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NSAIDs for arthritis - how long, how much?

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NSAIDs for arthritis - how long, how much?

Old 06-17-18, 06:17 AM
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NSAIDs for arthritis - how long, how much?

I hit 70 later this summer and have developed a case of arthritis in the hips. I have noticed some morning pain and stiffness for a while and then a severe flare in one hip sent me to the doctor. Xrays show that the cartilage is still in pretty good shape, just some detritus and flaky stuff causing the inflammation. Thus I am a candidate for symptom relief via NSAIDS. The flare was knocked out by a cortisone shot and the doc prescribed a small amount of diclofenac. After a month the arthritis pain is back. It is severe enough to effect my walking and bending, although I have seen no return of the acute flare so far. A single Aleve (naproxen) tamps the pain down pretty well for 12 hours as does the diclofenac. I go back to the sports medicine and pain specialist who gave me the cortisone shot in a few weeks and will seek his advice about long term management. In the meantime, I have read about the potential side effects of long term NSAID use but people I know get various opinions from varying docs and I am curious about experiences among the pills and ills readers. I am not looking for legitimate medical advice from us lay folks, I am more curious about the medical advice (from professionals) that people have gotten.

Is a single OTC Aleve twice a day likely to be safe long term or is that sufficient to cause ulcers and other problems in a significant number of users? Is two twice a day safe (as one of my friends' doctor asserts) or is that just throwing the dice? To the extent that prescription NSAIDs like the diclofenac or indomethecin work better are they more dangerous than Aleve? If you really shouldn't take NSAIDs long term, how long a break do you need between courses?
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Old 06-17-18, 06:54 AM
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These are miraculous and essential drugs with a downside, which I’ve never seen quantified in a satisfactory way. I am a physician, but not an expert and my wife and I, both of whom have busted up, creaky, high-mileage athlete’s bodies, which we abuse regularly, save the NSAIs for real bad days and acute injuries and keep the courses under two weeks. Anecdotally, her mother, who had crippling osteoarthritis and lived on anti inflammatories, including the notorious COX2 inhibitors, died in her 70s of congestive heart failure, presumably related to small vessel heart disease. Clearly a trade-off and in pain is not a good way to live.
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Old 06-17-18, 06:56 AM
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I see an Ortho every 3 months for a cortisone shot in my knee. I also take 75 mg Diclofenac twice a day. I had a flare-up in my hip a while ago and the Doc prescribed a Methylprednisone Dose pack which helped along with some ergonomic adjustments in the workplace, and of course more cycling. I think the most worrisome thing is the steroids long term, that's why they are more stingy with it. I believe the biggest issue with long term NSAIDs is as you well know is stomach issues. That's why they call for taking it at meal times. I have no stomach issues with Diclofenac and never take any other OTCs. You might consider asking your Doc about mixing NSAIDs. My Doc advises me that there very many NSAIDs out there and they can try different prescriptions if you feel the need.
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Old 06-17-18, 08:30 AM
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Originally Posted by donheff View Post
........................I know get various opinions from varying docs and I am curious about experiences among the pills and ills readers. I am not looking for legitimate medical advice from us lay folks, I am more curious about the medical advice (from professionals) that people have gotten................
Probably not what you are looking for but just a FYI.....

Arthritis diagnosed in hands from bicycle wheel building/truing/mechanics in early 80's and was prescribe ??? forgot since it was soooo long ago but remember that it caused side effects I DID NOT LIKE so started with Ibuprofen. As I aged, more arthritis in other joints and more Ibu. Knees, shoulders, wrist got worse with age and saw othos for x-rays/scans to see how bad joints became, BONE on BONE, and all said they could give shots that WILL NOT LAST and can prescribe X-Y-Z but side effects come with them. I responded that I DO NOT WANT DRUGS OR SHOTS and would continue to ELIMINATE added sugars as much as possible and continue on a low inflammatory diet. EVERY doc said GREAT and it would be what they would do but most patients would not and would want the easier way out using drugs.

2016 October 10th at 66yo new right shoulder since pain and restriction was TOO MUCH with knees/left wrist still awaiting replacement since diet is working to minimize pain and inflammation. Generally people are more comfortable with the medical way out and most would not "Go The Distance" trying to eat their way out of pain/inflammation. Just saying that for me the healthy alternative has worked and provided physical benefits that help my cycling. My doctors have all been very straight up when it came to using their medical knowledge to help me and all were impressed and glad that I chose to not use the prescription solutions since there are so many bad side effects.

p.s.-There are times when pain is present and I want quick relief so I pop an acetaminophen. NO IBU since is harmful to kidneys.
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Old 06-17-18, 11:10 AM
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The long term concern with. NSAIs is accelerated cardiovascular disease.
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Old 06-17-18, 01:06 PM
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Originally Posted by OldTryGuy View Post
There are times when pain is present and I want quick relief so I pop an acetaminophen. NO IBU since is harmful to kidneys.
N.B. and acetaminophen is tough on your liver. Don't exceed 3gm/day; less if you drink alcohol. And acetaminophen doesn't have the anti-inflammatory effects that are most helpful with conditions like arthritis.

And IIRC, all NSAIDs taken at high dose and/or long term can adversely affect your kidneys.

Ain't no such thing as a "free lunch …"
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Old 06-17-18, 07:52 PM
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Originally Posted by JohnDThompson View Post
N.B. and acetaminophen is tough on your liver. Don't exceed 3gm/day; less if you drink alcohol. And acetaminophen doesn't have the anti-inflammatory effects that are most helpful with conditions like arthritis.

And IIRC, all NSAIDs taken at high dose and/or long term can adversely affect your kidneys.

Ain't no such thing as a "free lunch "
For quick pain relief all I pop is ONE 500mg acetaminophen. Nothing is needed for inflammation since my diet has taken care of that issue.
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Old 06-18-18, 12:22 AM
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I live on NSAIDs. I probably take 1,000 ibuprofen a year. Have done since a 2001 wreck that broke my back and neck. And I had to increase the dosage after being hit by a car last month. My breakfast is 2 or 3 ibuprofen and coffee, almost every morning since 2001.

Frankly I'd be better off with just two or three ibuprofen in the morning for inflammation and a single Tramadol or codeine a day when the pain is really bad. When the pain is bad enough a single Tramdol is good enough to get me moving with no side effects -- it's very mild. Ditto acetaminophen with codeine. For years a 30 day supply would last me 3-6 months. Then they cut it back to a 10 day supply, which lasted me a month because I took only one a day, at most -- sometimes only half. If I was gonna be an addict it would have happened long again. Never happened. I don't have the craving. It doesn't take much to relieve the pain.

But, thanks to junkies screwing it up for non-addicts with real chronic pain who aren't trying to get high, doctors are so paranoid now about being busted by the DEA they won't prescribe opiates for long term chronic pain. So now they tell me to take 800 mg of ibuprofen three or four times a day. They know it's B.S. and will eventually destroy my stomach, liver and kidneys. But they won't lose their licenses for that. I'll have to live and die with the complications.

Opiates aren't the problem. Junkies are the problem. They screw it up for everybody.

I've tried every alternative available, every topical salve, balm, ointment and voodoo rub. I was about to try CBD oil when a friend gave me some cannabis based balm in a mix of lotion with camphor and menthol, so it's not intended to be ingested, just rubbed on. Frankly, I can't tell that it makes any difference. Same with any balm. It's not the ingredients that matter, it's the massaging. The active ingredients can't penetrate enough to reach the deep aches in muscles and joints. Even the highly touted extra strength capsaicin doesn't really do what it claims. Any analgesic effect is limited to the skin surface and maybe a fraction of an inch of the subcutaneous tissue. It can't reach any deeper. But I can tell that after awhile I build up a resistance where it doesn't sting on the skin. That's just the effect on the skin-deep nerves.

Soaking in a hot bath with Epsom salts helps more than any muscle rub, balm or ointment. I don't know whether the Epsom salts actually help, but it seems to work better than just soaking in hot water. Often I'll get up in the middle of the night when the pain keeps me awake just to soak in the tub.

A week or so ago the "geriatric" clinic's nurse practitioner suggested referring me to the health network's "pain management center". I'm already familiar with that racket. For years, until recently, I was my mom's caregiver, and before her I took care of both grandparents. Now I'm old enough to be considered "geriatric".

Here's how the "pain management" clinic goes...

If you complain of chronic or severe pain at the urgent care clinic or routine office visit, they won't give you anything like codeine or Tramadol anymore. They'll tell you to overdose on ibuprofen while waiting three weeks for your intake appointment with "pain management". Meanwhile, try not to commit suicide from the constant pain.

On your first visit to "pain management" they'll keep you waiting an hour or two past your appointment. Then they'll "evaluate" you, which means halfway listening to the patient while dismissing his/her complaints. Then they'll reschedule you for a follow up appointment. They do no actual treatment or therapy on the first visit.

Four to six weeks later, you see another doctor at the "pain management" clinic, who suggests local injections of anti-inflammatories, or a nerve block if it's bad enough. The patient agrees, because he/she has been in pain for weeks without relief. But the doctor doesn't actually do anything that visit. Nope, they reschedule you for another 4-6 weeks later.

So from the time you're referred to "pain management" until you actually get any kind of treatment, 4-6 months have passed, with at least three office visits. Depending on your insurance. that's a copay of zero to $100 -- for nothing. Just a bunch of consultations.

And this is why some of my elderly neighbors prowl the hallways begging for just one effective pain pill, anything... just one oxycontin, Tramadol, codeine, anything. And they aren't junkies. They're in real pain.

That's also why many of my neighbors drink heavily. It's the one time tested pain reliever they can buy without jumping through hoops. And reportedly some high ABV beers with certain hops have some proven anti-inflammatory characteristics.
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Old 06-18-18, 04:03 AM
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I'm in my low 50's.

My father had chronic knee pain which he developed sometime before his 50's, and it was pretty debilitating by his mid 50's. He eventually got a bilateral knee replacement.

I have also had knee pain for years, but lately I've discovered that the more I ride my bike, the less pain I am in. Knee issues have mostly resolved, at least if I keep riding 3+ days a week. Low level chronic back pain is also mostly resolved (also helped by sleeping changes).

Dad was of the opinion that he should take a regular base dosage of Voltaren (diclofenac) all the time to keep down inflammation.

He ended up with a ruptured Achilles Tendon near the end of his life. I have read that one of the side-effects of chronic NSAID use is bad for tendons, and perhaps muscles. Much of the body has stress and response to stress. Knock that out, and micro-tears or damage can potentially become a major issue.

No major stomach issues that I know of. There are, of course, other mostly independent stomach ailments such as a helicobacter pylori infection (apparently not related to NSAID ulcers), and gastroesophageal reflux disease (GERD)

Originally Posted by canklecat View Post
Opiates aren't the problem. Junkies are the problem. They screw it up for everybody.
Not completely true. Opiates can be bad in themselves. There is a guy battling chronic pain issues on another forum that I'm a member. For years he was posting how he wasn't addicted, and could control his doses, and doctors weren't giving him enough drugs. Then the last couple of posts were that his pain management clinic cut him off of opiates, and he is actually doing better without them.

Your body may not be meant to have pain masked. It is there for a reason. And, opiates may also create rebound pain in a self-perpetuating cycle.

Anyway, I'm against drugs for chronic pain management. Use them for acute pain, but look for other changes for chronic pain.
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Old 06-18-18, 05:24 AM
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I take a 200mg Celebrex daily in AM, and have for many years...in annual discussion, my doctors seem unconcerned about the dosage. Their consensus has been to take an additional 200mg in the evening following big events (>60 mi). I notice it by evening if I miss taking my pills. I also take glucosamine twice a day...seems to help. I was prescribed Meloxicam a year or so ago to use in addition to the Celebrex a day prior to big physical activities, but rarely remember to use it (joint pain).
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Old 06-18-18, 05:48 AM
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Originally Posted by OldTryGuy View Post
Probably not what you are looking for but just a FYI.....

Arthritis diagnosed in hands from bicycle wheel building/truing/mechanics in early 80's and was prescribe ??? forgot since it was soooo long ago but remember that it caused side effects I DID NOT LIKE so started with Ibuprofen. As I aged, more arthritis in other joints and more Ibu. Knees, shoulders, wrist got worse with age and saw othos for x-rays/scans to see how bad joints became, BONE on BONE, and all said they could give shots that WILL NOT LAST and can prescribe X-Y-Z but side effects come with them. I responded that I DO NOT WANT DRUGS OR SHOTS and would continue to ELIMINATE added sugars as much as possible and continue on a low inflammatory diet. EVERY doc said GREAT and it would be what they would do but most patients would not and would want the easier way out using drugs.
.
Interesting. I read up on AGE's and will give this a shot. I am a candy addict and used to eat tons of chocolate. I dropped almost all sugar and a lot of carbs five years ago and dumped 35 pounds is a few moths. Since then I slowly added carbs back while maintaining weight. More recently (contiguous with the arthritis outbreak) I started experimenting with chocolate. I found I could eat what anyone would consider excessive chocolate without gaining weight as long as I stayed on my real food diet otherwise. For me that meant Katie bar the door for chocolate binging. Worth quitting again to see if the inflammation eases. I will watch those evening wines as well.
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Old 06-18-18, 09:03 AM
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Originally Posted by donheff View Post
Interesting. I read up on AGE's and will give this a shot. I am a candy addict and used to eat tons of chocolate. I dropped almost all sugar and a lot of carbs five years ago and dumped 35 pounds is a few moths. Since then I slowly added carbs back while maintaining weight. More recently (contiguous with the arthritis outbreak) I started experimenting with chocolate. I found I could eat what anyone would consider excessive chocolate without gaining weight as long as I stayed on my real food diet otherwise. For me that meant Katie bar the door for chocolate binging. Worth quitting again to see if the inflammation eases. I will watch those evening wines as well.
My chocolate favorites--- Organic 100% Cacao Nibs and Ghirardelli 100% Dark Chocolate, both of which help to reduce inflammation and have no sugar. An acquired taste, but then I also really enjoy Nespresso's Kazaar Espresso. A minimum of 70% Dark Chocolate has some sugar but still retains health advantages over lesser percentages and milk chocolate.
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Old 06-18-18, 02:00 PM
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Probably the best non-pharmacological way to reduce inflammation systemically is to lose intra-abdominal fat if you can. And, of course, the best way to do that is simply to drop weight. Intra-abdominal fat seems to be chronically inflamed in fat people, where it harbors activated immune cells, and secretes immune mediators, which promote inflammation in other tissues. It also promotes insulin resistance in some way which I don't understand. The diet thing is a little more speculative, but I certainly do it too.

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Old 06-18-18, 06:45 PM
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Originally Posted by CliffordK View Post
I'm in my low 50's.

My father had chronic knee pain which he developed sometime before his 50's, and it was pretty debilitating by his mid 50's. He eventually got a bilateral knee replacement.

I have also had knee pain for years, but lately I've discovered that the more I ride my bike, the less pain I am in. Knee issues have mostly resolved, at least if I keep riding 3+ days a week. Low level chronic back pain is also mostly resolved (also helped by sleeping changes).

Dad was of the opinion that he should take a regular base dosage of Voltaren (diclofenac) all the time to keep down inflammation.

He ended up with a ruptured Achilles Tendon near the end of his life. I have read that one of the side-effects of chronic NSAID use is bad for tendons, and perhaps muscles. Much of the body has stress and response to stress. Knock that out, and micro-tears or damage can potentially become a major issue.

No major stomach issues that I know of. There are, of course, other mostly independent stomach ailments such as a helicobacter pylori infection (apparently not related to NSAID ulcers), and gastroesophageal reflux disease (GERD)



Not completely true. Opiates can be bad in themselves. There is a guy battling chronic pain issues on another forum that I'm a member. For years he was posting how he wasn't addicted, and could control his doses, and doctors weren't giving him enough drugs. Then the last couple of posts were that his pain management clinic cut him off of opiates, and he is actually doing better without them.

Your body may not be meant to have pain masked. It is there for a reason. And, opiates may also create rebound pain in a self-perpetuating cycle.

Anyway, I'm against drugs for chronic pain management. Use them for acute pain, but look for other changes for chronic pain.
Excuse the lengthy rant, but I do have a lot of experience in this area, both as a health care provider and patient after two traumatic injuries when I was hit by cars on separate occasions (mostly recently in May this year).

I've been in health care for a long time, including as caregiver for three consecutive older family members. I'm very familiar with the complexities of pain management, and the risks and benefits of various prescription and OTC pain meds and alternatives to pharmacological treatments.

Opiates have only a few complications.
  • Drowsiness in concentrated doses (this side effect is reduced as patients become accustomed to the dosage).
  • Some risk of long term mental impairment, particularly in older folks (also true of general anesthesia).
  • Respiratory suppression (also a therapeutic effect to calm breathing in some patients, such as hospice patients suffering labored and spastic breathing).
  • Constipation.
  • Addiction.
That's about it. Opiates have a long history of observed usage, ranging from gnawing on the naturally occurring plant sources, to accurately metered pharmaceutical doses. Little or no known risk of permanent damage to internal organs (unless complicated by impurities common in street drugs, shared needles, etc.). No auto-immune disorders. No cancer. None of the many potentially debilitating side effects associated with the non-opiate analgesics and NSAIDs, most of which carry significant risks in long term use.

There's a reason why opiates have been used successfully for centuries. It works. That's why pharmaceutical researchers continue to isolate the factors that relieve pain while reducing the unwanted side effects. One of the most successful was Tramadol, which for years was regarded in European studies as the most effective opiate designed for long term chronic pain management because it had a very low demonstrated risk of addiction and unwanted side effects, while relieving moderate chronic pain (which patients would typically describe as level 4-7 on a scale of 10).

My mom's doctor prescribed Tramadol to her for years to control her chronic moderate pain from degenerative arthritis and scoliosis. My mom wasn't a candidate for surgery as she approached her 70s. And as a recovering alcoholic she was considered a moderate risk patient, although mom never had a slip-up in 30 years of sobriety after she quit drinking. Mom was extremely careful with her use of Tramadol, never in my observation taking even the full daily dosage of 3 tablets. At most she'd take 2 throughout a day. Often she'd cut one in half and that's all she'd need. Some days she didn't take it at all. That's a reasonably persuasive anecdote supporting the European studies indicating that Tramadol came very close to accomplishing the Holy Grail of analgesia: Pain relief without consequences.

Unfortunately Tramadol has now been inaccurately characterized as being as risky as oxycodone and heroin, without any clinical evidence supporting this hysteria. And it's been abused by professional cyclists who are always looking for an edge to persist in endurance races while minimizing pain without the unwanted side effects of interfering with voluntary and involuntary muscle function, respiration, etc. In other words, ironically, pro cyclists have proven why Tramadol is safe and effective for enabling normal physical activities while controlling chronic pain, while also ensuring yet another perfectly safe and useful analgesic will be demonized by the media and government.

Before Tramadol became the drug of choice for helping patients control chronic moderate pain, hydrocodone was the most popular prescription analgesic for long term use, often combined with acetaminophen. Both of my grandparents had spinal fusions from traumatic injuries and for decades had prescriptions for hydrocodone. I spent a lot of time with them and often ran errands for them, including fetching their prescription refills. While I didn't monitor their usage closely, I could observe that they requested refills far less often than the scripts allowed. If the script could be refilled every 30 days, in actual practice it was often two months between refill requests. They were "dependent" in the sense that they occasionally needed hydrocodone for pain relief. They were not addicted.

Over the decades I've seen a lot of changes in the approach to pain management, and right now we're in a nadir that does not benefit the typical patient suffering from chronic pain who is not at high risk of becoming addicted. Most of the media hype now is driven by ill informed paranoia, click bait that sells ads, fuels the legal system and does a disservice to real patients.

The "pain management clinic" paradigm is fraught with problems:
  • It removes the patient from the caregiver who is most familiar with the patient's problems -- his/her own doctor.
  • It escalates the cost dramatically without commensurate benefits to the patient.
  • The 1990s pain management clinics became associated with "pill mills" and feeding addiction. In my area some pain management doctors were busted for basically serving as fronts for backdoor drug dealing.
  • As a result the current paradigm for pain management has become so paranoid the doctors are primarily motivated by fear of being disciplined or prosecuted, rather than by a need to help patients.
  • If a pain management clinic was designed to be effective, they would -- upon the FIRST visit -- provide immediate pain relief and develop a plan for follow up care within one week at most, and long term plan to control chronic pain. But they don't do this. Instead patients who are suffering are forced to delay for weeks, even months. And I've seen the consequences in my own apartment complex, as elderly and disabled neighbors are forced to resort to illegal drugs and alcohol for pain relief. I've watched some of them who've been clean and sober for years end up in the ER with overdoses from unknown street drugs or the consequences of returning to alcoholism.

The supposedly rampant addiction problem we're told about is mostly confined to a few regions that were targeted by some abusive marketing and corruption schemes. That was combined with prescription pain meds that originally had a legitimate use but were over-prescribed or misused for recreational purposes. Most notably oxycodone and Fentanyl.

Oxycodone was intended for short term use to control severe pain, post-trauma or post-op, at home while folks were recovering. But too many physicians over-prescribed it or extended prescriptions beyond a 10-30 day window, beyond which they should have transitioned patients to lower dose opiates that were suitable for chronic pain with lower risk of addiction. When my neck and back were broken in a 2001 car wreck I had a 30 day prescription for oxycodone. It lasted me 10 years. I didn't care for the sensation and used it only when the pain was so severe that the only alternative was a trip to the ER or urgent care (and if you've ever gone to the ER or urgent care clinics complaining of pain that isn't immediately connected to a traumatic injury that's externally visible, you already know the routine -- they regard all such patients as GOMER junkies -- "Get Out Of My Emergency Room").

Around 15-20 years ago most of the folks I knew who were on long term oxy prescriptions were dying of cancer, or had inoperable degenerative arthritis and were too old or with compromised cardio/respiratory systems to be candidates for surgery. Who cares if they were addicted? The folks I knew still functioned, still enjoyed life and visits from family and friends. I still have an Oster bread machine I received from a neighbor who later died of cancer. Right up until her last few months she often stayed up late at night puttering in the kitchen, baking bread or goodies for neighbors, because it passed the time and she was too miserable to lay in bed. Being dependent on a pain med isn't always a bad thing, compared with the alternative.

Among the side effects of oxycodone was hearing impairment as aural nerves were temporarily deadened. That happened to schlock radio's Rush Limbaugh back in the late 1990s when he claimed he was going deaf, then miraculously was cured after he kicked his oxy habit.

Fentanyl is extraordinarily dangerous for self-medication because it's so highly concentrated. It's intended only for professional administration to quickly relieve severe pain for short duration -- around 20-30 minutes -- so it's ideal for use by EMTs/paramedics and in ERs for trauma victims.

When my mom's femur snapped spontaneously at home last December (her osteoporosis was much worse than her doctors realized), the ambulance crew gave her Fentanyl for the pain to transport her to the ER. It worked quickly, didn't knock her out or impair her to the point that she couldn't communicate with medical personnel, and lasted only about 30-60 minutes.

Unfortunately Fentanyl has become a popular and potentially dangerous drug with recreational users who are ruining the reputation of a perfectly good tool for pain relief when used by professionals.

At 60, with a permanently damaged C2 from a 2001 injury, and still recovering from a recent shoulder injury, I mostly use ibuprofen, hot and cold packs and exercise to help cope with pain. I'm lucky in that I'm still able to ride an indoor trainer while waiting for clearance to resume riding on the roads.

But exercise isn't an option for some folks. Some of my neighbors and family need electric wheelchairs to get around. Their shoulder, elbow and wrist joints can't tolerate using a manual wheelchair. Some folks have had debilitating arthritis and degenerative joint conditions since childhood. And not everyone responds to exercise. Even the best studies indicating benefits to elderly folks who exercise are limited to a select sampling group of people who were already basically healthy or at least capable of exercising. Unfortunately those studies are too often cited out of context without regard to the limited sampling group and misinterpreted to mean that everyone can benefit from exercise in the same way.
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