Narcotics technically refer to drugs that cause one to get sleepy but more commonly and legally the term applies to prescribed medications that are associated with addictive behavior. Opioids are derived from the poppy plant's opium and are just one kind of narcotic. Opioids include: Morphine, Heroin, Codeine, Hydrocodone, Oxycodone, Methadone, etc.
This paper is intended for the patients of Dr. Rotchford who are taking opioids (prescription pain medications) long term to help manage their pain. In addition to our opioid use contract which spells out some the safety issues for using opioids long term, this paper will try to clear up some misconceptions about opioids and help us all communicate better.

     In taking any medication the benefits should outweigh the risks. Pain reduction is a very important medical matter. The benefits of using narcotics for pain management can be a very significant. Nonetheless, there are risks and side effects. Some of the primary immediate side effects of taking opioids include: constipation, cotton mouth, mild sedation, itching of skin, and nausea and/or vomiting. Some people actually become mildly stimulated when first starting narcotics. Most of the side effects do improve with continued use but we will be working closely with you to avoid as much as possible you having any side effects. There are also three other possible consequences of taking opioids that need to be discussed and clarified.

     Addiction: Common language and usage of this word says that anyone who takes opioids repeatedly may well become addicted. When we speak of addiction in medicine, however, we have specific issues involved. These include behavior such as impaired control over drug use, compulsive use, continued use despite harm, and drug craving. Using standard medical term, the vast majority of patients who take opioids will not become addicted. Unfortunately, patients who have had addiction problems with other substances or who have been poorly managed with opiates often develop addictive problems on opiates. Addiction is a complicated term and inevitably we will be encouraging you to learn more about it in order to recognize it early on and to seek appropriate help for it.

    Physical Dependence: Most anyone who is on significant doses of opioids for more than a couple of weeks, is likely to experience some withdrawal symptoms if the amount of opioid used is quickly reduced. This physical phenomenon of opioid use is not strictly speaking related to addiction. Although a person who is addicted to opioids may well experience physical dependence if taking opioids regularly, an opioid addict can also not experience physical dependence.

   Tolerance: Some patients taking opioids experience a diminished effect of the drug over time. That is why some heroin addicts need higher and higher doses to experience the euphoria of opioids. Fortunately, most often in chronic pain patients we don't observe tolerance and people will do just fine on the same amount of opioid for long periods of time. With on going care we always hope to see less amount of pain medication required.

Methadone Use for Chronic Pain
     We often prescribe methadone on a trial basis to patients who are in chronic pain. Patients and their families are often scared by methadone because they associate it with heroin use and addicts. One spouse even confused it with methamphetamine a powerful and very dangerous illegal stimulant. We prescribe methadone for our patients with chronic pain problems for a variety of reasons. First, methadone is potent and it is long acting . As a result it allows patients to take their dose only two or three times a day. It tends to promote addiction less than many other opioids because of its steady level in the blood. It is relatively easy to adjust the dosages as it comes in a liquid form that can be adjusted by small amounts so that the optimal dosage for the patient can be readily found. All of the opioids are a little bit different despite the standard teaching that all opioids if taken in equivalent amounts help pain the same. Methadone actually blocks certain receptors in the spinal cord and brain that other narcotics don't touch. They are called NMDA receptors and often they are important in patients with chronic pain. Some patients can't tolerate methadone and it can be more constipating that some other opioids. If one is already taking another opioid it sometimes is tricky at first to find the right dose of Methadone. Many patients who are taking opioids do so because they help with anxiety and other troublesome emotions. All patients who see Dr. Rotchford will be encouraged to find ways besides medications to deal with anxiety and other feelings that contribute to pain.
Warnings: Mixing methadone with alcohol or other sedatives can be very dangerous. There was a case in Florida where an 18 year old who took only 10mg of Methadone and 1 mg of Xanax (Alprazolam) died. Of course this individual probably had some genetic susceptibility but it nonetheless highlights how dangerous these medications if used in someone not use to them or when used in combination with other medicines. Please inform any physician you are seeing of your use of opioids. The following recommendations apply to driving:
o When not to drive or work around dangerous machinery or at height
- If there has been a recent dose escalation
- If you feel drowsy (Lack of sleep also impairs one significantly)
- If you are in a great deal of pain
- If alcohol is taken
- If you are frail or elderly, consider doing some special testing
If you have questions about opioid use we encourage you to let us know. We also invite spouses/immediate family members to office visits to have their questions answered.

Consent: I have read the above and I understand all of it. I have had a chance to have all of my questions regarding this treatment answered to my satisfaction. I have been given other options for my pain but am proceeding because my condition is serious or other treatments have not helped my pain. By signing this form voluntarily, I give my consent for the treatment of my pain with opioid pain medicines.

Patient Signature: _______________________________ Date: ___________

Witness to above: _________________________________

There are many online references related to pain management:
http://www.painfoundation.org/page.asp?menu=1&item=3&file=documents/doc_033.htm reviews the use of pain medications and indeed the pain foundation website is very helpful. www.painfoundation.org
Dr. Rotchford belongs to the American Academy of Pain Management and their web address is: http://www.aapainmanage.org

Revised 2/2004