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“The primary cause of unhappiness is never the situation but your thoughts about it.”

— Eckhart Tolle

I ran across this quote recently. And, as quotes about living our lives often do, it struck me where I live.

Here’s why. I’d gone to my doctor (my primary care provider) for an annual checkup the day before I saw the quote. This was an important appointment. My rheumatologist had informed me a few weeks earlier that she would no longer prescribe opioid analgesics (with the exception of Tramadol) for pain caused by my rheumatoid disease. If I needed them, she said, I must ask my PCP to prescribe them for me.

This, of course, was a shock. My previous rheumatologist, who left the clinic last fall, had always prescribed opiates—at the lowest dose possible, and with caution and care—for my RD pain. After all, RD causessometimes severe and unremitting joint pain—it’s one of the disease’s major symptoms, maybe even the major symptom. And while opioids have never completely relieved that pain for me, they’ve always damped it down and made it easier for me to get on with my life in spite of it.

I’ve never abused them, and I’ve never asked for larger doses.

After my annual exam, I told my doctor what the rheumatologist had said. To my surprise—and considerable consternation—she said that she wouldn’t prescribe opioids, either. Instead, she recommended large doses of fish oil and grapeseed extract in addition to a new prescription for gabapentin, and nerve-pain medicine.

When I protested, she launched into an explanation of the government’s recent crackdown on the diversion and abuse of opioids, the large number of opioid-related deaths, and how these drugs change the brain’s response to pain and lower pain thresholds in those who take them.

“This is in your best interest,” she said firmly, and went on to inform me that the right thing to do was to treat the underlying disease that was causing my pain.

I didn’t say “duh,” but I thought it. I told her I’m taking four powerful DMARDs, including a biologic, for my RD, and had been for several years. These had, so far, not relieved my pain nor cured my disease. It’s incurable, after all, and while I continue to hope for remission, the truth is that only a few RD patients actually achieve it. Those who do frequently continue to have sometimes severe pain because of joint damage. Others achieve remission only to have the disease become active again without warning. The body’s immune system is wily. In its misguided attempt to “protect” me from my own synovial tissues, it always finds ways to get around treatment.

This seemed to fall on deaf ears. My PCP blithely told me to eat a healthy diet, work on losing weight, and to exercise daily, since all three could be helpful in dealing with RD. She also recommended acupuncture, if I could afford it. I can’t.

I left her office gobsmacked and feeling more desolate than I’ve felt in years. I’ve had RD since I was 31, and I’m six month short of 60 now. With the exception of a blessed and very unusual six-year remission that spanned the late ‘90s and early 2000s, I’ve frequently had severe pain that only opioid medications could relieve, and then only partially. How, I wondered, was I going to live with this pain now? And for the rest of my life? After all, this hair-on-fire opioid prohibition won’t end anytime soon.

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I have another appointment with my rheumatologist coming up. I’m going to ask her for a referral to a pain clinic. It’s possible (though not guaranteed) that they’ll prescribe opioids for my pain, and things will go back to normal. There will be a price, of course: constant monitoring, urine tests on demand, pill counts, and contracts. I don’t like the addict/criminal treatment, but I guess if that’s what I have to do in order to relieve enough of my pain to lead a relatively normal and productive life, then I’ll do it.

In the meantime—and into the future—I’m keeping Tolle’s quote: “The primary cause of unhappiness is never the situation but your thoughts about it” uppermost in my mind. Like most people, I can easily make a bad situation worse by being pessimistic and allowing myself to dwell on the negatives. How I think definitely influences how I feel.

Yet this situation is real, and the consequences of living without adequate pain relief are serious. Keeping pragmatic hope alive will make a real difference in how I handle it going forwar

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