Opioid pain killers and parasomnias

[barefoot]

I've injured my shoulder and I'm in quite a bit of pain. Waiting for a physiotherapy appointment to come through but, in the meantime, I'm finding it difficult to find a 'strong' painkiller (ie not just standard paracetamol or ibuprofen) that both significantly helps relieve pain and does not disturb my sleep.

I'm already taking a NSAID (non-steroid anti-inflammatory) every day for something else anyway and they don't affect my sleep – though I'm not sure how much pain relief I'm actually getting from it. And I'm taking paracetamol regularly every day, and that's no problem. But taking these alone still leave me in a lot of pain.

GP wanted to top me up with an opioid option (tramadol or codeine) but I have a long history of having terrible sleep with both of them. Whenever I take them, I end up having way more night terrors and hallucinations. I have been taking Melatonin as prescribed by a sleep consultant for a few years and they have helped get the non-REM parasomnias under control. But when I take these stronger opioid medications, the Melatonin doesn't seem to be effective and the parasomnias start coming thick and fast. And having a night terror while I have a painful shoulder is no fun - I have woken myself up a few times lately in severe pain because I've been flinging myself about in my sleep and have hurt myself!

For now, we are experimenting with me topping up with very low doses of codeine and avoiding taking codeine too late in the evening.

But I wondered whether anyone has any other suggestions. I'm in the UK and guess we are limited in what we can get on the NHS – I got the impression from GP that paracetamol, NSAIDs and opioids are the only pain relief options available. And that codeine and tramadol are the only options for opioids. Does anyone know of anything else that might be worth giving a go, even if I may have to pay more or get a private prescription etc? Though even if there are other opioids out there, I don't know if they are still likely to have this effect on my sleep?!

Has anyone else experienced this connection with opioid pain medication triggering more parasomnia episodes despite taking medication for the parasomnia? GP was patient about it as he kept trying to think of options that might work, but I got the feeling that he was a bit baffled by it! I know all medications potentially have side effects, that disturbed sleep is a potential side effect of lots of drugs, and that some drugs counteract others (for instance, amitriptyline seemed to cure my IBS pretty much overnight but it made my Melatonin completely ineffective, so it wasn't the right thing for me to continue with), so I'm really just particularly interested in whether other people with non-REM parasomnias commonly have this challenge with pain relief.

A steroid injection may be possible/needed at some point, but none of the GPs at my surgery can do them, so it would mean a referral to orthopaedics and probably a long wait. Hopefully, the exercises and physio and some time will sort me out. But this is another reminder for me that, when I'm ever in a lot of physical pain, I have quite limited options – or know that if I choose to take the pain relief, I'll be shouting, screaming, and running around in the night!

 

[LuckiLee]

I use Extra strength arthritis pain medicine. It's sold over the counter here in the U.S. I get the 500mg for when the weather messes with my knees.

Ice and heat rotations. 20 minutes on 20 minutes off.

Prescription strength Arthritis/Anti-inflammatory cream. Also sold over the counter.

Take care.

 

[DharmaGirl]

What about a muscle relaxant? A lot of pain is caused by the muscles reacting to the injury, so maybe relaxing them might help. I have parasomnias and took myself off Klonopin. I have a neck problem that requires a muscle relaxant every once in awhile and my sleep is so much better then.

 

[Friday]

As someone who has been on the wrong end of the piñata a little too often?

Big Boys (sans surgery)
- Opiates & Synthetic Opiates
- Benzos
- Muscle Relaxers
- Steroids / Anti-inflammatory
- Nerve blockers
- Nerve blocks
- Pain Psych (controlled/targeted disassociation & mood elevation)

DailyLiving
- Analgesics (paracetamol, ibuprofen, etc.)
- Capsaicin/ SubstanceP stimulator patches
- Camphor &/or mentholated balms
- Marigold &/or clove balms
- SUGAR, ideally glucose but sucrose is a close second. (it’s impossible for your brain to make endorphins without enough glucose // diabetics in acute/chronic pain reeeeally have to mind their blood sugar & insulin levels, because the part of the brain that makes endorphins is screaming for more sugar more sugar, so they can experience catastrophically loooooooooooow blood sugar using their normal as a guide, because all available sugars have been broken down and sent to the brain, rather than being ignored by the pancreas to float around in the bloodstream wreaking havoc.)

 

[Sideways]

Shoulder injuries are a b!tch of a thing. I definitely hear you. With crappy sleep even before you factor in shoulder pain - what a nightmare.

GP wanted to top me up with an opioid option

Oof, of course they did.

Shoulder injuries (partial thickness tears or bursitis) that require physio and/or steroid injection are a chronic injury. So opiates (even at the mild end) are *cough* an absolute last resort.

Sure, your GP gives you a quick answer today by writing the script and sending you on your way. But we're talking pain management for at least a few months, so hell no.

Unless I want to have to detox at the end of that period, because that's definite opiate-dependency territory. Which will likely play out as "the shoulder injury that never recovered" so the necessity for opiates never went away.

Seriously, we know that's how opiates work. Why are we still using them for this kind of pain relief!?

A steroid injection may be possible/needed at some point

Can you follow up this option with another GP? Because if they get it right, it could bring you relief within 24 hours of the injection. Like, Pain Gone relief. These injections are the silver bullet for some people.

Alternatives? (Because chronic pain and me are besties!). A physio or exercise physiologist should be able to give you a series of daily exercises to do that will isolate and strengthen the individual muscle groups in your shoulder. Not an overnight fix, but actually incredibly helpful.

I use the BetterSleep app for my nighttime guided relaxation, and love (love love) the mindfulness-based chronic pain track. Mindfulness is big business in pain management these days. It's a bit counterintuitive, takes a few nights to reeeeally hit the Relief button. But I love it a lot!!

And I'll throw this in because of the sheer volume of people I know who swear by it: have you considered accupuncture?

I used to use codeine for pain management. It used to be the shit.

I've stopped using it completely (even for migraine), and use targeted exercise and daily relaxation, souped up with slow-release paracetamol these days.

Paracetamol doesn't give complete relief for me, but it gives me enough (and I take it prophylactically when I'm not in pain, because it's a "get in early" type drug) relief that my other strategies get me through. Without the drama of side-effects or dependency that I got using codeine.

 

[barefoot]

Ice and heat rotations. 20 minutes on 20 minutes off

This is a good thought which, for some reason, I hadn't considered! Thank you!

Prescription strength Arthritis/Anti-inflammatory cream

Yeah, GP prescribed me a strong anti-inflammatory gel to try instead of the Meloxicam I've been taking for a while, so will see how that goes. At the moment, I'm just finding it very messy! I don't know whether I'm putting too much on or whether I'm not letting it dry enough before I get dressed, but when I take my tops off, they are absolutely covered in flakes and my skin has this film over it where it looks like I'm peeling really severely! I was wearing a black top yesterday and where the flakes of dried gel had seeped through, it looked like a had a terrible case of dandruff on one side! Will persevere!

What about a muscle relaxant

Yeah, I have actually taken a diazepam a few nights when it was particularly painful (partly to see if it helped the pain and partly to see whether it would mean I didn't have a night terror/hallucination. But I don't want to get through too many, otherwise I won't have enough for using them as and when I really need to use them for acute triggered anxiety. My doctor has already given me more in a shorter timescale than she would usually, because I had a bereavement a few months ago and it had quite an impact, so I got through them quicker. But I won't be able to get any more for another few months. I'm not sure what else GPs would prescribe here as a muscle relaxant....I've only known friends get diazepam for things like back spasm pain.

Opiates & Synthetic Opiates

Yeah, this is the group that I'm wondering if there are any other options that might be available to me (only options I seem to have been offered are codeine and tramadol) Or whether any kind of opiate is going to mess with my parasmonias anyway.

Shoulder injuries are a b!tch of a thing. I definitely hear you. With crappy sleep even before you factor in shoulder pain - what a nightmare.

Perhaps calling it an injury made it sound worse than it is...but thanks for the empathy and I'm sorry you've experienced the pain of it too. I haven't done anything serious, I don't think. I'm not sure whether I've pulled/strained/strained the muscles in the rotator cuff or whether there is perhaps a tear or something. Don't know.

I don't even know how I did it. The only thing I can think of is that a neighbour's (large!) dog launched at me a few weeks ago (being friendly, not trying to attack me) and it was unexpected and really full-on and the force of him on me and his persistence (I kept throwing him off me and he kept jumping right back on me while his owner stood there and didn't do anything to help!) threw me off balance in a sort of awkward twist. Plus I was using all my strength to push him away and throw him down and off me. I was quite shaken afterwards and had cuts and bruises all down both thighs and on my face where he had basically been on his back legs at eye level with me (and I'm pretty tall!) and just clawing at me to try to hang on. But as the day went on, I started to realise that my back felt sore and stiff and my shoulder was aching. But my shoulder was quite low level uncomfortable at that point. A couple of weeks later, I then raised that arm high really quickly as an instinctive response (trying to avoid getting swiped by my cat when she'd had enough stroked!) and there was searing pain in the front of my shoulder and right through, which brought tears to my eyes in that moment. And it's remained more painful every since. Sorry – long explanation there, probably not needed! Probably because I'm partly caught in a conflict with myself about whether I should have done something like reported the neighbours for not controlling their dog etc. But...I didn't, so....and that's probably another thread....that I now have great anxiety about the neighbours and their dog and whether I was stupid not making a thing of it. Anyway....back to this thread topic!

Oof, of course they did.

Sure, your GP gives you a quick answer today by writing the script and sending you on your way. But we're talking pain management for at least a few months, so hell no.

To be fair on him, he said to ensure I'm taking paracetamol regularly – emphasised that this was an important part of the treatment. Then swapped the NSAID I was already taking to a gel. And I said it was still very painful so what else could he recommend for now, so that's how we were talking about opioids. He wasn't pushing them. And he has also given me exercises to do at home. And has referred me to a physio, but said it would likely be 2-3 weeks before I could get an appointment. If it turns into too long a wait, and I'm really struggling, I will probably arrange a few private physio sessions and pay for them myself. So, I think we are both thinking that the codeine is just a top up as and when needed, in the short term, to calm the acute pain, so that then I can start doing exercises/physio treatment. Also, because of the challenges with codeine impacting my night terrors etc, he has given me very low dose tablets, and has advised me only taking 1 or 2 at a time when needed (officially, the instructions say I can take up to 4 at a time)

I am not in agony all the time. If I do certain moves, there's a real intense searing pain, that then makes everything feel more painful again (so then I might take a codeine) Most of the time, if I don't do any of those moves/positions, it feels ok-ish. Well, not really ok, but not that excruciating pain that brings tears to my eyes, takes my breath away, and makes me feel like I'm going to be sick! It is more of a dull achey pain radiating around my shoulder, collar bone and neck. That's quite uncomfortable but nothing near unbearable, so I am largely relying on paracetamol and the anti-inflammatory gel and then putting up with the remaining discomfort unless it's really flaring up. I think I've only taken four of the low dose codeine since Tuesday.

So...I get where you're coming from and, yeah, I agree that they dish codeine and tramadol out pretty easily. But I think GP and I are both thinking short term to tide me over as and when needed for times of acute, intense pain, until I can get started with physio. As I'm typing, I wonder whether I should just suck up the money and contact a physio myself and get booked in so that I can start getting it looked at asap...

follow up this option with another GP? Because if they get it right, it could bring you relief within 24 hours of the injection. Like, Pain Gone relief. These injections are the silver bullet for some people.

I know that none of the GPs at the surgery can do the injections themselves, which is a real pity. They used to have someone who did, but he retired. So it's now a referral to orthopaedics at the hospital, which could take some time... I do have an appointment in a couple of weeks with my usual GP so I will see where I am with it and, if current medications/exercises etc aren't helping at that point, I'll ask her about injections. I'm sure she will refer me to have one at that point if I say that's what I think I need. I've just no idea how long that would even take to get it.

A physio or exercise physiologist should be able to give you a series of daily exercises to do that will isolate and strengthen the individual muscle groups in your shoulder. Not an overnight fix, but actually incredibly helpful.

Yes, I already have some exercises that GP gave me, but he suggested waiting a few days to start to see whether the pain relief kicked in a bit first to make doing the exercises more possible.

have you considered accupuncture?

I had acupuncture for something else last year and I really didn't like it. I found it really emotionally distressing, for some reason, and also found it very painful physically. Not sure if she just wasn't the right practitioner for me. Or whether it was that I was getting treatment for a chronic illness (Long Covid) rather than needing a focus on one particular body part, so I had loads of needles in all over my body...whereas I guess this would be focused on one specific area, which might feel more bearable... Have you had any success with it?

I'm sorry that you have so much experience with chronic pain and also experience of adverse effects of opioid pain relief @Sideways and I appreciate you looking out for me :)

 

[DharmaGirl]

Yeah, I have actually taken a diazepam

I was thinking maybe Cyclobenzaprine, or Robaxin. Things that doctors are willing to prescribe. These may work better than the benzos.

 

[barefoot]

I was thinking maybe Cyclobenzaprine, or Robaxin. Things that doctors are willing to prescribe. These may work better than the benzos.

I’ve not heard of these so will look them up. Thank you!

 

[barefoot]

An update in case it helps anyone at any point…

I did manage to get a steroid injection into the joint by GP in the end, but it hadn’t made any difference. So, my shoulder pain has continued to worsen and movement in that arm is now much more restricted.

I managed to speak to the pharmacist at the sleep disorder clinic and he said the sort of disruption I was describing while taking opioids was very common, that they often fragment sleep. And that could affect anyone but is also an important thing to consider as I have a sleep disorder and as I’m taking Melatonin to consolidate sleep to reduce the parasomnias occurring. So, he has upped my Melatonin dose in the short term, while I’m experiencing this intense, acute pain, so that it can counter the effects of the opioids. That seems to be helping at the moment, but I am still choosing not to take tramadol or codeine later in the evening/at night.

I have a hospital appointment tomorrow to see a shoulder specialist, so I’m hoping I may get some clarity around what’s happening with my shoulder and what might help. Fingers crossed!

 

[DharmaGirl]

Good luck! If you have an MRI ask for dye. I had one without dye and it showed a small tear in my shoulder. I went to a different doc and got one with dye and it listed 8 different surgical problems. I got the surgery and feel better. I hope you feel better soon.

 

[barefoot]

Good luck! If you have an MRI ask for dye. I had one without dye and it showed a small tear in my shoulder. I went to a different doc and got one with dye and it listed 8 different surgical problems. I got the surgery and feel better. I hope you feel better soon.

Thanks @DharmaGirl - I didn’t have any x-rays or scans, but got diagnosed with frozen shoulder back in March. I had a guided injection using ultrasound, which massively helped the pain, so I’ve managed to stay off any stronger pain killers since then, which is good. Now need to wait til my shoulder decides to unfreeze and move properly again…the limited movement is annoying but not unmanageable so I’m not looking to go down the surgical route at this point.

Eight surgical problems - ouch! Glad you managed to get it sorted!