The Pill Box

Every week, either late Saturday night or at early light Sunday morning, I go through the ritual of filling my pillbox with my medications. My pillbox has 28 compartments. Each gets filled with a varying number of medications in the form of pills or capsules. On average, I take a combination of about 32 pills and capsules each day. However, the 32 pills and capsules don’t account for all the medications I take daily because I have others that come in different forms i.e. liquids, inhalers, and – on the odd occasion when my gastrointestinal system protests against ingesting certain types of oral pharmaceuticals – suppositories. Early on in my illness, I was even prescribed a topical anesthetic for pain that came in patch-form, but it did little to reach the source of the pain deep in my pelvis.

The largest part of the pills and capsules that fill each pillbox compartment are medications I take to manage my pain. They aren’t all opioids/narcotics, but the majority of what’s in the compartments usually is. Unfortunately, not all these medications always do what they are prescribed to do. Therefore, over the last four years there have been many changes made to my medications. Changes in doses are usually an increase in strengths – as petite as I am I seem to need large doses to manage my pain –, but I’ve learned that dose increases doesn’t have to mean an increase in quantity. Some medications have also been swapped for others of equal strength when they have caused unexpected side effects or delivered no benefit at all after weeks and in some cases, months of hoping for some relief with them; and occasionally new medications get added to the mix in an effort to boost the benefits of what works.

The Pill Box – 1

The Pill Box – 2

Sometimes, the number of pills and capsules I take might fluctuate from day-to-day. That fluctuation depends on whether my doctor(s) writes prescriptions for medications with a minimum and maximum dose. Because my pain medications are largely opioids/narcotics, I try – not always successfully – to take the lower end of a prescribed dose when possible to manage my pain. My Pain Specialist prescribes my primary pain medication in two forms. The first is a long-acting opioid/narcotic prescribed to be taken multiple times each day that is intended to manage my pain for a scheduled period. The second is a breakthrough or ‘rescue’ dose of that same opioid/narcotic that I take in between the long-acting doses; especially in times when my pain levels are high, which is most of the time. I try to take that breakthrough medication on the lower end of the prescribed dose(s), when I’m having a good day, which is rare; or if I’m lucky enough to sleep through the night the overnight breakthrough dose gets skipped.

The main point of having a pillbox is to make sure I don’t miss scheduled medication doses because I take so many throughout the day. Unbelievably, I’m not always successful and might miss a dose of something from time to time, whether it’s because I get distracted or I’m fortunate enough to get some restful sleep. Nonetheless, the brightly coloured compartments of the pillbox that I fill with brightly coloured pills and capsules is my constant companion and may remain so as long as I need a reminder to take 32 pills and capsules – give or take a few – each day.

If you don’t have a pillbox, how do you remember to take your daily doses of multiple medications?

 

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Opioid Induced Constipation & The Undignified Big Pharma Response

Last Sunday, like millions of other people, I watched Superbowl 50. As usual, there were some great commercials throughout the game. However, I can’t forget one commercial from the 2nd quarter. Not because it was funny and creative like most of them were, but because of the targeted medical condition: opioid induced constipation (OIC). The reason I can’t forget it was how embarrassed I felt as my friend with whom I watched the game laughed at the inappropriate humour the pharmaceutical company used to promote its product. For those of you who don’t suffer from chronic pain or have never had the need to take opioid (narcotic) pain medications for pain relief, I assure you this condition is a real thing. The Australian Pain Society states, One of the most common adverse effects of chronic opioid therapy is constipation. Up to 95% of patients prescribed an opioid report constipation as a side effect, which can occur soon after taking the first dose.”

Opioid induced constipation is also known as opiate bowel dysfunction (OBD); and according to the American College of Gastroenterology “constipation may be debilitating among those who require chronic analgesia [pain relief]. OIC/OBD affected an average of 41% of patients taking an oral opioid for up to 8 weeks.”   The reason for this is that “opioids cause constipation by binding to specific receptors in the gastrointestinal tract and central nervous system, resulting in reduced bowel motility through direct and indirect (anticholinergic) mechanisms.”  In short, the opioid pain medications delay or block messages throughout the body that tell you when you need to empty your bowels.

I understand that a commercial’s purpose is to grab its audience’s attention in a short time. However, the tone of this commercial failed to convey the seriousness of this condition, while using lowbrow humour to flog the product. Practical Pain Management, a publication founded and written by pain experts, notes that although opioids have been in use for centuries; it’s only in recent decades that this kind of medication has received any significant attention and investigation. Sadly, we are only beginning to understand and identify the many side effects of opioids. Constipation, nausea, emesis, pruritus, respiratory depression, and somnolence are well known. However, not so well known are effects on immune function, urinary retention, endocrinopathies, gastroesophageal reflux (GERD), gastroparesis, sleep apnea, cardiovascular system, osteoporosis, emotions, dentition, and renal function.”

This lack of knowledge about opioids begs the question, how many people know that if a patient that has OIC/OBD does not receive the proper medical treatment it “may cause rectal pain and bleeding, abdominal pain and distension, urinary incontinence, faecal impaction, rectal tearing, and, in very severe cases, bowel obstruction and colonic perforation?”  How aware are people that OIC/OBD can reduce a person’s quality of life as much as the chronic pain doctors prescribe the opioid medications to treat? The Australian Pain Society also notes that, Some patients would rather endure chronic pain than suffer from the severe constipation that can arise with long-term opioid therapy. One study found that approximately one-third of patients missed, decreased or stopped using opioids in order to make it easier to have a bowel motion; the majority (86%) of these patients experienced increased pain as a result, which reduced their quality of life. Reducing the opioid dose is not considered useful, as analgesia [pain relief] may be compromised and constipation may not resolve.”

I know that 30 seconds isn’t a long time and not all the points I raise most likely could have been touched on in that amount of time. However, I do know that the pharmaceutical company could have approached this issue in a more dignified way. When the commercial ended – and my friend’s laughter died down –, I did educate him about the seriousness of OIC/OBD, and how I’m affected by this condition because of the large doses of opioid pain medications I have to take to manage my pain. I hope that others who might have been in the same situation during the game were able to have similar conversations. If not, here’s a link to a therapeutic brief from an Australian Pain Society study that gives information about OIC in plain language in a downloadable PDF file: Opioid-induced constipation– a preventable problem

 

Bob Dylan – Dignity