Thread by @ScienceVet2

Senator Gillibrand posted over the weekend that the solution to the opiod problem is to limit prescriptions to 7 days.

This is patently ridiculous and could only come from someone who hasn’t experienced a whole raft of painful problems, or done the requisite research.

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Pain is an odd thing, and something that we don’t understand very well. So what do we know?

We know that pain and stress slow healing. This is important. Being in significant amounts of pain and the mental distress that results, slows healing.

We know that a low level of pain (so you know there’s an injury, but not enough to cause distress) actually helps injury healing. This effect may be partly due to a tendency to re-injure if you aren’t feeling ANY pain.

We know that pain is complex. That is, pain is your brain’s interpretation of a bunch of signals from your body and other parts of the brain. Pain goes through a whole passel of areas of the brain focusing on the thalamus and cortex.

The thalamus is the part of the brain that stores a “map” of your body, and thus is responsible for phantom limb pain in amputations.

We know that long term overdose of opiods causes pain sensitization. This makes sense as long term blockage of the receptors causes the brain to compensate and make MORE of them, enhancing the response to pain. Note here that I said “overdose.”

While there is real injury, depressing the signal does not have the same compensatory effect. Similarly, the brain can cause long term depression of pain, basically tell the active nerves to “sit down and shut up for a while, you’re too loud.”

If only we could figure out how to activate that response, eh?

We know that part of pain being complex is that it can be very unreliable. If there aren’t pain receptors in the right location, your brain will make up a location. This is why gallstones often cause pain in seemingly random places like your shoulder.

We know that psychology affects pain. If you feel safe, your pain goes down. However, being positive about your pain is not sufficient to prevent it. Similarly, pain can be reduced by moving as if you’re not in pain.

But that only works if it’s possible to move like you’re not in pain. If the problem is arthritis or MS, that’s not happening.

We know there is no such thing as a pain nerve or pain receptor. There are nerves/receptors that detect certain stimuli and send a signal to the brain as a result.

We DON’T know how to stop pain very well. Most drugs we have are modifications of the same basic structures and work on the same targets. This means they’ve mostly got similar problems (being too weak, or having high risk of addiction).

The 7 day limit a lot of states have adopted, and the Senator proposes, comes from recommendations put out by the CDC that MOST initial opiod prescriptions should be for 3-7 days. For example, most kidney stones cause pain for 3-5 days after passing. Wisdom teeth are similar.

However, “most” does not equal “all.” And the fact we don’t have many alternatives doesn’t mean we shouldn’t treat pain.

Cancer pain is the most often exempted from state level rules for obvious reasons. Are you going to tell someone with bone cancer they can’t have pain medication that will even touch it?

The problem is that it’s hardly the only example of long term pain that needs treatment. MS and a raft of auto-immune diseases can cause similar pain.

One big problem with this plan is that untreated acute pain is far more likely to become chronic. That’s right, it’s actually important to treat your pain early, and treat it for real. Toughing it through slows your healing and makes it more likely to turn chronic.

And once a pain turns chronic, it’s much harder to reverse the effect as the conversion to chronic pain actually involves physical changes in your brain.

It’s important to note that while all pain comes from your brain, it is not “all in your head.” This is to say, even if your brain has started to make pain without a “reason” it is still real pain, because pain comes from your brain.

Pain is your brain’s interpretation of the danger to your body. Even if it’s wrong, the pain it creates is real, just out of proportion with the actual danger. Also, just because we can’t find the danger/damage/problem doesn’t mean it isn’t there!

So, what to do we do? The guidance from the CDC is right. Initial prescriptions for opioids for MOST conditions should be no more than 7 days.

For most acute pain problems, and heading home from many outpatient procedures that’s enough. But legislating that limit and expecting that you can write in every logical exception is ridiculous. There are too many exceptions and side-cases. That is what doctors are for.

Unmanaged pain/stress slows healing: ncbi.nlm.nih.gov/pmc/articles/P…

A good summary of a lot of this from someone who's been studying and writing about pain for a long time: painscience.com/articles/pain-…