend MN for these common conditions: 1) joint pain at any site ( either from degenerative arthritis or from systemic illness-related arthritis) 2) back pain-- chronic spinal pain due to spinal arthritis, degenerative disc disease, or spinal mechanical factors 3)"fibromyalgia" 4) neuropathies 5) headache syndromes 6) musculoskeletal pain The indications for chronic narcotics maintenance are few. Most of the proper uses involve cancer-related pain. We are well aware that many who receive MN are addicted to them. Many misuse them for their euphoric effects. Some divert or sell them. All of these uses are inappropriate. All are dangerous; as drug overdose, complex withdrawal syndromes, and sudden death are known complications. All of these place patients, their physicians, and communities at risk. To bring about optimal treatment, the physician should do the following for each pt who receives MN: 1) Detailed documentation each visit of current and past history, physical exam findings, and test results facts that support the need for MN. 2) If these facts do not support the use of MN, the physician should inform the patient what medical science and practice guidelines do and do not recommend for pain syndromes. 3) The physician should offer the patient non-narcotic alternatives, including: -non narcotic analgesics (See Table 2) -pain modifiers (See Table 3) -physical therapy -education re: better habits involving diet, exercise, weight management, sleep, etc -more aggressive tx of psychiatric problems that enhance the perception of pain (e.g. depression/anxiety) 4) Offer pain clinic consultation when feasible 5) Suggest that the patient gradually taper off MN-- by about 25% less tablets per month; with the goal to reach within several months zero use of narcotics. MN rarely work well. Bad side effects are essentially universal (See Table 4). We are well served to avoid MN if at all possible. The tables below should be helpful. I do not mention every possible entry in the categories, just the common ones. I do not list doses of the drugs, as these vary widely. Remember, ALL drugs-- prescription AND over-the-counter ones-- can cause side effects. ALL can be dangerous, especially if used improperly. It is always best to discuss with your physician all of the medicines you take, even the ones you take infrequently. Senior citizens are especially vulnerable to medications side efffects. Table 1 Some Commonly Prescribed Narcotics acetaminophen/codeine ("Tylenol w/ codeine") acetaminophen/hydrocodone combination ("Vicodin" and others) acetaminophen/oxycodone ("Percocet" and others) oxycodone ("Oxycontin" and others) methadone morphine fentanyl transdermal ("Fentanyl" patch)

tramadol (not a true narcotic, but close; and with definite addiction/abuse potential) Table 2 Some Commonly Used Non-narcotic Analgesics acetaminophen ("Tylenol") aspirin ibuprofen naproxen celecoxib ("Celebrex") tramadol ("Ultram") topical lidocaine ("Lidoderm") topical diclofenac ("Voltaren Gel") topical capsaicin liniment Table 3 Some Approved Pain "Modifiers" amitriptyline nortriptyline gabapentin ("Neurontin") pregabalin ("Lyrica") duloxetine ("Cymbalta") Table 4 Common Side Effects Of Narcotics constipation fatigue confusion depression anxiety mood swings withdrawal addiction rebound pain (especially headaches) accidental overdose respiratory failure (EG)

(This piece appeared several years ago on the senior citizens resource website:

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