SBK - The problem with addiction to opiate-like drugs is that one does build a tolerance to their effects, requiring a person, over time, to take higher and higher doses to achieve the required analgesic effect. While you may not be addicted yet, the odds are that it is only a matter of time.

When using narcotics for chronic pain, the incidence of addiction is greatly reduced, but it still does occur; the properties realated to addiction (tolerance, drug-seeking behavior, etc.) are still a real possibility.

Demerol™ (meperidine) is especially a bad analgesic to which to become addicted. The major metabolite of Demerol is hepatotoxic; that is, it causes liver damage with continued use. For this reason Demerol should only be used on a short-term basis. The phenomenon of tolerance, which requires one to take higher doses more often to achieve pain relief makes Demerol a poor choice for treating chronic pain.

Have you tried some of the alternative therapies for neuropathic pain. Low doses of some of the tricyclic antidepressants (eg. Elavil™ [amitriptyline] [10-50mg], Anafranil™ [clomipramine] [20-100mg] or sometimes Tofranil™ [imipramine] [25-50mg]) are successful in many cases. Low doses of Effexor XR™ (venlafaxine) (37.5mg) have also shown to be of use in these conditions. Neurontin™ (gabapentin) has also shown to reduce several types of neuropathic pain. For migraines, I have seen low doses of the ß-blocker (heart drug) Inderal™ (propranolol) (20-80mg) work in many instances.

The above dosages are what I generally see being successfully used in clinical practice, and are only guidelines. The mechanisms of action of the above drugs in analgesia are different from the usual mechanisms related to the normal uses of these drugs. For example, for Elavil it is thought that the molecule may block the adenosine-A2A receptor which may interupt pain signals through the dorsal horn of the spinal cord. Also, pain relief is usually seen at lower doses and much sooner than relief from depression using these agents. Pain relief with the TCAs usually begin in a week or two, rather than the two to four weeks needed for relief of depressive symptoms.

One reason that docs do not like prescribing narcotic analgesics is that they like to keep their licences. Their Colleges and Associations are hard on their members that produce too many addicts. Also, people who become addicted have a tendency to blame the doctor for causing the addiction, resulting in lawsuits.

Another reason that docs do not like prescribing addicting substances (opiates, benzodiazepines, hypnotics etc), be they physically or psychologically addicting, is that these patients, as a rule, take up much of their time trying to get early refills and increased dosages. I can attest to the fact that much of a pharmacist's day is hearing from people wanting early refills on addicting substances.

I am the first to agree that docs under prescribe when using opiates for pain relief. It is true that people who are using opiates for true chronic pain are not very likely to become addicts and do not develop tolerance to the drugs very readily. It is a similar situation with benzodiazepine use in those suffering from bipolar disorder. The problem is is how to tell those using opiates for escape rather than just pain relief.

I'm sorry that I cannot give a more complete answer, but I am really behind in answering posts, and I still haven't the energy I'd like. - Cam