Drug Dependency?

My husband was injured in a work comp accident 17 years ago. He spent 5 years on comp and was found to have a tilted pelvis which has also laterally rotated causing his hip bones to be turned down and on center where they should of been by about 1/2 inch. It took years of therapy and working only on one side of his back to strenthen the muscles so they would pull the pelvis back in place as well as the hip bones. He also spent 1 month in a pain rehab hospital learning to deal with the pain he would always have.

Years have passed and he really doesn’t complain too much about low back pain anylonger. The pain seems to be in the upper back now. He has recently been diagnosed with spinal scroleosis, osteoporosis and kyphosis of the upper back. He also has frozen shoulders which he has had for many years. The Doctor he is currently seeing just did a MRI of the spine and the findings were negative with no spinal issues of disk or bone issues. He described to the dr. that his severe pain is muscular. He continues to work full time in janitoral maintenence. He has a three story building which he is totally resposible for. Which includes running large floor scrubbing machine, large waxers and buffers. He also does alot of daily mopping of large hallways and moving around of furniture. He complains that on the left side of his back he has what feels like a hard knot the size of a golf ball which by afternoon pulls. He states that the knot is right under the shoulder bone where the bone meets with the spine. It tightens up and causes either pain running down the spine and into the sciatic nerve and down the back of his leg. This causes him to do alot of limping favoring the bad side. Other times depending on what movements he had done progressivly over and over the knot will pull tight and cause the pain to come around the left side under the shoulder bone and around the left front of his body to the chest wall. This is when he will come home holding onto the left side of his chest wall and be bent over slightly favoring it.

His current physicain put him on Lortab 7.5 tid daily, Darvocet N 100 qid, skelexin 400mg tid, predisone 15mg daily. My husband did not realize that with the prednisone therapy that he should not take large doses of advil each day also. After approximately 2 years he ended up in the hospital with a perforated bowel and had sx and spent 9 days in the hospital. At this time they gave him a moriphine pump for pain which he used very little of. He did go through withdrawl of the drugs and had chills, severe sweating, and his sweat had a awful smell requiring 2 showers a day to knock the smell. The surgeon cut him cold turkey off the 15 mg predisone without realizing it. When he was released from the hospital he was given tylenol 3 with codeine tid, pepcid bid, and was found to have thyroid problems and was placed on thyroid 60mg daily. They do every other month thyroid test but he is so terribly thin that if they give him the dose he really needs, he drop weight severly. After the 2 years on 15 mg of predisone he lost 40 pounds in 30 days.

The problem now is that we are awaiting a rereading of the MRI because we had mentioned to the dr. that we wanted the areas around the shoulder blade and spine xrayed. His MRI results of the spine at age 32 read as disc L 2-3 show minimual concentric disc bulging with no evidence of focal herniation. The disc space at L 4-5 show slightly more prominent right lateral concentric disc bulging with no inpingement upon the exiting nerve roots or thecal sac. The disc space L5-S1 shows no evidence of disc herniation or spinal stenosis. These were taken because of the intitial injury with low back pain.
The new MRI taken about 2 weeks ago shows that a thoracic spine was done. The lumbar spine is performed with sagittal T1, T2 and STIR sequences and with axial T1 and T2 weighted images extending from the T6-T7 through the T10- T11 levels. The thorasic and verebral bodies have normal heights, conturs, alingments and marrow signal. THe intervertebral disk spaces are preserved with no disk buldges seen. The thorasic cord has normal course, caliber and signal and no central or neural foraminal stenosis is identified. The MRI of the lumbar spine read as lumbar spine is performed insagittal T1, T2 and STIR sequences and with axial T! and T2 weighted sequences extending from L2-L3 through the L5-S! levels. The lunbar verebral bodies have normal heights, contours and alignments and marrow signal. The intervertebral disk spaces are preserved without disk desiccation. NO disk buldges are observed. The xray was signed by a D.O. Because I did not recognize the intials as being read by a radiologist I called the dr. and stated that I was disappointed with the results I has just read because there was no mention to muscles and spinal nerves and ect. that we were suppose to be xraying for. Dr. stated that he would have the head of radiology read it and we would have out results within the week. So far nothing.

My concern is all the medication the Dr. has him on and freely prescibes it without what I believe he had knowlegde of what all he had him on. He currently takes 4 lortab 7.5 daily, 4 darvocet N 100 daily, 3 tylenol 3 with codeine daily, 3 soma daily, 3 - 25mg flexeril daily, thyroid, pepcid, 25mg elavil at HS for chronic pain, 37.5 mg of effexor daily, 10 mg predisone daily, and he continues to use tylenol 500 mg daily inbetween for pain. He has no interest in life and does not do the things he use to. He sits all weekend on a heating blanket on his recliner for pain relief. Come Monday thru Friday he suffers. I am concered with all the drugs and the dr. who I don’t believe knows how much he is prescribing and refilling every month. Mean while for some unknown reason he has started to lose weight again and is what the dr. said a poster boy for a starving nation. You can see all his ribs, spinal column and ect. I started him on Ensure Plus 3 cans daily with his regular meals. But so far no results. He eats like a pig and consumes alot of fatty foods, red meats, cookies, 1 gallon a week of milk, 1 case of pepsi weekly and 10 medium bottles of gatorade a week. Please help with your advice and suggestions. I just don’t know what to so any more. THerapy puts him in agonising pain and only causes things to be worse. I feel like they are missing something, but I don’t know what.

Dr. Joshua’s Answer:

Your husband is dependent on opioid painkillers. Continued simultaneous use of Lortab, Darvocet and Tylenol with Codeine is causing this. He needs detox for opioid dependency. His quality of life is decreased by opioid dependency and he may suffer from constipation, stomach discomfort, morning headaches and other related symptoms. These medications also decrease his performance and ability to enjoy life. This does not mean he’s an addict - opioid dependency is a common problem in patients with chronic pain, and withdrawal from excess opioid painkillers should be a priority for him to regain control of his life. This is the most important thing.

He is taking too much acetaminophen daily, not even counting the extra Tylenol. This means he is at risk for liver damage. He should definitely not take any extra Tylenol, and the amount of acetaminophen should be reduced immediately. He should have lab tests for liver enzymes taken. Liver failure may result in a situation where fat is not properly absorbed by the intestines, and the energy from fatty food is not utilized. Also, steatorrhea may occur, this means fatty stools that float. He does not necessarily have liver damage, but it should be checked.

Your husband is also taking two separate muscle relaxants, which is not recommended for continued use (Soma and Flexeril). Also, he is taking two antidepressants (Effexor and Elavil) which is not totally out of the question, but is not generally recommended.

I’m not sure why he is still on Prednisone? If there is no absolute need for prednisone, it should be gradually discontinued as long-term corticosteroid use is detrimental to his health in many ways, possibly resulting in high blood pressure, diabetes, and osteoporosis (weakening of the bones).

From the MRI reports, I find nothing conclusive. There appears not to be any cause for his pain in the thoracic or lumbar spine.

My recommendation is that he see a pain specialist as soon as possible. The pain specialist needs to review your husband’s medication carefully, and reduce his opioid painkillers as well as acetaminophen, and come up with a strategy for treating the pain and the apparent depression. It seems that your husband is depressed, and if there is one class of drug he is not getting a high enough dose of, it’s antidepressants. He needs a sufficient dose of antidepressant.

To sum up, the following should be considered, and may I stress that this must absolutely be done under the supervision of a doctor, preferrably with expertise in the field of pain medication. Also, I emphasize that these recommendations are just pointers, based on what you have written down, and only a physician who examines your husband can conclusively determine whether these steps are necessary or not.

-reduce or discontinue hydrocodone, codeine and propoxyphene
-reduce or discontinue acetaminophen
-review the indication for prednisone use and discontinue prednisone if possible
-reduce muscle relaxants, avoid polypharmacy (several overlapping drugs)
-check for liver status
-check for thyroid function, TSH, T4V and have him on the proper dose of thyroxine
-check blood pressure, and blood sugar levels, and HbA1c
-a clinical examination needs to be done of the offending lump in the shoulder, and possibly ultrasound/MRI/biopsy if needed
-a thorough history and clinical examination needs to be done to assess his overall health and reason for recent loss of weight
-a sufficient dose of antidepressant is needed if depression can be diagnosed
-if neuropathic pain is present, consider carbamazepine, pregabalin (Lyrica) or Neurontin (gabapentin)
-a tricyclic antidepressant such as Elavil is not a bad idea as it also treats chronic pain
-continued use of H2 blocker (Pepcid) is not recommended unless a gastroscopy has been performed
-a consultation with a psychiatrist is recommended
-review non-medical alternatives to support pain therapy (TNS, physical therapy, physiotherapy, psychological therapy)

Please discuss these issues with your doctor. Please DO NOT make any changes to his medication without the supervision of his own doctor.

A review of the medication used by your husband as reported to me:
lortab 7.5 acetaminophen 500 mg hydrocodone 7.5 mg x 4
darvocet N acetaminophen 650 mg propoxyphene 100 mg x 4
tylenol with codeine no 3 acetaminophen 300 mg codeine 30 mg x 3
soma carisoprodol 350 mg
flexeril cyclobenzaprine 5 mg
elavil amitriptyline 25 mg
effexor 37.5 mg
prednisone 10 mg
thyroxine
pepcid (famotidine)

Good Luck!