Dr. Keith Roach

DEAR DR. ROACH: I have horrible neck, shoulder, back and hip pain, which are all from different traumas. I’ve been seeing a pain doctor for the past 14 years. I started out taking 5 mg of Vicodin and 4 mg of trazodone. Over the years, my prescriptions have been raised to 7.5 mg of oxycodone four times a day and 800 mg of ibuprofen three times a day. I see my doctor every two weeks, and during these visits, I normally get shots (different ones in different places).

My problem is that my pain medicine isn’t working anymore. Will I have to keep raising the dosage? I can’t take it easy as I am my husband’s sole caregiver. He’s had multiple strokes, and his leg was just amputated. Is there any other medication I can add to my current list that might help? Or is there a better pain medicine than oxycodone? — A.S.

ANSWER: I’m very sorry to hear about your predicament. Being a full-time caregiver while trying to deal with one’s own medical problems is a very difficult situation that many of my patients (and their caregivers) have been in.

The most important advice I have is that opiates like hydrocodone (Vicodin is a brand name for hydrocodone and acetaminophen) and oxycodone aren’t good long-term options for most people. As you have found, the dose often needs to be increased just to maintain the same pain relief.

The body gets used to the dose of opiates — a response that is called “tachyphylaxis,” which is caused by decreasing the sensitivity of the receptors that opiates bind to in the brain. I’ve seen people get on exceedingly high doses of strong opiates and not receive adequate pain relief. Unfortunately, side effects of high-dose opiates can include severe constipation, to which the colon doesn’t become accustomed to.

While I don’t know the details of the traumas that led to your chronic pain, a pain medicine specialist will usually use a combination of different medications to help. This might include injections; low-dose or microdose opiates; antidepressant medicines that help with chronic pain such as duloxetine or amitriptyline; antiseizure medicines that help with pain such as gabapentin; and physical therapy.

Anti-inflammatory drugs like ibuprofen sometimes provide significant pain relief when used in combination with other medicines. However, very high doses (you are on the highest recommended dose) can cause toxicities.

I do want to make it clear that tachyphylaxis is the usual response to opiates, especially at a high dose, but it isn’t universal. I have patients who do very well with moderate amounts of opiates and remain on a stable dose with adequate pain control. Physicians should always consider the risks of opiates before prescribing them for long-term use.

DEAR DR. ROACH: I’m an 82-year-old woman with sluggish gut issues. I recently heard a doctor say, “Don’t take fiber supplements because they mess up your gut,” and “Don’t take laxatives. Take stool softeners, and it’s OK to take them every day.” I’m skeptical of both statements. What do you say? Thank you. — E.G.

ANSWER: The only statement I wholeheartedly agree with is that it’s OK to take stool softeners (such as docusate) daily. I disagree with the recommendation against fiber supplementation. Fiber is very helpful for both diarrhea and constipation, and it also has other benefits, including modestly lowering cholesterol.

However, when fiber supplementation isn’t enough, then laxatives such as polyethylene glycol 3350 (MiraLAX) are a very reasonable choice. People who need laxatives every day should still discuss this with their physicians to be sure that there’s not some other medical reason for the constipation.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu.