I’m not sure whether you really intended to say that you understood that the second time morphine was used it was less effective than the first or not, but I can assure you that this is not so. I’ve been using Percocet or Lortab, (both semi-synthetic opioids) for about a year and a half for breakthrough migraines. Sometimes I have to use it for several days at a time. I’ve seen no sign of the drug becoming less effective over time. However, if my chronic pain were of a constant rather than intermittent nature two things would certainly happen.

The first is that I would become physically dependent on the drug, i.e. I would need to keep taking it to prevent withdrawal symptoms (which I’m told are quite nasty for opioids). I need to emphasize that this is not the same thing as addiction, and I’ll talk about that in a later paragraph. During my pregnancy, when I could not take the drug that prevents (most of) my migraines I was at risk of dependence. Fortunately, it never happened due to really excellent medical care, and that was better both for the baby and me. In order to stop taking the drug once the pain was gone, I would have had to have been tapered off of it. My understanding is that it does not take very long to develop dependence on opioids, but that it’s also reasonably straightforward to taper off since it is very rare for pain patients to become addicted simply because they are being treated for pain.

The second consequence of long-term use is that after some length time the patient requires a larger dose to get the same pain relief. This is called developing tolerance to the drug. I’ve read in so many places, though, that the dose can be increased infinitely. (Not all at once, of course, but as tolerance develops, and that is something that happens gradually.)

To quote Wikipedia on drug addiction:

Drug addiction is a condition characterized by compulsive drug intake, craving and seeking, despite negative consequences associated with drug use.[1]

Although being addicted implies drug dependence, it is possible to be dependent on a drug without being addicted. People that take drugs to treat diseases and disorders, which interfere with their ability to function, may experience improvement of their condition.

Such persons are dependent on the drug, but are not addicted. One is addicted, rather than merely dependent, if one exhibits compulsive behavior towards the drug and has difficulty quitting it.

You said that your “impression has always been that painkillers are limited.” That used to be my own impression before I became more familiar with the subject. My own current impression is that all painkillers have their limitations. There is a limit to the amount of Tylenol you can take before it starts to damage your liver. Same thing for ibuprofen, except it’s the kidneys and the GI tract. Ditto aspirin, except it’s hemmorhagic stroke and GI tract bleeding (not to mention tinnitus). Opioids do not cause organ damage, and they provide vastly superior pain relief to any of the alternatives that I listed. You’ve got to admit that that’s a great upside to narcotics over other analgesics. The incredible downside of narcotics you already know: they induce physical dependence and tolerance. I would suggest that all of these things (potential for organ damage and dependence/tolerance) should simply be considered side effects of the drugs in question and be weighed carefully when considering whether to use it or not.

It is very important to recognize that, though the words are often used interchangably (even by me when I’m not careful), there is a huge difference between drug dependence and drug addiction in spite of the apparent overlap. I don’t know whether it is that people don’t understand the difference between the two or whether it is that they really believe that drug dependence for theraputic reasons is morally wrong. I don’t believe that it is. A diabetic, epileptic, or schizophrenic needs their medication in order to live a semblance of a normal life, and if they don’t take their medicine, there are severe consequences. The same is true for a pain patient. I don’t see a difference.

Sorry I’m so late replying to this, Lynx. If you remember, though, that’s about par for the course for me: the last and belated commenter in a dead or dying thread.

It is not for other people to question motives or alternatives or the rights and wrongs of it.

What is available for relied of mental or physical suffering is an interesting and valuable sub-topic. But it should not be used to undermine a person’s ability to make his own decision.

Again, if the option exists to treat pain, especially in cases where pain is the main problem, I think it’s criminal to withhold treatment. However, many end-of-life situations involve things other than physical pain that for many people, still warrant preferring to not live. I firmly believe all options need to be open, including ending your life.

I belong to a religious tradition which prohibits suicide, and I’m averse to the idea of encouraging or facilitating suicide among those whose beliefs don’t prohibit suicide. This aversion isn’t a matter of wanting to impose my beliefs upon others; it has to do with what C Stanley said about people eventually coming under pressure to commit suicide. I can see that becoming a issue, especially in a family where resources are scarce.

However, I am so frustrated with the rampant opiophobia (and phobia of cannabis) in this country that is causing so many patients to receive entirely inadequate care and leaving them miserable when there is no legitimate medical excuse for their misery that I am about at the point of saying that we really do need assisted suicide if we aren’t going to allow doctors to treat pain adequately.

There are doctors who specialize in chronic pain who end up going to jail. Do a search on Dr. William Hurwitz, who specialized in high-dose opioid treatment for difficult cases of chronic pain, for a current example. He’s not the only one, though. And I personally am close to a psychiatrist who has a strong interest in chronic pain and used to treat some pain patients. (This is very cool because chronic pain has both physiological and psychological element and pain patients often suffer from depression, and he is one of the few psychiatrists left who does extensive psychotherapy.) However, he stopped treating chronic pain patients some years ago and no longer prescribes narcotics because it is too risky.

While reading about Dr. Hurwitz recently, I learned something interesting about Dr. Kevorkian that caused me to see him in something of a different light. At this point, I don’t have the time to look up the patient’s name, but a man came to Dr. Kevorkian, and Dr. Kevorkian insisted on referring him to Dr. Hurwitz for pain treatment, which treatment was effective until the DEA forced Dr. Hurwitz out of practice. A number of Dr. Hurwitz’s former patients ended up contacting Dr. Kevorkian when they were no longer able to obtain pain relief. I believe that some of them also have committed suicide on their own.

I’ve suffered from migraines for 15 years, and I have always had a lot of breakthrough migraines in spite of prophylactic treatment, and I’ve got fibromyalgia and some osteoarthritis to boot, so I have a clue about the sort of physical pain that leads people to want to die. Actually, there was one time, years ago, when I had a particularly bad migraine (and this was long before anyone had thought of prescribing me a narcotic for the breakthrough migraines.) My young daughter brought me my pillow and a blanket and tucked me in on the living-room floor (I was too sick to move) and put herself to bed. When my husband came home, he found me there and asked how I felt, and I told him (quite truthfully; I was not exaggerating), “I wish I were dead.” But I did know that, deep down, I would really rather be alive and that the migraine would pass, so after a moment’s thought I added, “No, I don’t; I wish I were on Demerol.”

Christine, as a veterinarian you must have to put animals down quite often as well as counsel their owners as to when and whether their pet should be put down. How does your experience with animal euthanasia inform your thoughts about human euthanasia? (As a matter of fact what sort of feelings do you have about animal euthanasia? i.e. are people too quick to have their pets euthanized, too slow, etc.)

Well, as usual, my comment is both too long and too late (though I started writhing this around 1pm. sigh.) Hope someone actually reads it.

Concerns about coercion can be dealt with, and with everything else, it’s a case of MYOB.

There are people in such pain, who have to suffer day in and day out, while other people sort our their queezy feelings? Some of them are too weak to administer the fatal drug, and I hope someone is there to help each one of them.

CS wrote earlier:
1) I described, with elderly people opting to end their lives to prevent themselves from being a burden?
2) Or what about terminating the life of infants with disabilities?

In the case of (1), the decision and participation is very involved. The “burden” isn’t listed.
http://www.oregon.gov/DHS/ph/pas/faqs.shtml#onbehalf

Q: How does a patient get a prescription from a participating physician?

A: The patient must meet certain criteria to be able to request to participate in the Act. Then, the following steps must be fulfilled: 1) the patient must make two oral requests to the attending physician, separated by at least 15 days; 2) the patient must provide a written request to the attending physician, signed in the presence of two witnesses, at least one of whom is not related to the patient; 3) the attending physician and a consulting physician must confirm the patient’s diagnosis and prognosis; 4) the attending physician and a consulting physician must determine whether the patient is capable of making and communicating health care decisions for him/herself; 5) if either physician believes the patient’s judgment is impaired by a psychiatric or psychological disorder (such as depression), the patient must be referred for a psychological examination; 6) the attending physician must inform the patient of feasible alternatives to the Act including comfort care, hospice care, and pain control; 7) the attending physician must request, but may not require, the patient to notify their next-of-kin of the prescription request. A patient can rescind a request at any time and in any manner. The attending physician will also offer the patient an opportunity to rescind his/her request at the end of the 15-day waiting period following the initial request to participate.

Physicians must report all prescriptions for lethal medications to the Department of Human Services, Vital Records. As of 1999, pharmacists must be informed of the prescribed medication’s ultimate use.

The case of (2) is now being revised by Texas Right to Life. Where are the buffoons Billy Donahue and Randall Terry on this one?
http://www.christianliferesources.com/?/news/view.php&newsid=5917

Within weeks of his admission, the facility rendered Emilio’s life futile and repeatedly pressured his mother to withdraw care and treatment, yet Catarina fought to protect his life.

In an email to LifeNews.com, Texas Right to Life, which began a campaign to help Catarina find a new facility to care for her son, commented on the case.

“Baby Emilio was the latest victim of Texas’ futile care law, a law enabling doctors to withdraw treatment from a patient after providing ten days notice of their intent to do so,” the group said.

I read recently that none of the dire slippery slope predictions of detractors ever happened, and that the transition has been mostly uneventful.

Lynx,
That depends on who you ask. What about the scenario I described, with elderly people opting to end their lives to prevent themselves from being a burden? Or what about terminating the life of infants with disabilities? I’m sure Michael will take issue with me, but right to life advocates do feel that the Netherlands is on a slippery slope with those cases. Are they exaggerating it? Quite possibly, but then you’d also have to assume that people who support legal assisted suicide are bending the reporting of facts as well.

And on the issue of ‘doing no harm’ meaning that a physician should end a life of someone who’s suffering: pain management has become sophisticated enough that that is not an issue. People can be assisted to die without agonizing pain and with dignity while also respecting the natural course of life instead of people taking it into their own hands.

Once upon a time, there was a reason to oppose assisted suicide. Sickness was something quick, you really couldn’t be at the edge of death in agony very long before actually dying. Now you can be a virtual vegetable for decades, or kept alive and miserable by machines. The number of people in a situation that can hardly be called “life” is increasing, hence the increasing need to get more enlightened laws passed.

I never quite thought of it that way. Lynx, thanks for bringing up an interesting point.

I am aware that you have religious beliefs against this sort of thing, and I also understand how it could make some people squeamish, but I find interesting that even in the US, supposedly a very religious nation, an ample majority of people believe people should be allowed to end their life when THEY wish, and that the government can go F-itself, thank you very much.

Correct me if I’m wrong Michael, but I seem to remember that the Netherlands (as always ahead of the game) is the only country that allows euthanasia. I read recently that none of the dire slippery slope predictions of detractors ever happened, and that the transition has been mostly uneventful.

Once upon a time, there was a reason to oppose assisted suicide. Sickness was something quick, you really couldn’t be at the edge of death in agony very long before actually dying. Now you can be a virtual vegetable for decades, or kept alive and miserable by machines. The number of people in a situation that can hardly be called “life” is increasing, hence the increasing need to get more enlightened laws passed.

First change the law, then act. Not the other way around (in a liberal democratic society at least, I am not talking about life under a dictator).

I guess you aren’t a big student of U.S. history. For example, breaking bad laws led to many of our breakthroughs in civil rights.

Unless you’re a rich political donor, it’s hard to get the law changed without stirring public outrage. That’s the reality of American “democracy.”

It is most certainly possible, the question does the political will exist to do it?

Also – Christine, there is no doubt in my mind that reasonable people can disagree with me. Just to make that clear. I understand your reasoning, I simply hold a different view.