Transcript: Pain | Apr 30, 2001

(music plays)

An animated slate shows the title inside the shape of a house: "More to health." The opening sequence shows a wooden table with a small lit candle.
Fast clips show different sets of hands performing activities on the table such as pulling petals from a daisy, drawing a big red heart, tuning a violin, flipping through the pages of a book, cooking, and pouring a glass of red wine.
In animation, the title appears inside the shape of a house: "More to life."

Then, Maureen Taylor appears in a studio with textured yellow walls and the logo of the show in the background, which reads "More to life."

Maureen is in her late thirties, with wavy brown hair in a bob. She's wearing a gray blazer over a red blouse.

She says WATCHING MORE TO LIFE. IF YOU'RE ONE OF THE THOUSANDS OF CANADIANS WHO SUFFER CHRONIC PAIN, STAY TUNED. WE'RE GOING TO LET AN EXPERT IN PAIN MANAGEMENT ANSWER YOUR QUESTIONS IN A FEW MOMENTS. NOTHING IS BETTER FOR MANAGING PAIN THAN NARCOTICS OR OPIOIDS BUT EXPERTS ESTIMATE AS MANY AS 70 percent OF CANADIANS WHO EXPERIENCE PAIN DON'T RECEIVED A "A PAIN TREATMENT, IN LARGE PART BECAUSE DOCTORS ARE AFRAID TO PRESCRIBE STRONG DRUGS SUCH AS MORPHINE OR METHADONE. THEY'RE AFRAID THEIR PATIENT ALSO END UP ADDICTED TO THEM BUT PAIN EXPERTS SAY THE MEDICAL COMMUNITY IS CONFUSING ADDICTION WITH DEPENDENCY.

A clip plays in which a woman stands in a backyard and pushes a toddler in a swing.
A caption reads "Name: Laura de Costa. Pain Source: Crushed discs in spine. Drug: Oxycodone."

Laura sits on a couch in a living room. She's in her late thirties, with wavy chin-length chestnut hair. She's wearing a pink sweater and a patterned brown vest.

She says I'M TAKING SOMETHING, A PILL CALLED OXYCODONE, AND IT'S A TYPE OF MORPHINE. AND IT REGULATES THE PAIN VERY WELL. IT'S ALMOST NOT THERE NOW. I HAVE A BIT OF BREAKTHROUGH PAIN THROUGH THE DAY, BUT VIRTUALLY NO PAIN ALL DAY LONG COMPARED TO BEING IN CONSTANT PAIN WHEN THIS ALL STARTED.

Now another woman measures a piece of glass in a workshop.

A caption reads "Name: Gayle Gibson. Pain Source: Osteoarthritis and injured shoulder. Drug: Methadone."

Gayle is in her forties, with long straight brown hair and bangs. She wears a black sweater.

She says THAT'S MY MAIN SOURCE OF PAIN RELIEF, IS THE OPIOIDS. I TAKE THE OPIOIDS EVERY DAY LIKE REGULAR MEDICATION. I TAKE METHADONE. I TAKE APPROXIMATELY 330 MILLILITRES A DAY.

A short clip shows Gayle pouring a clear liquid into a clean glass using a syringe.

Maureen says HOW DO YOU TAKE METHADONE?

Gayle says WHAT WE DO IS WE HAVE TO PICK IT UP FROM THE PHARMACY IN A SYRUP AND POUR IT INTO SOMETHING THAT YOU ENJOY DRINK AND DRINK IT, BECAUSE IT TASTES VERY BITTER.

She pours an orange soda pop into the glass, then drinks it.

Maureen says DALE GIBSON AND ON LAURA DA COSTA ARE TWO OF THOUSANDS OF CANADIANS WHO LIVE WITH CHRONIC PAIN BUT THEY DON'T SUFFER BECAUSE THEIR DOCTOR PRESCRIBES POWERFUL NARCOTICS OR OPIOIDS AND THEY TAKE THEM EVERYDAY. Dr. ROMAN JOVEY IS ONE OF CANADA'S LEADING EXPERTS ON THE USE OF OPIOIDS TO TREAT PAIN.

Roman sits in an office.

A caption reads "Doctor Roman Jovey. General Practitioner."

Roman is in his fifties, with short white hair and a mustache. He wears a dark blue shirt.

He says INITIALLY WE LEARNED FROM THE CANCER POPULATION THAT WE COULD USE OPIOIDS OVER A LONG PERIOD OF TIME IN HIGH DOSE WITHOUT CAUSING A LOT OF ADDICTION OR IN FACT IF THE DOSE WAS CAREFULLY TITRATED AND THAT MEANS ADJUSTING THE DOSE TO GET THE PROPER EFFECT, THEN IN FACT PEOPLE COULD FUNCTION QUITE NORMALLY ON OPIOID THERAPY. NOW THAT EXPERIENCE HAS BEEN TRANSLATED TO THOSE PEOPLE WITHOUT CANCER PAIN. PEOPLE WITH SO-CALLED CHRONIC NON-CANCER PAIN.

Maureen says BUT NOT ALL DOCTORS ARE COMFORTABLE PRESCRIBING SUCH STRONG DRUGS FOR PEOPLE WHO AREN'T TERMINALLY ILL.

Roman says IF YOU LOOKED AT THE OLDER CLINICAL STUDIES FROM 15 YEARS AGO, THE THOUGHT WAS THAT ANYBODY WHO IS EXPOSED TO AN OPIOID LONG ENOUGH WILL BECOME ADDICTED. AND THIS SCARED A LOT OF PHYSICIANS OFF FROM USING THEM. BUT IN THIS AREA, CHANGES ARE VERY SLOW. THAT IT'S TAKING SOME PHYSICIANS A LONG TIME TO ACCEPT THAT THERE IS A ROLE FOR OPIOIDS IN CHRONIC PAIN.

Gayle says MY FIRST DOCTOR DID NOT UNDERSTAND. AS A MATTER OF FACT, HE HAD WRITTEN IN MY FILE THAT I WAS AN ADDICT. HE WAS NOT ASKING THE RIGHT QUESTION, AS FAR AS I'M CONCERNED. HE DID NOT INVESTIGATE MY PROBLEM AS DEEPLY AS HE SHOULD HAVE. HE DIDN'T TAKE THE TIME TO... WASN'T FAMILIAR ENOUGH WITH PAIN, AND I DON'T THINK A LOT OF DOCTORS ARE FAMILIAR WITH PAIN. YOU KNOW, WHEN I... UNLESS YOU GO THROUGH IT YOU DON'T KNOW.

Roman says WHAT DID YOU PAINT?

Gayle says PEOPLE WHO TAKE OPIOIDS FOR CHRONIC PAIN SAY THE DRUGS DON'T GIVE THEM THE SAME HIGH THAT THEY GIVE AN ADDICT. IT'S AS IF ALL THE MEDICATION IS USED UP IN TREATING THE PAIN.

Laura says I MYSELF PERSONALLY DON'T FEEL ADDICTED. I DO FEEL DEPENDENT, BECAUSE IT ALLOWS ME TO LIVE NORMALLY DAY TO DAY. I CAN DO ALL THE NECESSARY THINGS, TAKE MY CHILDREN TO SCHOOL, TAKE THEM TO EXTRA CURRICULAR THINGS, BE ABLE TO WORK, BE ABLE TO RUN MY OWN BUSINESS. WHEREAS... AN ADDICT, I BELIEVE, IS TOTALLY JUST COMPLETELY OUT OF IT. THEY CRAVE IT. THEY HAVE TO HAVE IT, MAYBE MORE THAN TWICE A DAY. AND THEY'LL GO TO ANY LENGTHS TO DO THAT.

Gayle says ADDICTED? I LOOKED UP THE WORD THE OTHER NIGHT, AND NO I'M NOT ADDICTED. I'M DEPENDENT. DEPENDENT ON IT. JUST LIKE A DIABETIC WOULD BE DEPENDENT ON INSULIN. I'M THE SAME WAY. IF I DIDN'T TAKE IT, I SURE WOULD FEEL SOME SIDE EFFECTS OF WITHDRAWAL. BUT I'M SUPPOSED TO TAKE IT SO THAT'S WHAT I DO.

Roman says IT'S CONFUSING TO MANY HEALTHCARE WORKERS, THIS DIFFERENCE BETWEEN PHYSICAL DEPEND SENS AND ADDICTION. SO PHYSICAL DEPENDENCE SIMPLY MEANS THAT YOU ARE TAKING A, IN THIS CASE A MEDICATION ON A DAILY BASIS, AND IF YOU WERE TO SUDDENLY STOP THAT MEDICATION, YOU WOULD HAVE A CHARACTERISTIC SET OF WITHDRAWAL SYMPTOMS. IN THE CASE OF OPIOIDS THAT WOULD BE ANXIETY, SWEATS, BONE CHILLS, DIARRHEA, ABDOMINAL AND MUSCLE CRAMPS. AND THIS CHARACTERISTIC WITHDRAWAL REACTION WOULD GO ON FOR SOME DAYS, ONE DAY, TWO DAY, THREE DAYS AND THEN GRADUALLY PETER OUT. NOW THAT'S DIFFERENT FROM ADDICTION. ADDICTION IS CHARACTERIZED BY REPEATEDLY USING A PARTICULAR SUBSTANCE, IN THIS CASE FOR EXAMPLE OPIOIDS OR EVEN A BEHAVIOUR, SUCH AS EATING OR GAMBLING, USING IT REPEATEDLY TO THE POINT IT STARTS TO DISRUPT YOUR LIFE.

Now a man walks in a park. His face remains out of frame.

A caption reads "Name: Frasier. Pain Source: Leg injury. Drug: Oxycontin."

Frasier says I WENT THROUGH A NUMBER OF GENERAL PRACTITIONERS. WELL NOT A NUMBER. I WENT THROUGH THREE OR FOUR GENERAL PRACTITIONERS...

Maureen says FRASIER IS ALSO ON OPIOIDS FOR CHRONIC PAIN IN HIS LEG. HE SAYS HE'S QUALIFIED TO TELL THE DIFFERENCE BETWEEN DEPENDENCE AND ADDICTION TO A DRUG.

Maureen sits on a park bench with Frasier, who is shown from behind.

Frasier says I HAVE BEEN ADDICTED TO COCAINE AND HEROIN FOR YEARS PRIOR TO TO MY ACCIDENT. I WAS VERY INVOLVED IN THE DRUG CULTURE, IF YOU WILL, AND I KNOW WHAT IT'S ALL ABOUT TO BE A DRUG ADDICT. AND HOW A DRUG ADDICT THINKS AND AT LEAST FOR ME, HOW I THOUGHT AS A DRUG ADDICT AND WHAT MOTIVATED ME AS A DRUG ADDICT. AND IT'S VERY DIFFERENT THAN WHAT I EXPERIENCE NOW. IT'S ALMOST LIKE A DIFFERENT PERSON.

Maureen says CAN YOU GO INTO THAT A BIT? WHAT ARE THE DIFFERENCES?

Frasier says AS A DRUG ADDICT... AS A DRUG ADDICT YOU'RE MOTIVATED BY THE DRUG. THE DRUG PRETTY MUCH CONTROLS YOUR LIFE. IT CONTROLS WHAT YOU DO, WHO YOU SOCIALIZE WITH, THE WAY YOU BEHAVE. IT CONTROLS YOUR VALUES, YOUR MORALS, BASICALLY IT TAKES OVER YOUR ENTIRE LIFE AND YOU LIVE TO SATISFY THE NEED TO GET THAT DRUG. WITH THE NARCOTIC THAT I'M ON NOW, THERE IS NONE OF THAT THE NARCOTIC THAT I'M TAKING NOW DOESN'T HAVE ANY... THERE ARE NO HIGHS. YOU DON'T GET STONED FROM THIS NARCOTIC.

Maureen says BUT PUTTING SOMEONE WITH FRASIER'S HISTORY ON OPIOIDS DOES CARRY RISKS. ALTHOUGH THE OXYCONTIN HE'S ON HASN'T REKINDLED HIS ADDICTION, Dr. JOVEY SAYS IN RARE CASES IT HAPPENS.

Roman says WHAT I HAVE A ARE PEOPLE THAT HAD HIGH RISK PAST HISTORIES WHO WERE PUT ON OPIOIDS FOR PAIN AND IT REKINDLED, SORT OF WOKE UP THEIR ADDICTION, IF YOU THINK OF IT. I'VE YET TO MEET A SINGLE PATIENT MORE IN SPEAKING WITH COLLEAGUES ACROSS MY COUNTRY HAVE YET TO HEAR OF A GENUINE CASE OF SOMEBODY WHO HAD NO RISK FACTORS FOR ADDICTION, WAS PUT ON AN OPIOID FOR PAIN AND BECAME ADDICTED. I'M SURE SOMEWHERE IN THE COUNTRY THERE WERE ONE OR TWO WHERE THAT'S HAPPENED BUT THAT'S HOW RARE IT IS.

Standing inside the reception in a clinic, Maureen says THERE ARE MANY EXAMPLES OF DOCTOR, ESPECIALLY IN THE U.S. WHO HAVE BEEN PROSECUTED FOR PRESCRIBING TOO MUCH MEDICATION, SPECIFICALLY NARCOTICS. BUT LAST YEAR A DOCTOR IN OREGON WAS DISCIPLINED FOR UNDER TREATING A CANCER PATIENT. HE GAVE THE MAN TYLENOL WHEN WHAT HE REALLY NEEDED FOR THE PAIN WAS MORPHINE. SO HAVE WE COME FULL CIRCLE IN THE DEBATE OVER PAIN MANAGEMENT?

Roman says AS THE PUBLIC BECOMES AWARE THAT THERE IS NO REASON, FOR EXAMPLE, WHEN THEY BREAK THEIR LEG THAT THEY SHOULD SUFFER EXCRUCIATING PAIN FOR HOURS AND HOURS, WE HAVE THE TECHNOLOGY TO IMPROVE THAT SIMILARLY POST OPERATIVELY THERE'S NO REASON IN THIS DAY AND AGE SOMEBODY SHOULD HAVE UNCONTROLLED PAIN AFTER A SURGICAL PROCEDURE. AND I THINK SIMILARLY, NOW THE POPULATION WILL BECOME AWARE THAT IF THEY HAVE CHRONIC NON-CANCER PAIN, IT'S NOT THAT WE CAN TAKE AWAY AND CURE ALL OF THESE PAINS BUT I THINK THEY CAN BE MUCH BETTER MANAGED THAN THEY HAVE BEEN IN THE PAST. AND SO THERE WILL BE A PUBLIC PRESSURE NOW ON THE HEALTHCARE SYSTEM, ON PHYSICIANS TO PROVIDE BETTER PAIN MANAGEMENT. AND I THINK THAT THAT CASE IN OREGON IS PROBABLY JUST THE BEGINNING.

Maureen says BUT NO ONE RELISHES THE THOUGHT OF STAYING ON NARCOTICS FOR THE REST OF THEIR LIFE. AND WHETHER IT'S BECAUSE OF THE SIDE EFFECTS OR THE STIGMA OF BEING ON STRONG PAIN KILLERS, THESE PEOPLE LOOK FORWARD TO THE DAY WHEN THEY CAN GIVE THEM UP.

Laura says THEY'RE MAKING GREAT STRIDES IN BACK MEDICINE THESE DAYS AND THEY SAID PERHAPS IN FIVE YEARS THEY'LL HAVE SOMETHING OUT THERE TO SOLVE MY PROBLEM AND I HANG ONTO THAT EACH AND EVERYDAY. AND I DO HOPE TO BE OFF THIS MEDICATION ONE DAY, BUT FOR THE TIME BEING, IT'S A REAL LIFE SAVER FOR ME.

Gayle says I THINK THE WORST PART IS THE THOUGHT OF BEING ON IT AND WHAT PEOPLE THINK OF ME. I THINK... IT'S SOMETHING THAT I USED TO DISCUSS WITH PEOPLE, IT'S SOMETHING NOW THAT MAYBE I DON'T BRING UP QUITE AS QUICK.

Roman says IF THERE WAS SOMETHING BETTER RIGHT NOW TO TREAT PAIN THAN OPIOIDS WITHOUT THAT SMALL RISK OF ADDICTION, I WOULD GO FOR IT. BUT THE FACT IS RIGHT NOW THERE ISN'T.

The clips end.

Back in the studio, Maureen says IF YOU FEEL YOUR PAIN ISN'T BEING ADEQUATELY TREATED OR IF YOU HAVE QUESTIONS ABOUT ADDICTION AND DEPENDENCY, Dr. ROMAN JOVEY CAN PROVIDE SOME ANSWERS. HE IS A GENERAL PRACTITIONER WITH AN INTEREST IN PAIN MANAGEMENT AND ADDICTION. HERE ARE OUR NUMBERS.

A caption reads "416-484-2727. 1-888-411-1234."
Then, it changes to "moretolife@tvo.org"

Maureen says NICE TO SEE YOU AGAIN. HI.

Roman says HELLO, THANK YOU.

Maureen says WHAT KIND OF GUIDELINES DO ONTARIO DOCTORS HAVE WHEN IT COMES TO PRESCRIBING OPIOIDS LIKE THE ONES THAT YOUR PATIENTS THERE ARE ON?

A caption appears on screen. It reads "Doctor Roman Jovey. General Practitioner."

Roman says WELL IN NOVEMBER OF 2000 THE ONTARIO COLLEGE OF PHYSICIANS AND SURGEONS, THAT'S THE GOVERNING BODY FOR PHYSICIANS THAT PRACTICE IN ONTARIO DID PUBLISH A SET OF GUIDELINES, AND THEY CALL THEM THE EVIDENCE BASED GUIDELINES FOR THE MANAGEMENT OF CHRONIC NON-MALIGNANT PAIN.

Maureen says EW, LONG TITLE.

Roman says LONG TITLE AND WHAT THEY DEFENSE CALLED IT EVIDENCE-BASED, WHICH MEANS THEY REVIEWED THE MEDICAL LITERATURE, THE RESULTS OF EXPERIMENTS OF CLINICAL TRIALS AND BECAUSE IT TOOK SO LONG TO CREATE THIS DOCUMENT, THEY WERE WORKING ON IT FOR ALMOST FOUR YEARS THAT THEY ENDED THEIR REVIEW IN 1998. SO ALREADY WHEN IT'S PUBLISHED, IT'S BECOME A BIT DATED. HOWEVER IT DID PULL TOGETHER A LOT OF THINGS. IT DID SAY WITHOUT A DOUBT THAT THERE IS A ROAM FOR OPIOIDS AND THE TREATMENT OF CHRONIC NON-CANCER PAIN AND GAVE SOME GUIDE LINE FOR PHYSICIANS ON DO'S AND DON'TS IN PRESCRIBING OPIOIDS.

Maureen says AND DO YOU FEEL IT ADEQUATELY DIFFERENTIATES BETWEEN ADDICTION AND DEPENDENCE?

Roman says IT DID NOT SPECIFICALLY DEAL WITH THAT ISSUE IT. DID SAY THE TRUE RISK... THE RISK OF ADDICTION FOR PEOPLE WHO ARE ADEQUATELY SCREENED IS QUITE LOW. IT DIDN'T SPECIFICALLY GO INTO THAT DIFFERENCE BETWEEN ADDICTION AND DEPENDENCE?

Maureen says HOW DO YOU FEEL AS A DOCTOR FOUR, AS A DOCTOR WHO HELPS PEOPLE MANAGE PAIN, ARE YOU RESTING EASIER KNOWING THEY WON'T AM IN AND SWOOP DOWN AND LOOK AT HOW MUCH YOU'RE PRESCRIBING?

Roman says I HAVE SOME ADDITIONAL DEGREE OF REASSURANCE. UNFORTUNATELY, THE GUIDELINES WERE LEFT WANTING IN SOME AREAS. IN PARTICULAR THERE'S A SO-CALLED OPT-OUT CLAUSE WHICH SAYS IF YOU'RE A PHYSICIAN AND UNCOMFORTABLE WITH PRESCRIBING OPIOIDS FOR PAIN YOU CAN OPT OUT. I FIND THAT OBJECTIONABLE BECAUSE IT DOESN'T PUT AN ETHICAL OBLIGATION ON THE PHYSICIAN TO REFER SOMEONE TO SOMEONE ELSE WHO DOES, IS ABLE TO DO THAT OR FOR SOME OTHER WAY OF MANAGING PAIN.

Maureen says IS THAT TRUE FOR ACUTE PAIN AS WELL AS CHRONIC?

Roman says NO, THIS GUIDELINE WAS SPECIFIC TO NICK PAIN.
BECAUSE THAT'S WHERE THE CONTROVERSY EXISTS. THERE SHOULD BE NO CONTROVERSY IN THIS DAY AND AGE FOR TREATING ACUTE PAIN WITH OPIOIDS.

Maureen says AND YET WHEN I HAD SURGERY ON MY FOOT I WAS ONLY GIVE TYLENOL 3'S WHICH DIDN'T EVEN TOUCH THE PAIN IS THERE ANYTHING ON THE PHYSICIAN FORCING HIM TO PRESCRIBE ANYTHING STRONGER FOR ACUTE PAIN?

Roman says THERE ARE MANY STUDIED PUBLISHED THAT INDICATE PHYSICIANS ARE STILL POOR AT TREATING ACUTE PAIN. WHETHER IT'S IN THE EMERGENCY DEPARTMENT, TREATING A BROKEN LEG, POST OPERATIVELY. BECAUSE OF OUR FEARS OF ADDICTION OF... ADDICTION OF CREATING ADDICTS, MORE OFTEN THAN NOTE PHYSICIANS UNDER DOSE PATIENT FOR ACUTE PAIN AND IN MY OPINION THERE'S NO EXCUSE FOR THAT IN THIS DAY AND AGE.

Maureen says AND AS A PATIENT THEY FEEL RELUCTANT TO ASK FOR MORE. THEY'RE WORRIED HE'LL THINK THEY'RE ADDICTED TO THE DRUG AND THEY'RE SOME KIND OF DRUG ADDICT.

Roman says YEAH, I AGREE. THINGS ARE CHANGING. IN THE UNITED STATES NOW, STARTING THIS YEAR, IF YOU WANT TO BE ACCREDITED, MEANING IF YOU WANT TO BE APPROVED AS A SORT OF FORWARD-THINKING HOSPITAL, THERE ARE NOW STANDARDS THAT HAVE BEEN PUBLISHED THAT HOSPITALS WILL HAVE TO MEET. AND THE LONG AND SHORT OF IT IS THAT THEY'LL HAVE INSPECTORS THAT WILL COME TO A HOSPITAL. THE HOSPITAL WILL HAVE TO DEMONSTRATE AN INTEGRATED PLAN FOR PANE MANAGEMENT ACROSS THE ORGANIZATION. THAT MEANS THAT THEY HAVE TO TRAIN NURSES, DOCTORS TO ASK ABOUT PAIN ROUTINELY AND IT'S NOW BEING CALLED THE FIFTH VITAL SIGN. HEARTRATE AND BLOOD PRESSURE, TEMPERATURE, BUT THEY WILL HAVE TO DEMONSTRATE AN ORGANIZED APPROACH TO ASKING ABOUT PAIN AND AN ORGANIZED APPROACH ACROSS THE ORGANIZATION FOR TREATING PAIN SO INSTEAD OF IT BEING ON THE BACK BURNER AS AN AFTER THOUGHT IT WILL NOW COME FRONT AND CENTRE OR THEY WILL RISK NOT BEING ACCREDITED.

Maureen says HOW LONG BEFORE THAT SYSTEM COMES TO CANADA? WE'RE A BIT OF A LAG BEHIND THEM.

Roman says WE'RE STILL... YEAH, WE'RE STALE BIT BEHIND IN THAT SENSE. ALTHOUGH THAT'S A GROUP, CANADIAN PHYSICIANS ARE LEASE FEARFUL, OPIATE PHOBIC THAN OUR AMERICAN COUNTERPARTS.

Maureen says THAT'S BECAUSE OF THE WHOLE NARCOTICS THING DOWN THERE. IN FACT THAT'S BECOMING A BIT OF A PROBLEM I READ IN NEW YORK CITY, THAT THIEVES ARE BREAKING INTO PHARMACIES AND STEALING THE OPIOIDS TO SELL ON THE STREET AS STREET DRUGS.

Roman says THERE'S ALWAYS BEEN SOME OF THAT GOING ON.

Maureen says IS THAT RIGHT?

Roman says THERE'S ALWAYS BEEN A CERTAIN PERCENT OF OPIOIDS DIVERTED TO THE ILLICIT MARKET BUT THAT DOESN'T NECESSARILY MEAN WE SHOULD STOP PRESCRIBING OPIOIDS. THERE ARE AIDS DRUGS DIVERTED TO THE ILLICIT MARKET BUT NOBODY WOULD SUGGEST WE SHOULD STOP TREATING AIDS. THERE ARE A SMALL PERCENTAGE OF PEOPLE WHO WOULD MIMIC SYMPTOM, SEE THE DOCTOR AND OBTAIN OPIOIDS FOR HE'LL HIS SIT PURPOSES.

Maureen says OKAY. IF YOU HAVE ANY QUESTIONS ABOUT YOUR PAIN CALL US IN TORONTO AT...

A caption reads "416-484-2727. 1-888-411-1234."
Then, it changes to "moretolife@tvo.org"

Maureen says SARA IS IN TORONTO. HI SARA, WELCOME.

The Caller says HI THERE. THANKS VERY MUCH FOR HAVING ME ON.

Maureen says YOU'RE WELCOME. GO AHEAD.

The Caller says MY BASIC QUESTION, I GUESS, IS I FEEL VERY BAD RIGHT NOW, NOT ONLY BECAUSE MY PAIN LEVEL IS SO HIGH, BUT BECAUSE THERE SEEMS TO BE SUCH A STIGMA WITH BEING ON THESE DIFFERENT MEDICATIONS AND WHAT NOT. AID CAR ACCIDENT IN SEPTEMBER, THE SECOND ONE I HAD ACTUALLY IN THREE YEARS. I'VE NOW BEEN DIAGNOSED WITH FIBROMYALGIA AND I THINK I HAVE SOMETHING CALLED CUSHING'S DISEASE. I'VE BEEN WAITING TO TRY AND SEE IF MY PAIN DOES GET BETTER, IF I TRY AND GET BACK TO A REGULAR, NORMAL LIFE BUT IT'S NOT GETTING BETTER. IT'S GETTING WORSE AND I JUST FEEL REALLY... I FEEL ALMOST LIKE I'M FIGHTING A LOSING BATTLE HERE, TRYING TO STAY OFF STUFF, BUT I KNOW THERE'S GOT TO BE SOMETHING THAT CAN HELP ME. I JUST DON'T KNOW WHAT.

Maureen says OKAY, DO YOU WANT TO ASK HER ANY QUESTIONS BEFORE YOU ANSWER? WHAT SHE'S ON OR...

Roman says YEAH, COULD YOU TELL ME WHAT MEDICATION YOU'RE CURRENTLY TAKING AND A LITTLE BIT ABOUT THE SYMPTOMS THAT YOU'RE HAVING.

The Caller says WELL CURRENTLY RIGHT NOW THEY'VE GOT ME ON AMITRIPTYLINE TO HELP ME SLEEP AT NIGHT BECAUSE I'M SO UNCOMFORTABLE I DON'T GET A PROPER SLEEP. I HAVE TO GO INTO A SLEEP STUDIES BECAUSE THEY DON'T THINK I'M GETTING TO THE PROPER LEVEL OF SLEEP AS WELL AS JUST NOT GETTING ANY. OCCASIONALLY I'VE TAKEN FIORINAL FOR MY MIGRAINES. I WAS ON PERCOCET BEFORE FOR THE FIRST ACCIDENT. I HAVEN'T GONE TO SOMETHING THIS HEAVY FOR THIS ACCIDENT. I HAVE A FIVE-YEAR-OLD DAUGHTER I HAVE TO TAKE CARE OF AND MY HUSBAND WORKS AND COMES HOME AND TAKES CARE OF EVERYTHING ELSE. I FEEL USELESS. I REALLY DO.

Maureen says OKAY.

Roman says AMITRIPTYLINE NOT A BAD DRUG TO START WITH. IT COMES FROM AN OLDER FAMILY OF DEPRESSANTS AND WE USE THEM VERY OFTEN IN TREATING VARIOUS CHRONIC PAIN STATES. IF YOU'RE ON THAT, IT'S NOT A BAD PLACE TO START. I THINK YOU SAID 50 MILLIGRAMS. THAT MAY BE A LOW DOSE, AND THE PRINCIPLE WHEN USING ANY MEDICATION TO TREAT CHRONIC PAIN IS CALLED DOSE TO EFFECT. MEANING THAT YOU CONTINUALLY GRADUATE THE INCREASING DOSE OF A MEDICATION UNTIL EITHER IT GIVES YOU INCREASING PAIN RELIEF OR YOU HAVE UNACCEPTABLE SIDE EFFECTS. A NUMBER OF PHYSICIANS PREVIOUSLY TRAINED ASSUME THERE'S SOME KIND OF MAGIC DOSE SEALING AND THAT'S NOT TRUE. SO THAT WOULD BE ONE REASONABLE MEDICATION YOU CAN START WITH. IF YOU NOW OR AT LEAST SIX MONTHS AFTER THE ONSET OF THIS CHRONIC PAIN PROBLEM, BY DEFINITION YOU HAVE CHRONIC PAIN AND YOU'RE LOOKING TO USE AN OPIOID TO TREAT PAIN, USING PERK SET IS PROBABLY NOT THE BEST OPTION BECAUSE IT'S VERY SHORT ACTING AND YOU WOULD LIKELY NEED TO TAKE A NUMBER OF THEM A DAY AND OVERTIME THE ACTION OF THE PERCOCET MAY GET SHORTER AND SHORTER AND SHORTER SO IF YOU'RE GOING TAKE AN OPIOID LONG-TERM FOR TREATING YOUR PAIN IT'S PROBABLY BETTER TO TAKE A LONG ACTING DRUG SCHEDULED BY THE CLOCK INSTEAD OF PERCOCET AS REQUIRED. BUT THERE STILL MAY BE OTHER OPTIONS YOU NEED TO EXPLORE SO PROBABLY AT THIS POINT YOU NEED TO SEE IF YOUR PHYSICIAN CAN DO AN ASSESSMENT OF ALL THE FACTORS RELATED TO YOUR PAIN OR PERHAPS REFER TO YOU A PAIN CLINIC IF YOU CAN FIND ONE ON A TIMELY BASIS AND THEN TO APPROACH IT IN A SYSTEMATIC WAY.

Maureen says AND SHE SEEMS TO BE WORRIED OPIOIDS WILL SOMEHOW MAKE HER INCAPABLE OF LOOKING AFTER HER YOUNG DAUGHTER BUT AS WE SAW IN THE PIECE, LAURA WHO HAD YOUNG CHILDREN WAS ON... IT WAS OXYCONTIN OR SOMETHING, AND SHE'S STILL ABLE TO RUN THE HOUSE AND LOOK AFTER HER KIDS AND IT DOESN'T HAVE TO PUT YOU IN A FOG I GUESS IS WHAT YOU'RE SAYING.

Roman says IF YOU'RE TAKING... YOU'RE MORE LIKELY TO BE FOGGY IF YOU USE SHORT-ACTING OPIOIDS LIKE Percocet BECAUSE THEY TYPICALLY HIT YOUR BRAIN WITHIN 45 MINUTES TO AN HOUR, THAT'S WHEN YOU HAVE THE GROGGY EFFECTS. THEIR EFFECT ON PAIN LASTS ABOUT FOUR HOURS AND SO IF YOU CAN IMAGINE YOUR BRAIN, IT'S LIKE A YOYO, THE KRUG IS EITHER IN OR OUT OF YOUR BRAIN AND IT'S VERY HARD FOR YOUR BRAIN TO ADOPT TO THE SIDE EFFECTS, SUCH AS DROWSINESS AND THAT'S THE ADVANTAGE. IF YOU'RE GOING TREAT PAIN WITH AN OPIOID THERE'S AN ADVANTAGE TO TAKING ONE THAT LASTS 12 HOURS BECAUSE STUDIES SHOW IF YOU'RE ON THE SAME DOSE ON A REGULAR BASIS YOUR BRAIN USUALLY WILL ADOPT TO THE DROWSY SIDE EFFECTS WITHIN FIVE TO SEVEN DAYS.

Maureen says GOOD LUCK, SARA. THANKS FOR CALLING. TAMMY IS IN CHATHAM. HI TAMMY.

The Caller says HI, HOW ARE YOU?

Maureen says GOOD, THANKS.

The Caller says GOOD. I'VE GOT A HUSBAND THAT HAS ARTHRITIS. HE WAS ADDICTED TO PERCODANS, FOR QUITE A WHILE. HE MANAGED TO GET OFF THOSE. NOW HE'S ADDICTED TO OXYCOCET. HE'S TAKING 20 TO 30 OF THEM A DAY. HE TRIED TO GET OFF THOSE, COULDN'T DO IT. WENT DOWN TO GET SOME KIND OF HELP. THEY PUT HIM ON A TIME RELEASE DRUG, I DON'T KNOW WHAT IT IS, NOW HE'S WAITING TO GET INTO A METHADONE PROGRAMME SO HE CAN GET OFF OF EVERYTHING COMPLETELY. I KNOW HE'S IN A GREAT DEAL OF AMOUNT OF PAIN. HE'S ON HIS FEET ALL DAY AND THE ARTHRITIS IS IN HIS FEET.

Roman says WELL, ARTHRITIS... HAS HE HAD ADVANTAGE OR SOMEONE TRYING OTHER SO-CALLED MODIFYING AGENTS? IN THE VARIOUS TYPES OF TART ARTHRITIS THERE ARE OTHER DRUGS THAT CAN DECREASE THE INFLAMMATION. THAT'S WIDE VARIETY OF THEM IS THERE A RHEUMATOLOGIST CHECKING THOSE OUT WITH HIM ONE AFTER ANOTHER TO SEE IF ONE OF THOSE MAY BENEFIT HIM?

The Caller says WHAT HE'S TRIED FROM ONE IS ANTI INFLAMMATORIES AND THEY DIDN'T HELP.

Roman says THERE ARE OTHER POSSIBILITIES, OTHER THAN ANTI-INFLAMMATORIES AND THEY'RE CALLED " degrees degrees-MODIFYING DRUGS" AND THERE'S A WHOLE LIST OF THEM. IT SHOULDN'T JUST STOP AT ANTI INFLAMMATORIES. THERE MAY BE SOMETHING ELSE THAT CAN DECREASE THE INFLAMMATION OF HIS PSORIATIC ARTHRITIS THAT WILL DECREASE HIS PAIN. HE MAY BE GOING ON METHADONE TO TREAT HIS PAIN RATHER THAN TAKE HIM OFF OF HIS OXYCONTIN BECAUSE METHADONE CAN BE USED FOR EARTH PURPOSE AND MY QUESTION OF HIS DOCTORS WOULD BE IF YOU'RE GOING TO TAKE HIM OFF THE OXYCONTIN HOW ARE THEY GOING TREAT HIS PAIN?

Maureen says WHEN SHE TOLD US THE NUMBER HE WAS TAKING OF... WHAT WAS IT, THE OXYCONTIN DID, THAT SOUND LIKE A LOT TO YOU?

Roman says I THINK SHE SAID OXYCOCET WHICH IS IS THE SHORT-ACTING FORM. IT'S LIKE PERCOCET, AND ANYTHING ABOVE 10 TO 12 TABLETS A DAY IS A HIGH DOSE IT'S ACTUALLY THE TYLENOL COMPONENT OF IT THAT'S RISKY.

Maureen says TO THE LIVER?

Roman says YES. WE KNOW EVEN NOW TAKING THERAPEUTIC DOSES OF ACETAMINOPHEN CAN CAUSE ACUTE LIVER DAMAGE IN SOME PEOPLE. IT DOESN'T HAPPEN COMMONLY BUT UNFORTUNATELY THERE'S NO WAY TO PREDICT WHO WILL AND WON'T GET IT IT. EVEN LONG-TERM WE'RE AWARE TAKING TYLENOL-CONTAINING PRODUCTS ON A REGULAR BASIS CAN CAUSE KIDNEY DAMAGE.

Maureen says SHE SAYS HE WAS ADDICTED TO THIS AND THEN GOT ADDICTED TO THAT, WAS THAT ADDICTION DO YOU THINK OR COULD IT JUST BE HE NEEDED IT BECAUSE HE WAS IN PAIN? DEPENDENT ON.

Roman says WELL, THAT'S A GOOD QUESTION. AS THE PIECE THAT WE JUST PLAYED, THERE IS A DIFFERENCE IN MY MIND AND IN THE MINDS OF PEOPLE WHO UNDERSTAND PAIN AND ADDICTION, BETWEEN ADDICTION AND PHYSICAL DEPENDENCE. SO IF HE WAS TAKING AN OPIOID ON A DAILY BASIS TO TREAT HIS PAIN, ONE MIGHT SAY HE'S PHYSICALLY DEPENDENT, BUT THE DIAGNOSE OFSIFS ADDICTION IS MUCH MORE THAN THAT. YOU WOULD HAVE TO TAKE A DETAILED HISTORY AND ASK ABOUT BEHAVIOURS FROM THOSE AROUND YOU.

Maureen says THERE'S ALWAYS THIS RUSH WHEN YOU'RE ON SOMETHING LIKE THAT TO "GET ME OFF OF IT." I MEAN, EVERYBODY IN THE PIECE EXPRESSED CONCERN THEY WANTED TO KNOW WHEN AM I GOING TO GET OFF OF IT. HOW MANY OF THEM WILL JUST HAVE TO FACE THE FACT THEY MAY BE ON IT FOR THE REST OF THEIR LIFE IN ORDER TO MANAGE THEIR WAYNE?

Roman says WELL PROBABLY THE MAJORITY AS FAR AS WE KNOW NOW IN 2001 WE HAVE SOME EXCITING POSSIBILITIES FOR THE FUTURE AND MAY FIND A BETTER COMPOUND FOR THE TREATMENT OF PAIN THAT DOESN'T HAVE THE SMALL RISK OF ADDICTION OR THE SEDATIVE SIDE EFFECTS, ET CETERA, BUT WE DON'T HAVE ONE NOW AND WE'RE NOT LIKELY TO HAVE ONE IN THE NEXT FIVE YEARS IN OUR HANDS THAT WE CAN USE.

Maureen says SO YOU PROBABLY HAVE TO TELL YOUR PATIENTS TO GET AROUND THAT THINKING, ABOUT WHEN AM I COMING OFF OF THIS.

Roman says YES. WHAT I SAY IS THERE A IS LOT OF RESEARCH GOING ON. I'M VERY HOPEFUL WE WILL FIND OTHER OPTIONS FOR TREATING PAIN AND IN THE MEANTIME, IF YOU HAVE TO HAVE SOMETHING IN ORDER TO IMPROVE YOUR QUALITY OF LIFE, WHY NOT TAKE SOMETHING THAT HAS THE LEAST RISK PHYSICAL DAMAGE, ORGAN DAMAGE, AND ALL OF THE PATIENTS I SEE ARE WORRIED ABOUT THE... WARNED ABOUT THE SMALL RISK OF ADDICTION AND I SAY TO THEM I'LL MONITOR YOU OR YOUR FAMILY PHYSICIAN WILL MONITOR YOU AND IF THAT HAPPENS WE'LL MANAGE IT.

Maureen says ALL RIGHT. ALL RIGHT, THANK YOU, TAMMY. GOOD LUCK. KARINSKAIRN IS IN PETERBOROUGH. HI KAREN.

The Caller says HELLO.

Maureen says HI.

The Caller says HOW ARE YOU?

Maureen says GOOD, THANKS.

The Caller says I'M GLAD SOMEBODY IS I HAVE BEEN DIAGNOSED WITH FIBROMYALGIA SYMBOLISTIC DYSTROPHY AND PAIN DISORDER. I NOW SEE AN DOCTOR AT SUNNYBROOK FOR NERVE BLOCKS WHICH SEEM TO BE HELPING BUT BEFORE I'VE BEEN ON OXYCODONE, PHENAPHEN AND SUFFER FROM SEVERE MIGRAINES. I HAVE BEEN THROUGH EVERY THERAPY GOING. I GET THE MIGRAINES SO BAD I CANNOT FUNCTION. I HAVE TWO YOUNG CHILDREN, SEVEN AND FIVE, AND I GET NAUSEATED, VERTIGO, I GET ZIGZAGGED LINES, I GET A GREY AREA, IT'S IN THE RIGHT TEMPLE, AND I'M BESIDE MYSELF AND VERY DISTRAUGHT BECAUSE MY FAMILY PHYSICIAN JUST RETIRED AND TO GO AND GET PRESCRIPTIONS I HAVE TO GO TO AN EVENING CLINIC. AND I CANNOT DEAL WITH THE MIGRAINES ANYMORE.

Maureen says HOW OFTEN ARE YOU GETTING THEM?

The Caller says I HAD ONE ON FRIDAY AND WENT IN AND HAD A DEMEROL SHOT AND I'VE GOT ANOTHER ONE TODAY AND SOMETIMES MINE SEEM TO BE TRIGGERED BY BAROMETRIC PRESSURE AND I CAN'T CONTROL THE WEATHER.

Maureen says NO. OKAY. WHAT DO YOU THINK?

Roman says WELL, PROBABLY ONE OF THE MOST CHALLENGING... YOU HAVE PROBABLY TWO OF THE MOST CHALLENGE PAIN PROBLEMS TO DEAL WITH. THAT IS CHRONIC... IS YOUR HEADACHE DAILY?

The Caller says UM, I COULD GO A COUPLE OF DAYS WITHOUT IT.

Roman says OKAY, BUT MULTIPLE TIMES PER WEEK. SO DEALING WITH RECURRENT CHRONIC HEADACHES IS ONE OF THE MOST CHALLENGING PAIN PROBLEMS EXISTS, AND THEN I HEARD YOU SAY THAT YOU HAVE R.S.D. OF WHERE?

The Caller says I GET NERVE BLOCKS IN MY BACK BECAUSE OF MY LEFT KNEE.

Roman says SO IT'S IN YOUR LEFT LEG THEN.

The Caller says YES.

Roman says YEAH.

The Caller says AND OSTEOARTHRITIS STAGE TWO.

Roman says SO R.S.D. OR REFLEX SIM PATHETIC DYSTROPHY IS POORLY UNDERSTOOD, HARD TO MANAGE PAIN. IN ESSENCE, WHAT'S HAPPENING IN THE SPINAL CORD AND BRAIN IS THAT THERE'S A SHORT CIRCUIT AND THAT A NERVE IN THE BODY THAT NORMALLY WOULDN'T COVER PAIN SIGNALS DOES. AND IT'S DIFFICULT PAIN TO TREAT BECAUSE MOST OF OUR DRUGS THAT WE HAVE AVAILABLE TO TREAT PAIN DON'T SPECIFICALLY BLOCK THAT PARTICULAR NERVE. AND SO ONE OF THE ACCEPTED TREATMENTS FOR R.S.D. IS TO GET WHAT ARE CALL SYMPATHETIC BLOCKS AND I PRESUME THAT THAT'S WHAT YOU'RE GETTING. IT'S THE SYMPATHETIC BLOCKS USUALLY AREN'T PERMANENT, THEY'RE USUALLY A SHORTER TERM SOLUTION AND SO THERE ARE SOME PATIENTS WHO GET COMBINATIONS, SO THEY GET SYMPATHETIC BLOCKS BECAUSE OTHER MEDICATIONS WHICH MAY INCLUDE OPIOIDS. THE APPROACH TO MIGRAINE IS A BIT MORE COMPLICATED. IF YOU ARE GOING TO SUNNYBROOK, HOWEVER, THEY HAVE ONE OF THE PREMIER HEADACHE SPECIALISTS IN THE COUNTRY AT SUNNYBROOK HOSPITAL, AND YOU MIGHT ASK TO BE REFERRED BECAUSE THE TREATMENT OF CHRONIC DAILY HEADACHES IS A KIND OF SYSTEMATIC, FIRST OF ALL DETAILED HISTORY OF THE HEADACHES AND WHAT TRIGGERS THEM AND SIMPLY TRYING ONE MEDICATION AFTER ANOTHER TO SEE IF PUCK FIND SOME COMBINATION THAT WORKS.

Maureen says AND THERE ARE SOME NEW THINGS FOR MIGRAINES SUCH AS THE BOTOX AND STUFF BUT I DON'T KNOW HOW READILY AVAILABLE IT IS AND IT'S EXPENSIVE IF IT'S NOT COVERED FOR. THE FIBROMYALGIA THING THOUGH, YOU MUST SEE A LOT OF PEOPLE WHO HAVE BEEN DIAGNOSED EITHER WITH CHRONIC FATIGUE SYNDROME OR FIBROMYALGIA. ARE THOSE CHALLENGES TO TREAT AS WELL?

Roman says WELL I SPEAK ACROSS THE COUNTRY TEACHING PHYSICIANS AND IT'S ALWAYS A QUESTION, EVERY SINGLE SEMINAR SOMEBODY ASKS ABOUT FIBROMYALGIA AND ARE OPIOIDS USEFUL FOR IT. THE PROBLEM WITH FIBROMYALGIA THERE'S NO... WE DON'T KNOW WHAT IT IS. THERE'S NO DOUBT IN MY MIND IT IS A REAL CONDITION THAT EXISTS AND THERE'S SOME RESEARCH LOOKING AT DIFFERENT CHEMICALS IN THE BRAIN THAT MAY BE OUT OF BALANCE WITH PEOPLE WITH FIBROMYALGIA BUT WE REALLY DON'T KNOW WHAT IT IS AND MY EXPERIENCE WITH PATIENTS WITH FIBROMYALGIA IS THAT THEY ARE VERY SENSITIVE TO SIDE EFFECTS OF ANYTHING. NO MATTER WHAT MEDICATION AND THE WORST THING THAT COULD HAPPEN IS IF YOU TAKE AN OPIOID WHICH CAN CAUSE SOME DROWSINESS, INITIALLY, AND THEN IN SOME PEOPLE WHEN YOU REACH THE TARGET DOSE CAN CAUSE LONG-TERM DROWSINESS, SO THE WORST THING YOU CAN DO IS TAKE SOMEBODY WITH FIBROMYALGIA WHO ALREADY HAS FATIGUE, PUT THEM ON A DRUG THAT PUTS THEM IN BED AND I THINK THAT THAT'S NOT DOING ANYBODY A FAVOUR. SO SGI LARGE OPIOIDS AREN'T THE FIRST DRUG OF CHOICE FOR PEOPLE WITH FIBROMYALGIA SAD TO SAY. BECAUSE IF ONE LOOKS AT WHAT ARE THE OPTIONS THERE AREN'T VERY MANY.

Maureen says NO. DO YOU OFTEN RECOMMEND A SORT OF PSYCHOLOGICAL TREATMENT COMPONENT FOR PEOPLE WITH THOSE THINGS? BECAUSE FOR SOME REASON THERE IS SOME HELP THERE FOR THEM, IF THEY CAN TALK IT OVER WITH SOMEONE.

Roman says WELL THE APPROACH CURRENTLY FOR FIBROMYALGIA IS TO MAINTAIN ACTIVITY, SO WE RECOMMEND AEROBIC PROGRAMMES, WARM POOL THERAPY, SWIMMING OR WALKING, COUPLED WITH THE USE OF PSYCHOLOGICAL TECHNIQUES. A LOT OF PEOPLE ARE PUT OFF BY THAT THINKING THAT YOU'RE DISMISSING THEM. YOU'RE SAYING IT'S ALL IN MY HEAD BUT IN FACT IT'S NOT SO WE NOW HAVE EVIDENCE IN THE PAST YEAR OR TWO, FROM SOME VERY EXCITING EVIDENCE THAT SUGGESTS THAT CERTAIN PEOPLE BY LEARNING STRUCTURED PSYCHOLOGICAL TECHNIQUES CAN ACTUALLY CHANGE THEIR CHEMISTRY AND DOWN INTO THE SPINAL CORD THERE'S A PATHWAY FROM THE BRAIN DOWNWARDS WHERE YOU CAN CHANGE SO CHEMISTRY THAT AFFECTS PAIN. SO RATHER THAN THAN IT BEING A NEGATIVE DISMISSAL, SOME PEOPLE CAN FIND GOOD RELIEF. OTHERS CAN'T AND I THINK IN THE PAST, THE MISTAKE WE MIGHT MAID IS THAT EVERYBODY SHOULD RESPOND AND IF THEY DON'T RESPOND, WHAT'S WRONG WITH YOU? THAT'S NOT TRUE. ONLY SOME PEOPLE CAN RESPOND REALLY WELL. MOST PEOPLE CAN GET A VERY MILD BENEFIT FROM IT.

Maureen says OKAY. ALL RIGHT, THANK YOU, KAREN. BEST OF LUCK. WE'RE TALKING ABOUT PAIN MANAGEMENT THIS AFTERNOON WITH Dr. ROMAN JOVEY. IF YOU HAVE QUESTIONS ABOUT CHRONIC PAIN AND HOW TO TREAT IT, THEN GIVE US A CALL.

The phone numbers and email reappear briefly.

Maureen says AND I HAVE AN E-MAIL HERE.

She reads from a laptop computer and says
"I HAVE CROHN'S DISEASE I AM BEING TREATED FOR ABDOMINAL BE A ABSCESSES AND FISTULAS. I'VE BEEN GIVE TYLENOL THREE TO TAKE THE... TREAT THE PAIN BUT I FIND THIS ISN'T TAKING IT AWAY. COULD YOU RECOMMEND A MEDICATION THAT WOULD WORK BETTER? THEY'VE TAKEN ME OFF PREDNISONE TO SEE WHAT HAPPENS, BUT SOME DAYS THE PAIN IS INTOLERABLE. I ALSO HAVE TWO CHILDREN AND NEED TO FUNCTION THROUGH THE DAY.

Roman says COMMON RECURRING THEME.

Maureen says CROHN'S DISEASE. I DON'T KNOW IF YOU SEE A LOT OF THAT.

Roman says NOT A LOT BUT AGAIN A VERY DIFFICULT PROBLEM TO TREAT. THIS SOUNDS LIKE SOMEBODY WITH SEVERE CROHN'S WHO HAS RECURRENT ABSCESSES. VERY CHALLENGING MEDICAL PROBLEM TO TREAT. THE WHOLE PROBLEM WITH THIS, WHETHER FROM CROHN'S DISEASE TO ULCERATIVE COLITIS, IT IS A WHOLE NEW AREA OF PAIN MEDICATION. 1 PEOPLE WITH VISCERAL PROBLEM, THEIR PAIN IS AFFECTED IN THE SAME WAY AS PEOPLE WITH CHRONIC BACK PAIN OR LEG PAIN AND THEREFORE WE'RE STARTING TO LEARN ABOUT APPROACHES TO IT. UNFORTUNATELY THERE ISN'T REALLY ONE GOOD TREATMENT.

Maureen says SO THERE'S NO MEDICATION THAT YOU'D SAY "JUST TRY THIS OVER THE TYLENOL 3s."

Roman says YOU KNOW, IDEALLY, THIS PATIENT, IF SOMEONE COULD FIND A BETTER WAY TO CONTROL THE INFLAMMATION OF HER CROHN'S DISEASE AND IN THE END IT MAY END UP SHE HAS TO HAVE SURGERY TO REMOVE PART OF HER BOWL, THAT MAYBE THE SOLUTION TO IT BUT IN THE SHORTER TERM, OPIOIDS CAN GIVE TEMPORARY RELIEF. ONE OF THE PROBLEMS IS CONSTIPATION IS A PROMINENT SIDE AFFECT IF YOU HAVE CROHN'S DISEASE IT COULD BE DEVASTATING IF YOU HAVE DIFFICULT TO MANAGE CONSTIPATION.

Maureen says WHEN DO YOU START TO WORRY ABOUT A PATIENT ON TYLENOL, ESPECIALLY AT THAT STRENGTH, OVER A LONG PERIOD OF TIME?

Roman says WELL, WE... DOCTORS WERE TAUGHT, AND IN FACT AS RECENTLY AS IF YOU LOOK AT THE AMERICAN RHEUMATOLOGICAL ASSOCIATION GUIDELINES FROM THE FALL OF 2000, THEY STILL HAVE THE SAME DOSE LIMITS AND SAY NO MORE THAN 4,000 MILLIGRAMS PER DAY AND THAT TRANSLATES INTO 12 PLAIN ACETAMINOPHEN TABLETS.

Maureen says 12?

Roman says TWELVE PER DAY, OR IF YOU TOOK TYLENOL THREE, FOR EXAMPLE, IT'S LIKE HAVING ONE ACETAMINOPHEN PLUS CODEINE SO YOU REALLY IN A YOUNG HEALTHY PERSON SHOULDN'T EXCEED 12 PER DAY FOR A LONG PERIOD OF TIME BUT WITH THE INCREASED CONCERN OVER THE POSSIBILITY OF LIVER COX SIT TEE FROM TYLENOL, ACETAMINOPHEN, WE'RE NOW SUGGESTING IF YOU'RE GOING TO TAKE IT LONGER TERM WE DECREASE THOSE LIMITS PERHAPS TO EIGHT TO TEN PER DAY. PARTICULARLY IF YOU'RE AN OLDER PERSON. IF YOU ALREADY HAVE HEART DISEASE, YOU HAVE KIDNEYS THAT ARE STARTING TO FAIL, IF YOU'RE A REGULAR DRINKER, IF YOU'RE SOMEBODY WHO IS FASTING FOR WHATEVER REASON, THEN THAT CEILING LIMIT OF ACETAMINOPHEN SHOULD BE EVEN LOWER.

Maureen says UNDER A DOCTOR A'S CAR, DEFINITELY. LISA IS IN TRENTON.

The Caller says HI, I WAS IN A CAR ACCIDENT AND WAS PLACED IN PERCOCET BUT WITHOUT A FAMILY DOCTOR I HAD TO GO TO CLINICS.

Maureen says WALK-IN CLINICS?

The Caller says YEAH, OR THE HOSPITAL, AND I HAD A LOT OF TROUBLE BECAUSE A LOT OF DOCTORS THOUGHT I WAS AN ADDICT. WHEN THEY DID GIVE IT TO ME, THEY WOULD ONLY GIVE ME FIVE OR TEN TABLETS AT A I AM TOO. AND THEN WHEN I WAS FREQUENTLY RETURNING, BECAUSE THEY WOULDN'T LAST, I ENDED UP A YEAR AND A HALF LATER AN ADDICT ON THE STREET, INJECTING MORPHINE. AND NOW I'M ON METHADONE. WHAT DOES SOMEONE DO WHEN THEY DON'T HAVE A FAMILY DOCTOR AND THEY CAN'T GET REGULAR PRESCRIPTIONS?

Maureen says YEAH. HAVE YOU HEARD OF THIS PROBLEM?

Roman says MORE FREQUENTLY ALL THE TIME. IT'S A GROWING PROBLEM. BECAUSE OF ACTIONS TAKEN BY GOVERNMENTS YEARS AGO WHERE THEY DECREASED THE TRAINING SLOTS FOR PHYSICIANS WE'RE NOW IN A SHORTAGE SITUATION, THAT WE... THERE AREN'T ENOUGH FAMILY DOCTORS TO GO AROUND, AND EVEN IN THE COMMUNITY WHERE I LIVE AND WORK, MISSISSAUGA WITH 600,000 PEOPLE, IT'S EXTREMELY DIFFICULT TO FIND A NEW FAMILY DOCTOR. THERE ARE PLACES LIKE KITCHENER, WATERLOO WHERE THEY HAVEN'T HAD NEW FAMILY DOCTORS FOR YEARS SO THAT PATIENTS ARE TURNING TO WALK-IN CLINICS FOR THEIR MEDICAL CARE AND THE PROBLEM WITH THAT IS IF YOU'RE GOING TREAT CHRONIC PAIN WITH OPIOIDS IT'S NOT A VERY GOOD WAY TO DO IT. YOU NEED TO HAVE ONE CONSISTENT PHYSICIAN. SO I'M NOT SURE HOW YOU CAN DO IT, BUT YOU NEED TO ACCESS ALL THE VARIOUS PLACES, USUALLY IN YOUR COMMUNITY, IF YOU ASK AT THE HOSPITAL MEDICAL STAFF OFFICE, THEY MAY HAVE THE NAMES OF SOME PHYSICIANS WHO WILL STILL TAKE NEW PATIENTS. THE COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO, WHO ARE IN THE PHONE BOOK, THEY MAY GIVE YOU SOME NAMES OF PEOPLE. AND OFTEN IT'LL BE... I'VE SUGGESTED, FOR INSTANCE, SOMEBODY WHOSE HUSBAND OR GIRLFRIEND OR SOMEONE ELSE HAS A FAMILY DOCTOR THAT IF THAT... IF THE PATIENT CAN ATTEND WITH THEM AND SORT OF GET TO KNOW THE PHYSICIAN, IF THEY SIMPLY WALK IN THEIR FIRST VISIT AND SAY I NEED A PRESCRIPTION FOR PERCOCET, IT MAY NOT GET THEIR FOOT IN THE DOOR. BUT IT'S A SAD COMMENTARY ON THE STATE OF OUR HEALTHCARE SYSTEM.

Maureen says YOU'RE VERY BUSY. YOU HAVE NO ROOM FOR NEW PATIENTS IN YOUR PRACTICE AND I'LL BET YOU'RE BUSIER WHEN THINGS LIKE WHAT HAPPENED TO Dr. FRANK ADAMS ARE GOING ON UP IN KINGSTON, NOT THAT ANYBODY WOULD TRAVEL THAT DISTANCE TO SEE YOU BUT I'M SURE OTHER DOCTORS IN THAT AREA HAVE HAD TO TAKE OVER HIS PATIENTS. AND FOR PEOPLE WHO AREN'T UP ON THAT STORY, DO YOU WANT TO GIVE US A QUICK RECAP OF WHAT HAPPENED TO HIM?

Roman says WELL FRANK ADAMS WAS TRAINED AS A PSYCHIATRIST, CALLED HIMSELF A NEUROPSYCHIATRIST AND WAS INVOLVED IN PAIN MANAGEMENT FULL-TIME. SO HE HAD BEEN CANADIAN TRAINED. HE HAD GONE TO TEXAS AND PRACTICED, ATTACHED TO ONE THE BIG CANCER HOSPITALS THERE, M.D. ANDERSON. AND GRADUALLY DRIFTED INTO TREATING CHRONIC NON-CANCER PAIN. SO HE WAS SANCTIONED BY THE TEXAS BOARD OF MEDICAL EXAMINERS. THEY'RE THE COUNTERPART TO OUR COLLEGE OF PHYSICIANS AND SURGEONS AND UNDERWENT A TWO OR THREE-YEAR COURT BATTLE AND FINALLY WAS EXONERATED OF ALL CHARGES. HE WAS CANADIAN BORN HE DECIDED TO COME BACK TO CANADA FOR I THINK FAMILY REASONS. SET UP PRACTICE IN KINGSTON AND HE WAS SEEING A GROUP OF SOMEWHERE BETWEEN 200 AND 250 PATIENTS, ALL OF WHOM HAD SEVERE... THESE WERE PEOPLE WHO HAD SEEN MULTIPLE SPECIALISTS ALREADY, HAD SEVERE PAIN, AND HE WAS MANAGING THEM WITH OPIOID THERAPY. SO HE WAS SANCTIONED BY THE COLLEGE BECAUSE IN THE OPINION OF THE DISCIPLINE OPINION OF THE COLLEGE, HIS USE OF OPIOIDS WAS INAPPROPRIATE AND THEIR ARGUMENT ON BOTH SIDES ABOUT HOW TRUE THAT WAS, NEEDLESS TO SAY, THEY HAVE THE FINAL WORD AND THIS DECIDED THAT HIS PRACTICE WITH OPIOIDS WAS INAPPROPRIATE AND THEY SUSPENDED HIS LICENSE IN THE FALL OF 2000 AND THE CRITICISMS WERE THAT IN LOOK AT HIS CHARTS HE DIDN'T CONSISTENTLY DO A HISTORY AND PHYSICAL EXAMINATION OF HIS PATIENTS. HIS ARGUMENT WAS THAT HE WAS THE END OF THE LINE, THIRD OR FOURTH... LIKE WHAT WE CALL A TERTIARY SPECIALIST. AND IN HIS OPINION, PATIENTS WERE BEING REFERRED HIM NOT TO DO AN INITIAL ASSESSMENT OF THEIR PAIN BUT TO GET HIS ADVICE ON TREATING THEM WITH MEDICATION. AND PARTICULARLY WITH OPIOIDS.

Maureen says BUT HE IS NOT PRACTICING ANYMORE IN CANADA. WHERE HAS HE ENDED UP?

Roman says WELL THE COLLEGE ASKED HIM TO BASICALLY GO BACK TO SCHOOL AND LEARN HOW TO DO HISTORY AND PHYSICAL. HE DID... MY UNDERSTANDING IS THAT HE FOUND SOMEONE IN THE FACULTY OF MEDICINE AT QUEEN'S UNIVERSITY AND DID DO A SORT OF A PRECEPTORSHIP WITH HIM, WAS FOUND NOT TO BE LACKING IN SKILLS OF HISTORY AND PHYSICAL BUT THAT THE COLLEGE STILL IMPOSED SOME PRETTY STRICT CRITERIA ON HIS RETURN TO PRACTISE SO SADLY, FOR THOSE OF US DOING PAIN MEDICINE, HE DECIDED TO GO BACK TO TEXAS.

Maureen says AND HE'S PRACTICING THERE?

Roman says WELL I DON'T KNOW. THIS IS ALL VERY RECENT, WITHIN THE PAST MONTH.

Maureen says IS THAT RIGHT? SO WE DON'T KNOW EXACTLY WHAT HE'S DOING. WHAT ABOUT HIS PATIENTS? WHERE ARE THEY?

Roman says WELL THEY BASICALLY WERE DISTRIBUTED TO PHYSICIANS, FAMILY PHYSICIANS MOSTLY IN THE KINGSTON AREA, WHO OF COURSE ARE NERVOUS ABOUT IT. SO THAT HE WAS USING HIGH DOSE OPIOID MEDICATION IN COMBINATIONS THAT PROBABLY WOULD MAKE MOST FAMILY PHYSICIANS NERVOUS.

Maureen says SO THEY MAY NOT HAVE THEIR PAIN AS WELL-MANAGED AS IT WAS WHEN HE WAS THEIR DOCTOR.

Roman says WELL THE LUCKY ONES WILL HAVE A FAMILY PHYSICIAN WHO KNEW Dr. ADAMS AND THAT THEY'LL TAKE THEM ON AND CONTINUE. SOME OF THEM WILL HAVE PHYSICIAN WHOSE WILL SAY, THEY'LL USE THE OPT-OUT CLAUSE OF THE ONTARIO GUIDE LINES AND SAY I'M NOT COMFORTABLE WITH THIS, I'M SORRY, I CAN'T PRESCRIBE AND THAT PATIENT PROBABLY WOULD HAVE A DIFFICULT TIME FINDING SOMEBODY ELSE TO DO IT.

Maureen says OKAY. WE'LL MOVE TO PEMBROKE. JENNIFER'S ON THE LINE.

The Caller says HI, HOW ARE YOU?

Maureen says GOOD.

The Caller says I WAS VERY SURPRISED TO SEE YOUR PROGRAMME ON AIR TODAY. I'M SO GLAD THAT YOU'VE DECIDED TO DO THAT I'M 36 YEARS OLD AND I'VE GOT RHEUMATOID ARTHRITIS IT FIBROMYALGIA AND CHRONIC EPICONDYLITIS IN BOTH ELBOWS AND I'VE BEEN ON OXYCONTIN THERAPY FOR THREE YEARS NOW VERY SUCCESSFULLY. MAY PAIN FOR MOST DAYS IS VERY WELL MANAGED. I HAVE EXTRA MEDICATION FOR BREAK-THROUGH PAIN. I WAS VERY LUCKY TO HAVE A FAMILY DOCTOR WHO UNDERSTOOD WHAT I WAS GOING LOU AND ACTUALLY TALKED ME INTO GOING ON THE MEDICATION. I WAS VERY NERVOUS ABOUT DOING IT. IT WAS A DECISION THAT I DIDN'T MAKE EASILY. SHE GAVE ME A BOOKLET TO READ CALLED "CHRONIC... OR PAIN MANAGEMENT FOR CHRONIC PAIN THAT'S NON-MALIGNANT AND OPIATE THERAPY USED." IT REALLY SHOWED ME USING OPIATES TO MANAGE YOUR PAIN IS OKAY. IT KIND OF GAVE ME PERMISSION TO GO ON IT AND SINCE I'VE BEEN ON IT I'VE BEEN VERY SUCCESSFUL. AND I HAVE A QUESTION. ARE MEDICAL SCHOOLS TRAINING NEW DOCTORS IN METHODS AND WHICH DRUGS AND HOW TO USE THEM AND HOW TO COPE WITH PATIENTS THAT ARE SUFFERING FROM CHRONIC PAIN? I WANTED TO KNOW WHAT MEDICAL SCHOOLS ARE DOING NOW? IS IT A COURSE THAT THEY'RE TAKING OR WHATEVER WHAT?

Maureen says IS IT HAPPENING IN MED SCHOOL?

Roman says WELL THE SHORT ANSWER TO THE QUESTION IS NOT ENOUGH. MY EXPOSURE... I TRAINED 20 YEARS AGO. MY EXPOSURE TO PAIN AND PAIN MANAGEMENT PROBABLY WAS AN HOUR OR TWO OF LECTURES IN MEDICAL SCHOOL IN A FOUR YEAR CURRICULUM. NOW THERE ARE SOME ATTEMPTS TO MAKE SOME IMPROVEMENTS OF UNDERSTANDING MANAGING PAIN IN GENERAL BUT COMPARED TO HOW COMMON PAIN IS IN SOCIETY, IT NOWHERE NEAR REFLECTS THE. A TIME SPENT TRAINING.

Maureen says YEAH, AND I'LL BET THE EDUCATION IS NOW LEFT UP TO THE DRUG COMPANIES TO DO FOR DOCTORS. AND THAT GETS INTO THIS OTHER COMPONENT OF, YOU KNOW, THEY WANT YOU TO GO WITH THEIR PARTICULAR DRUG. ARE THEY... ARE THEY DOING A GOOD JOB OF EDUCATING DOCTORS IN THIS?

Roman says WELL MOST DOCTORS LEARN HOW TO TREAT PAIN WHEN THEY'RE INTO THEIR PRACTICAL PART OF THEIR TRAINING. AT THE UNIVERSITY OF TORONTO, THE FOURTH U. OF CALLED CLINICAL CLERKSHIP SPENT TOTALLY IN THE HOSPITAL AND THEN THERE'S AN INTERNSHIP, WHICH IS TWO YEARS. IT'S DURING THAT TIME DOCTORS LEARN HOW TO MANAGE PAIN AND TIP TYPICALLY LEARN IT FROM THOSE ABOVE THEM. SO THAT THE PHYSICIANS PASS ON TREATMENT OF PAIN TO THE JUNIOR DOCTORS IN TRAINING. THE PROBLEM THAT IF YOU'VE BEEN TAUGHT IMPROPERLY, YOU PASS ON IMPROPER TREATMENT AND IMPROPER ATTITUDES.

Maureen says TO THE NEXT GENERATION.

Roman says AND YOU PASS ON THIS UNREASONABLE FEAR OF USING OPIOIDS TO DOCTORS WHO ARE TRAINING. THEY THEN GO OUT INTO THE WORLD AND THEY HAPPEN TO BE IN A TEACHING SITUATION WILL PASS THAT ON AGAIN, SO THAT THERE IS REALLY A DEFICIT IN TEACHING PHYSICIANS HOW TO MANAGE PAIN.

Maureen says SURELY IT'S GOING CHANGE A LITTLE BIT, BECAUSE THERE'S NO PROBLEM FINDING IN THE MEDIA ARTICLES THAT SUPPORT YOUR POINT OF VIEW, THAT NOBODY SHOULD HAVE TO SUFFER IN THIS DAY AND AGE, AND THERE ARE SAFE TREATMENTS THROUGH OPIOID USE. SURELY DOCTORS ARE READING THOSE ARTICLES TOO, AREN'T THEY?

Roman says WELL I JUST TO WANT CAUTION YOU THAT IT'S NOT A MAGIC BULLET, AND ONE OF THE PHRASES I USE OVER AND OVER WITH PATIENTS IS "I'M NOT A MAGICIAN AND OPIOIDS ARE NOT MAGIC." THEY CAN IMPROVE THE QUALITY OF LIFE OF MANY PEOPLE BUT IT'S ONLY A SMALL MINORITY OF PEOPLE IN WHOM THEY CAN TAKE PAIN AWAY. SO I THINK ANY CHRONIC PAIN SUFFER EVERY HAS TO ACCEPT BASED ON OUR KNOWLEDGE TODAY THEY'RE PROBABLY GOING TO HAVE SOME DEGREE OF CHRONIC PAIN THE REST OF THEIR LIVES. THE BEST WE CAN HOPE TO DO IS TO NOTCH THAT PAIN DOWN TO A LEVEL WHERE THEY CAN AT LEAST DO SOMETHING, FUNCTION, HAVE SOME QUALITY OF LIFE.

Maureen says I SEE. OKAY. THANK YOU VERY MUCH, JENNIFER, FOR YOUR CALL. GWEN IS IN WATERLOO. HELLO, GWEN.

The Caller says HI. I HAVE M.S... I HAVE MUSCULAR DYSTROPHY AND HAVE CHRONIC PAIN WITH, WELL, JUST MUSCULAR DYSTROPHY AND TENDONITIS AND I'VE BEEN PUT ON M.S. CONTIN, WHICH IS MORPHINE, 15 MILLIGRAMS MORNING AND NIGHT. I TOOK IT LAST NIGHT, AND I DON'T SLEEP WITH IT AT ALL AND I WAKE UP WITH MY VOICE REALLY BAD AND IT'S HARD TO BREATHE, AND I HAVE THE SAME PROBLEM WITH TYLENOL 3. YOU KNOW, I'M WONDERING IF THIS WILL GO AWAY OR IF IT'S SOMETHING I'M ALLERGIC TO AND SHOULDN'T BE ON IT OR JUST WHERE I SHOULD GO.

Roman says CAN I ASK YOU HOW OLD YOU ARE AND WHAT OTHER MEDICAL CONDITIONS YOU'VE GOT AND WHAT OTHER MEDICATIONS YOU SNAKE.

The Caller says I'M ON AMITRIPTYLINE AND I'M 58 YEARS OLD.

Roman says HOW MUCH AMITRIPTYLINE?

The Caller says 25 IN THE MORNING.

Roman says AND YOU'VE BEEN ON THE M.S. CONTIN HOW LONG NOW?

The Caller says I ACTUALLY TOOK IT FOR THE FIRST TIME LAST NIGHT. I COULDN'T SLEEP AT ALL. I HAD SEVERE DRY MOUTH AND I WAS AWAKE ALL NIGHT AND I HAVE THAT SAME PROBLEM, IF I TAKE TYLENOL 3s SO I JUST STAY AWAY FROM IT. I THOUGHT IF I TRY THIS M.S. CONTIN AND I HAVE THIS SAME EFFECT SHOULD I NOT BE ON IT AT ALL OR WILL THIS EFFECT GO AWAY IF I'M ON IT FOR A WHILE?

Roman says FIRST OF ALL BOTH THE AMITRIPTYLINE AND AND THE M.S. CONTIN CAUSE DRY MOUTH THAT PROBABLY WILL GO AWAY AFTER A BIT OF TIME BUT YOU'RE PROBABLY GOING TO HAVE TO TAKE SPECIAL CARE OF YOUR DENTAL HYGENE. YOU'RE GOING TO HAVE TO SUCK ON ON SUGARLESS CANDIES, SINCE OF WATER BUT ANY SIDE EFFECT IS WORSE IN THE FIRST WEEK. IF YOU JUST STARTED THE M.S. CONTIN, THAT'S A LONG ACTING MEDICATION, AND IT'S NORMAL FOR THE FIRST WEEK TO FEEL A BIT OF NAUSEA, KWA, DRY MOUTH, BUT GENERALLY IF YOU STICK WITH THE DRY DOSE, TAKE EXACTLY THE SAME DOSE AS PRESCRIBED, WITHIN A WEEK, OFTEN, AND AT THE OUTSIDE PERHAPS TWO WEEK, YOU WILL GET USED TO THE SIDE EFFECTS, AND THE ONLY SIDE EFFECT YOU'LL BE LEFT WITH OVER THE LONGER TERM IS CONSTIPATION.

Maureen says AND IF SHE'S HAD THESE SIDE EFFECTS WITH TYLENOL BEFORE DOES THAT MEAN SHE'S NECESSARILY GOING TO EXPERIENCE THEM LONGER TERM WITH THESE OTHER DRUGS?

Roman says NO, IT'S INTERESTING RESEARCH FINDINGS. WE USED TO THINK ALL OPIOIDS WERE THE SAME. IN OTHER WORDS YOU COULD FLIP A COIN AND SIMPLY PICK ANYONE AND IT WOULD DO THE SAME JOB AND IT'S BECOMING CLEAR NOW FROM RESEARCH, BOTH IN ANIMAL RESEARCH AND SOME EARLY HUMAN TRIALS THAT EACH OPIOID IS UNIQUE. AND THAT ONE CANNOT PREDICT WHETHER OR NOT OR HOW A PATIENT WILL DO ON A GIVEN OPIOID BASED ON THEIR RESPONSE TO ANOTHER ONE AND SO THE CONCEPTS THAT WE NOW USE TO TREAT CHRONIC NON-CANCER PAIN ARE SO-CALLED SEQUENTIAL DEVOTION. MEANING YOU START WITH ONE DRUG, GRADUALLY INCREASE THE DOSE SO THAT PEOPLE HAVE TIME TO GET USED TO THE SIDE EFFECTS. IF YOU HIT UP AGAINST A SIDE EFFECT CEILING, IN OTHER WORDS YOU CAN'T PROGRESS ANYMORE BECAUSE THEY SAY "I JUST CAN'T STAND THE SIDE EFFECTS," THEN NOW WE'RE RECOMMENDING THEY SWITCH TO AN ALTERNATE OPIOID AT A LOWER DOSE AND AGAIN START THIS GRADUAL PROCESS. AND IN SOME PATIENTS WHO I'VE TREATED OVER THE YEARS, YOU WILL GO THROUGH AS MANY AS FIVE OR SIX, TRYING SEQUENTIALLY, ONE AFTER ANOTHER, UNTIL YOU FINALLY FIND ONE THAT JUST HAS THE BEST BALANCE OF TREATING THEIR PAIN WITHOUT EXCESSIVE SIDE AFFECTS.

Maureen says TAKES A LOT OF PATIENCE, DOESN'T IT? PARDON THE PUN, ON BOTH YOUR PART AND THE PATIENT'S PART. AND I'LL BET THERE ARE SOME PHYSICIAN WHOSE JUST GET EXASPERATED BECAUSE THEY CAN'T HELP THE PATIENT RIGHT AWAY WITH THIS OR THAT DRUG. THEY'RE NOT USED TO THAT BECAUSE DRUGS USUALLY ARE, YOU KNOW, ALMOST MAGIC BULLETS OR WE'VE COME TO BELIEVE THAT. SO IT TAKES A CERTAIN TYPE OF DOCTOR I WOULD THINK TO GO THROUGH THAT ROUTINE WITH YOU.

Roman says WELL IT'S A SHIFT IN ATTITUDE. IF YOUR CONDITION WAS DIABETES INSTEAD OF CHRONIC PAIN THEY REQUIRE A LOT OF ONGOING INPUT, TOO.

Maureen says A LOT OF MANAGEMENT, SURE.

Roman says A LOT OF MANAGEMENT, DIETARY MANAGEMENT, MANAGING INSULIN, THEIR DRUGS. MOST PHYSICIANS HAVE ACCEPTED THAT THAT'S JUST WHAT YOU DO. BUT BECAUSE OUR TRAINING IS DEFICIENT, WHEN THEY'RE PRESENTED WITH SOMEBODY WITH CHRONIC PAINS THAT'S TENDENCY TO THROW UP OUR HANDS AND SAY I CAN'T DO ANYTHING. SEND THEM TO A PAIN CLINIC OR PAIN SPECIALIST AND THEN THE CHALLENGE IS TO FIND ONE.

Maureen says I DON'T WANT TO RUN OUT OF TIME BEFORE I ASK YOU ABOUT THE MOVE TO LEGALIZE MARIJUANA FOR MEDICINAL USE. YOU'RE INITIAL IMPRESSION OF THAT?

Roman says THERE'S NO DOUBT THAT THERE APPEAR TO BE CHEMICALS IN MARIJUANA THAT CAN HELP WITH PAIN MANAGEMENT. WE KNOW THAT IN ANIMAL, WHEREVER YOU FIND OPIOID RECEPTORS IN THE BRAIN, YOU ALSO FIND CANNABIS RECEPTORS. AND WE KNOW FROM ANIMAL RESEARCH THAT IF YOU GIVE ANIMALS BOTH AN OPIOID AND CANNABIS TOGETHER, YOU NEED LOWER AMOUNTS OF EACH OF THEM IN ORDER TO GET THE SAME DEGREE OF PAIN RELIEF. SO THERE'S SOMETHING IN CANNABIS THAT IN THE FUTURE MAY TURN OUT TO BE USEFUL IN PAIN MANAGEMENT. AND THE ONLY DOWN SIDE IS THAT CURRENTLY THE BEST WAY TO DELIVER IT IS THROUGH SMOKING. AND I REALLY HAVE A HARD TIME AS A PHYSICIAN RECOMMENDING THAT SOMEBODY SMOKE ANY DRUG. THERE'S A RULE OF THUMB THAT ONE REEFER OR ONE MARIJUANA CIGARETTE IS EQUIVALENT IN DAMAGE TO APPROXIMATELY FIVE REGULAR GET CIGARETTES. AND SO SOMEBODY WHO HAS TO TAKE A SMOKED DRUG LIKE MARIJUANA OVER THE LONGER TERM WILL INEVITABLY DEVELOP LUNG DAMAGE.

Maureen says WE HAD AN ADDICTIONS EXPERT ON THE SHOW A WEEK AGO SAID THIS MOVE TO LEGALIZE MARIJUANA WOULD JUST MEAN MORE BUSINESS FOR HIM IS THAT A VERY CASE?

Roman says MARIJUANA IS AN ADDICTIVE DRUG. IT'S A MYTH PEOPLE HAVE THAT YOU CAN'T GET ADDICTED OR IT'S NOT ADDICTIVE. WE SEE PEOPLE EVERY WEEK NOW, MY GENERATION, ACTUALLY, WHO WERE THE HIPPIES WHO HAVE BEEN TOKING ALL ALONG AND FINALLY GOT CAUGHT BY THEIR TEENAGED DAUGHTER ORSON AND WHEN THEY SAID TO THEM "OAK, I'LL QUIT" THEY CAN'T. AND THEY COME IN TO SEE US. SO IT IS ADDICTING. NOW HOW ADDICTING? IS IT ON THE ORDER OF COCAINE ADDICTING? MAYBE NOT. AND DOES IT DO MORE HARM THAN FOR INSTANCE ALCOHOL DOES? WELL, PERHAPS NOT. ALCOHOL PROBABLY IS THE MOST DAMAGING CHEMICAL ADDICTION, AFTER CIGARETTES. BUT ADDICTING? FOR SURE, IT IS ADDICTING.

Maureen says WILL YOU BE RECOMMENDING MARIJUANA TO ANY OF YOUR PATIENTS FOR PAIN IS.

Roman says I THINK I'M WAITING FOR ANOTHER DELIVERY METHOD. SO I'VE TRIED PRESCRIBING ORAL, THE ORAL ALTERNATIVES, BUT THEY DON'T WORK AS WELL. AND SO I'M HOPING THAT SOMETHING LIKE NASAL SPRAY OR PERHAPS AN INHALED, LIKE FROM A PUFFER, ASTHMA PUFFER, I'D BE QUITE WILLING TO TRY IN SOME OF MY PATIENTS WHO HAVE DIFFICULT PAINS.

Maureen says OKAY. DENNIS IS NEXT IN WINDSOR. HI DENNIS?

The Caller says HI HOW ARE YOU DOING?

Maureen says GOOD.

The Caller says I WAS WATCHING YOUR PROGRAMME, I HAVE KNEE INJURIES FROM WORK AND THE DOCTORS PUT ME ON TYLENOL 3s. I HAVE NOW DEVELOPED ARTHRITIS IN THE KNEES DUE TO THE INJURIES. I AM NOW TAKING... IS IT CELEBREX AND ALSO GLUCOSAMINE FOR IT. THE TYLENOL THREES THAT HE'S GIVING ME ARE NOT DOING ANY WORK NOW. THEY'RE NOT WORKING ANYMORE. IS THERE ANYTHING THAT HE CAN GIVE ME THAT WILL HELP ME RELIEVE THE PAIN? AS I AM... YOU KNOW, THE TYLENOL 3 JUST DON'T WORK ANYMORE AND HE'S BEEN RELUCTANT TO GIVE ME ANYTHING.

Maureen says THEY DID WORK AT ONE TIME? AND NOW THEY DON'T?

The Caller says YEAH, THEY DID AT THE FIRST. THE ACCIDENT HAPPENED ABOUT FOUR YEARS AGO AND THEY'RE JUST NOT WORKING NOW ANYMORE.

Maureen says IS IT THAT HE'S DEVELOPED A TOLERANCE FOR THIS?

Roman says WELL... HOW MANY DO YOU TAKE A DAY, DENNIS?

The Caller says UH, APPROXIMATELY SIX TO EIGHT, DEPENDING ON MY ACTIVITIES.

Roman says OKAY. SIX TO EIGHT TYLENOL 3 A DAY FROM THE POINT VIEW OF THE OPIOID IS ACTUALLY QUITE A MINIMAL AMOUNT. AND IT COULD BE THAT YOUR CONDITION HAS GOTTEN WORSE, SO THAT WE... BEFORE WE ASSUME IT'S TOLERANCE, TOLERANCE, MEANING THAT THE DRUG LOSES ITS EFFECT, IT MAY BE YOUR CONDITION IS WORSE. IT MAY BE... HAVE YOU ADDED ANY NEW DRUGS TO WHAT YOU'RE TAKING SINCE YOU FOUND THE TYLENOL STOPPED WORKING? BECAUSE SOMETIMES ONE DRUG WILL INTERFERE WITH ANOTHER. IT COULD BE THAT. OR IT COULD BE TOLERANCE. IT COULD BE THAT FOR THE AMOUNT OF OPIOID YOU'RE ON RIGHT NOW, IT'S LOST ITS EFFECT. AND SO IF IT WAS THE LAST ONE, THEN YOUR DOCTOR COULD EITHER INCREASE THE DOSE, COULD PUT YOU ON SOMETHING MORE POTENT, AND PARTICULARLY IF YOU'VE HAD THIS FOR FOUR YEARS NOW, BY DEFINITION THAT'S CHRONIC PAIN. YOUR DOCTOR MIGHT CONSIDER PUTTING YOU ON A LONG-ACTING MEDICATION. SO INSTEAD OF YOU HAVING TO TAKE IT FOUR OR FIVE TIMES A DAY, YOU WOULD JUST TAKE IT TWICE A DAY.

Maureen says AND IF THE DOCTOR IS RELUCTANT TO DO THAT... DO THE PATIENTS CARRY MUCH WEIGHT HERE WHEN THEY ARGUE WITH THE DOCTOR THAT THEY NEED SOMETHING STRONGER?

Roman says I THINK MOST PATIENTS IN OUR CLIMATE OF NOT ENOUGH FAMILY PHYSICIANS WOULD BE RELUCTANT TO CHALLENGE A PHYSICIAN, BECAUSE THEY DON'T WANT TO LOSE THEM. AND IF HE'S IN WINDSOR, WINDSOR ALSO IS A PLACE WITH A CHRONIC DOCTOR SHORTAGE SO PATIENTS ARE REALLY STUCK AND I THINK IT'S THROUGH EDUCATION AND ADVOCACY FOR PATIENTS TO START MAKING THIS AN IMPORTANT ISSUE POLITICALLY.

Maureen says TELL THEM YOU SAW THIS ON THE SHOW AND Dr. JOVEY'S NOT A QUACK, HE'S AN M.D. LIKE YOUR DOCTOR. SO GOOD LUCK, DENNIS. WHAT ABOUT THIS...

She reads from the laptop and says
LEN TAKES AN AVERAGE OF SIX TO EIGHT PERCOCET TABLETS FOR PAIN IN HIS UPPER BACK. HE SUFFERED A 30 FOOT FALL TEN YEARS AGO AND SUFFERED CRUSHED VERT BRA. WHAT ARE THE LIVER AND KIDNEY PROBLEMS?

Roman says LIVER AND KIDNEY PROBLEMS YOU CAN DIAGNOSE OFTEN THROUGH BLOOD WORK. SOMEONE HAS LIVER PROBLEMS MAY JUST FEEL ILL, MAY TURN YELLOW, JUANDICED AND THERE ARE CERTAIN TESTS CALLED LIVER ENZYMES YOU CAN MEASURE. WITH KIDNEY PROBLEMS YOU MAY EXPERIENCE SWELLING AND AGAIN IT CAN BE DIAGNOSED FAIRLY EASILY THROUGH DOING BLOOD TESTS. AS FAR AS... SORRY, WHAT WAS THE OTHER QUESTION?

Maureen says ADDICTION.

Roman says ADDICTION. SO THE SIGNS OF ADDICTION WOULD BE THAT IF YOU'RE A MEMBER OF THE THREE Cs, ONE IS COMPULSIVE USE, AND THAT MEANS THAT YOU START TAKING THE OPIOID FOR SOME REASON OTHER THAN PAIN. FOR EXAMPLE I'VE HAD PATIENTS SAY TO ME THAT IT ENERGIZES THEM OR IT RELAXES THEM. SO COMPULSIVE USE. LOSS OF CONTROL, MEANING THAT YOU CAN'T TAKE YOUR OPIOIDS IN AN ORDERLY REGULAR FASHION. WHEN YOU TAKE THEM, YOU'LL TAKE HANDFULS AT A TIME BECAUSE WHAT YOU'RE LOOKING FOR IS THE MOOD-MODIFYING EFFECT. AND CONSEQUENCE. THAT IF YOU TAKE THE OPIOID AND YOU'RE SUFFERING SOME KIND OF CONSTABLE QUEENS, WHETHER THAT BE A HEALTH CONSEQUENCE, A SOCIAL CONSEQUENCE, AND YOU CONTINUE TO SEEK AND TO USE THEM, THEN THOSE THREE TOGETHER WOULD BE INDICATIVE OF ADDICTION.

Maureen says AND ONCE AGAIN, IN CASE LEN MISSED IT, HOW COMMON IS ADDICTION IN PEOPLE WITH CHRONIC PAIN?

Roman says WELL, THE... THERE'S DEBATE ABOUT HOW COMMON IT IS IN PEOPLE WHO HAVE CHRONIC PAIN. CERTAINLY AMONG THE GENERAL POP HIS WE ESTIMATE THAT BETWEEN 5 percent AND 7 percent OF PEOPLE ARE ADDICTED TO ONE CHEMICAL OR ANOTHER AND MAYBE AN IN ADDITION PALL 10 percent WHO WILL ABUSE THEM BUT HAVE NOW CROSSED THE LINE TO ADDICTION SO YOUR RISK OF BECOMING TRULY ADDICTED TO YOUR OPIOID IF YOU HAVE CHRONIC SPAIN PROBABLY SIMILAR TO THE REST OF THE POPULATION. SOMEWHERE BETWEEN 5 percent TO 7 percent.

Maureen says OKAY. SO THE THREE Cs. THAT'S A GOOD THING TO KNOW. IT'S BEEN GREAT TO HAVE YOU HERE. THANKS VERY MUCH FOR DOING THIS.

Roman says THANK YOU.

Maureen says Dr. ROMAN JOVEY IS A PHYSICIAN WITH INTEREST IN TREATING PAIN AND ADDICTIONS. FOR MORE ON CHRONIC PAIN AND PERHAPS SOME INFORMATION ON HOW TO FIND A PAIN SPECIALIST IN YOUR AREA, CONTACT...

A slate reads "North American Chronic Pain Association. 1 800-616-PAIN (7246). www.chronicpaincanada.org"

Maureen says I'M MAUREEN TAYLOR AND THAT CONCLUDES MORE TO LIFE FOR TODAY. I HOPE YOU'LL JOIN US AGAIN FOR NEW PROGRAMS AND NEW TOPICS MONDAY THROUGH FRIDAY AT ONE O'CLOCK.

A slate reads "The advice given in the preceding program is of a general nature only. Viewers should consult their own medical professional for medical advice specific to their circumstances."

Watch: Pain