A Publication of the East Bay Headache Support Group
A Member of the Americal Council for Headache Education (ACHE) Support Group Network  

VoLUME 11, ISSUE 4  
JULY 2006

July 11,2006 Meeting

The East Bay Headache Support Group is pleased to have Richard Gracer, M.D., and Steve Peterson, LCSW, present information on substance abuse and pain management at its July 11th meeting.  Over the past 10 years we have covered many different topics at our meetings, and pain management is a big one for headache sufferers.  Whether you’re dealing with extreme and/or chronic head pain, with medication use there is always the possibility of overuse or even abuse.  Dr. Gracer and Mr. Peterson will provide information on some new developments in this field.

Richard I. Gracer, M.D., has been practicing orthopedic and pain medicine in Contra Costa County since 1977.  He is board certified in Family Practice and Chronic Pain Management and runs an active substance abuse program.  Dr. Gracer recently retired after 25 years as an Assistant Clinical Professor of Community and Family Medicine at UC San Francisco School of Medicine. He has also taught orthopedic medical and pain topics at many seminars and courses in North America and Europe.  His current interest is in the nutritional aspects of musculoskeletal disorders and in the comprehensive treatment of substance abuse, and has written a book on addiction that will be published in the second half of 2006.

Steven M. Peterson is a licensed clinical social worker (LCSW) and a certified alcohol and other drug abuse counselor (CADCIII).  He is the director of the Gracer Behavioral Health Services program that is focused on helping people with mental health conditions and drug addiction and dependency problems.  Mr. Peterson is certified in several evidence-based therapy methods including Combined Behavioral Intervention, BRENDA therapy, and EMA therapy.  He has worked at both inpatient and outpatient substance abuse treatment agencies and has been in private practice since 1990.  He was also an ad hoc professor at the University of Wisconsin at Milwaukee in the application of social work methods with substance abusers and their families.  He is a frequent presenter at Social Work and Substance Abuse Counselor conferences on evidence-based intervention methods, and served as a trainer for the Minority Counselor Training Project.

Join us in the Hanson Room downstairs at John Muir Medical Center—Walnut Creek Campus from 7:30 to 9:00 p.m. on Tuesday, July 11.   Call Carol at 925-229-5550 for more information.

Future Meetings:

September 12, 2006:  Len Saputo, M.D.:  “New Strategies for Managing Headaches”

November 14, 2006:  Robin Polokoff, Ph.D. :  “Effective Nutrition for Headache Pain Management”

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Controversies in Headache Medicine: Narcotic Drugs for Acute or Preventive Treatment

From Headache, the newsletter of the American Council for Headache Education, Summer 2000, vol. 11, no. 2. 

No one disputes the need to use narcotic analgesics to treat the severe but short-lasting pain of surgery or trauma, or to relieve the agony of a terminal illness.  Headache and pain specialists disagree, however, on the proper role—if any—of opioid or narcotic drugs in the management of chronic headache.  The two potential roles for narcotic analgesics are for acute treatment of severe headache attacks or as a daily preventive treatment for severe, frequent headaches that fail to respond to other acute and preventive medicines.  Two eminent headache physicians present their views on the use of opioids and narcotics in migraine.  Dr. Robbins argues for their use in selected patients (see Page 2), while Dr. Tietjen presents the arguments against their use (see Page 3).

Long-Acting Opioids as Preventive Medicine for Severe Headaches

By Lawrence Robbins, M.D.

Preventive medications only help no more than half of patients with chronic daily headache (CDH).  The medication options for those whose headaches have not responded to the usual preventives remain limited.  Long-acting opioids (drugs related to or derived from opium), taken as preventives several times per day, are one of the “end-of-the-line” options.  In my experience, treating 450 severe CDH patients with these opioids, a small number of people (15% to 20%) achieve long-lasting relief, reporting a greatly enhanced quality of life.  While the short-acting opioids, like hydrocodone, codeine, meperidine and propoxyphene, often lead to rebound headaches and overuse, these problems are rarely observed with the longer-acting opioids.  Of course, prior to utilizing any stronger therapy, we must be sure that the patient is not experiencing rebound headaches from analgesics.

One drawback to short-acting opioids, lasting only several hours in the body, is that patients have a good effect, then rapidly come down and have “mini-withdrawals” throughout the day, which can lead to overuse.  Rebound headaches also can occur with these short-acting opioids.  The smoother, longer-acting opioids give a much steadier level in the bloodstream, protecting against the ups and downs and rebound.  A number of patients who experienced rebound headaches due to short-acting opioids have done well with the longer-acting formulations.  Another disadvantage of the short-acting narcotics is that they contain acetaminophen or aspirin.  The long-acting forms are pure narcotics without these extra ingredients.  The longer-acting opioids I have given to patients include MS Contin, Oramorph SR and Kadian (all forms of morphine), oxycodone (OxyContin), and methadone (Dolophine).  I have not had success with fentanyl (Duragesic).

When they are not overused, the opioids are safe medications.  The major side effects that lead to discontinuation include constipation, nausea and fatigue. They have not been associated with weight gain, often seen with antidepressants such as the tricyclic antidepressants. When the usual daily preventives do not work, alternatives for patients with severe headaches include the MAO inhibitors, stimulants, daily DHE, or even daily triptans.  Each of these has possible side effects.  The side effects of even several opioid tablets per day are generally less than those from many other headache preventives.

The doses must be kept low.  My patients have averaged daily doses of 40 mg of morphine, 30 mg of oxycodone, and 10 to 15 mg of methadone.  These are relatively low doses.  It is necessary to achieve a balance between medication and headaches, and to strive not to overmedicate.  If a low-to-medium dose decreases the pain by 40% to 80%, we may need to accept this level, keeping in mind that these patients had no relief from other daily headache preventives.  Relief of pain by 40% to 80% is enough to greatly improve functioning and quality of life.

Each of the opioids has its pluses and minuses.  The longest-lasting form of morphine is Kadian, which lasts 12 to 24 hours in the body.  I prescribe this at 20 mg (a low dose) twice per day.  Patients often state they do not feel as if they are “on” a medication; they experience no “ups or downs,” only pain relief.  However, some people do better with MS Contin or Oramorph SR, 15 to 30 mg 3 times per day.  Oxycodone (OxyContin) is generally well tolerated, with pain relief lasting from 6 to 12 hours.  Methadone causes more fatigue, and typically more severe withdrawal.  However, methadone is the most effective medication for some patients.  Despite its original development as a narcotic painkiller, methadone has been widely used to control heroin addiction.  So, there is more social stigma associated with being prescribed methadone.  On the other hand, methadone is much less expensive than the other long-acting opioids.

Occasionally, the body develops tolerance to the narcotic and the patient needs increasing doses to achieve the same effect.  Rather than increase doses, at times we will discontinue the opioid for 1 to 2 months to restore efficacy.  Another strategy is to switch to a different opioid.  A small number of patients have remained on the same low-dose opioid for many years.

While dependency (needing the medication but continuing on the same dose) is to be expected after continuous use of an opioid, addiction to the long-acting opioids is relatively uncommon.  Only 3% to 5% of people will show addictive behaviors.  In treating chronic severe pain, dependence has to be accepted, but not addiction.  Addictive behaviors include: increasing the dose without discussion with the doctor; seeing multiple physicians for the same medication; obsessing about the supply; calling the physician with phony stories to obtain additional refills; selling or hoarding the drug; or concurrent use of other addictive or illicit drugs.  Ongoing drug-seeking behaviors like these label the person as “addicted” to the opioid.  Previous addiction to short-acting opioids has proven to be only a mild risk factor for addictive behavior with the longer-acting ones.  A number of patients who previously had overused short-acting opioids have done very well on the longer-acting ones, without addiction.  Patients on daily opioids require close monitoring by the physician, with office visits every 1 to 2 months.

A few patients have become depressed as a side effect of opioid treatment.  It has been controversial and is generally not a good practice to treat depression or anxiety with opioids, because of the risk of addiction.  However, patients in my practice who have continued on the long-acting opioids for a number of years report less depression and anxiety, along with enhanced quality of life.  Most importantly, pain is decreased in these headache sufferers, and they function daily at a much higher level.

For those suffering with severe CDH, the usual treatments often are ineffective.  It is not realistic to expect these people to accept no relief.  For a small number of patients, the long-acting opioids offer a chance at a greatly enhanced quality of life.

Lawrence Robbins, M.D.  Robbins Headache Clinic.  Northbrook, IL; and Assistant Professor of Neurology, Rush Medical College.   Chicago, IL

Narcotics for Acute and Preventive Headache Therapy — Opposing View

By Gretchen E. Tietjen, MD

For many headache sufferers, the experience of intermittent or chronic severe pain is a demoralizing and isolating one.  It is natural to want to obtain the most effective relief available and get on with one’s life.  Narcotics are potent pain medications that may offer welcome relief, as many who have sought help in the emergency room for unremitting migraine will attest.  With that aside, it is my opinion that the role of narcotics is limited in the treatment of headache, particularly in chronic headache disorders.

Acute headache therapy.  With the introduction of the triptan medications (sumatriptan, naratriptan, zolmitriptan, and rizatriptan)*, many migraine sufferers have been able to obtain rapid relief from pain, as well as from the nausea and the sensitivity to light and noise that frequently accompany the headache.  These highly effective medications have the added benefit of being non-sedating, enabling many to continue work or other activities.  Unfortunately, for reasons that are not entirely clear, these medications are ineffective for some persons.  In others the triptans are effective but cause side effects.  And for many, particularly older patients, they may be contraindicated because of other medical conditions, such as high blood pressure, heart disease, or a history of stroke.

For persons who have not, for whatever reason, been candidates for triptan or other migraine-specific therapies, narcotic analgesics are frequently prescribed. These medications come in many forms, including tablets and capsules, nasal sprays, skin patches, and injections.  The oral preparations may combine a narcotic with acetaminophen or aspirin or another nonsteroidal anti-inflammatory (NSAID) medication.

There are many drawbacks to using opioid-containing medication.  They may be sedating and impair judgment, necessitating that the user sleep, or at least refrain from important decision-making activities, driving, and operating machinery. They rarely stop the migraine completely and often there is a “hung-over” aftermath.  Narcotics are also constipating. And of course they may be habit forming. The addictive potential of butorphanol nasal spray, for example, was not recognized until it was on the market for some time, and it has since been reclassified as a Schedule IV drug with restrictions on its use to reflect this potential for abuse. With other non-opioid habit-forming medications, including those with butalbital, it has been my experience that many persons will escalate the use of these drugs, taking higher doses to achieve the same relief that a lower dose used to provide, or taking the drug more frequently.  Whether the use of the narcotic leads to more headache, a rebound phenomenon, or whether the headaches become more frequent by another mechanism and the increased use is simply a reflection of this, the end effect is the same—more headaches, more medication use, less relief.  This scenario must be anticipated and avoided by careful monitoring of both headache frequency and medication use whenever narcotic analgesics are prescribed for a chronic, recurrent headache disorder such as migraine.

Preventive headache therapy.  People with frequent headaches that do not respond well to acute treatment are often candidates for a daily preventive medication.  Commonly prescribed medications come from a number of different classes of drug, including antidepressants, anti-epileptics, beta-blockers, and calcium channel blockers.  For persons with severe, frequent headaches that are resistant to conventional therapy, the question of prevention with narcotic pain medicines is sometimes raised.  Although for the reasons already stated, I avoid narcotics whenever possible, like many headache specialists I have prescribed regimens of regularly dosed narcotics, most frequently methadone or extended-release morphine, in the hope of preventing or relieving chronic migraine pain.  In my experience this has rarely been successful, and in most instances the headaches have actually worsened.

There is a sound scientific basis for why this is so.  In addition to the pain fibers that transmit signals of pain back to the processing portion of the brain, there is also a pathway from the emotional center of the brain (the limbic system) that influences or modulates the transmission of pain, either activating or inhibiting it.  In chronic pain this modulating pathway has a major role.  Experiments have shown that a person’s expectation for relief of pain and the emotional and physical context in which the medication is used have as much to do with the effectiveness of and tolerance to the drug as the drug itself.  Specifically, with regards to the chronic use of sustained release opioid narcotics, increasing doses offer more relief initially, but this drops off rapidly over a 6-week period.  They may also decrease the effectiveness of other medication known to work.  This means that initiating a conventional headache preventive medication in someone regularly using narcotics is usually not successful.

The solution?  I have found that most patients who use narcotics and still have frequent headaches do much better once the narcotics are stopped completely, although this benefit is usually delayed.  I caution all persons who are using narcotics regularly to discuss their medication regimen with their physician before making a change.

Gretchen E. Tietjen, M.D.  Department of Neurology.  Medical College of Ohio. Toledo, OH

* Editor’s Note:  This article was published in 2000.  Since that time, 3 more triptans have come on the market.  The complete list includes sumatriptan (Imitrex), zolmitriptan (Zomig), naratriptan (Amerge), rizatriptan (Maxalt), almotriptan (Axert), frovatriptan (Frova) and eletriptan (Relpax).   

From Headache, the newsletter of the American Council for Headache Education (ACHE), Summer 2000, vol. 11, no. 2.  Found on the Internet at www.achenet.org.

Notes…The East Bay Headache Support Group features medical and other professionals as speakers at its meetings.  Notes are taken of most presentations and made available for a suggested donation of $2.00 each, or read them on our Web site at www.headachesupport.org.

Past topics include:  Biofeedback therapy, genetics, care giving, dietary headache triggers, chiropractic treatment, pharmaceutical remedies, hormonal triggers, reducing stress in the workplace, dealing with holiday stress, acupuncture and Chinese herbal therapy, children’s headaches, temporomandibular joint disease (TMJ), somatic headache relief, compounding medications, allergies, experimental headache drugs, prevention of stress headaches, non-traditional therapies, tension-type headaches, menopause, head injury headaches, environmental medicine, emotional impact of headaches, sleep disorders, chronic pain management, exercise headaches, cluster headaches,

5-HTP, Emergency Room visits, dealing with frustrations, Botox injections, naturopathic medicine, the Alexander Technique, effective nutrition for headache pain management, acupressure, medication overuse headache, and many more.

The East Bay Headache Support Group is a nonprofit organization dedicated to providing a forum for headache sufferers.  The support group meets the second Tuesday evening every other month from 7:30 to 9:00 p.m., at John Muir Medical Center—Walnut Creek Campus.  It is open to all headache sufferers and their families, and interested persons.  The meetings are free; however, donations to cover printing, postage, and Web site expenses are appreciated!  The support group meetings include lectures by guest speakers, question and answer sessions, and informational materials.

Directions to John Muir Medical Center─Walnut Creek Campus:  Take Highway 680 to the Ygnacio Valley Road exit in Walnut Creek.  Turn right and go East toward Mount Diablo approximately 1-1/2 miles, and turn right onto La Casa Via at the top of the hill.  Turn left into the medical center parking lot, and enter at the main lobby.  Take stairs or elevator to the lower level and follow signs to the meeting room.

We value your input!  Call, write, or e-mail us if you have comments or suggestions, or would like to help.  The planning committee meets occasionally and welcomes new members. Michael Stein, M.D., Medical Advisor; Leslie Davis, Editor/Webmaster; Donna Johnson, Treasurer; Carol Bartlett, Reg Fong, Trish Harrison, Holly Prehn, Jean Tamayo, Richard Tomchalk, Janet Young.

East Bay Headache Support Group

1844 San Miguel Drive, Suite 316

Walnut Creek, CA 94596

Phone:  925-229-5550 or 925-938-5252

E-mail:  info@headachesupport.org

The intention of the East Bay Headache Support Group is to provide information and resources.  It does not provide medical advice, which should be obtained directly from a physician.