Oxycodone vs oxymorphone

Been looking for a new GP since my wonderful doctor retired 1½ years ago, and I saw one yesterday that I'm not too sure about. I take oxycodone (because oxymorphone isn't available) fentanyl and gabapentin for pain, and I get 15 days worth of Ambien every month for my pretty extreme, lifelong insomnia. New GP was immediately really intense about wanting my to stop the Ambien, and first wanted to give me trazadone. I know I've taken it before, a long time ago, and that it did not work for me but I couldn't immediately remember the details. When I finally got him to tell me what type of med it is (why won't doctors ever tell me, I'll just Google it when I get home anyways) I learn it's an SARI and I know that those types of meds really mess me up so I tell him no. Next he wants to get me a sleep apnea study, I say fine. He seemed surprised I said ok, so I don't know what his motivation was if he's not actually wanting me to get this test. Did he think a sleepover was some kind of deterrent?
Because then he changes his mind and wants me to go to CBT for my insomnia, after I told him I don't want a therapist (he just asked if I had a therapist, then if I wanted one... no context) I say fine to that because why not? The only reason I didn't want a therapist is that I haven't had much success with them in the past, and I don't really have any mental health concerns other than very occasional anxiety and the possibility that I have undiagnosed ADHD, which I've been trying and failing to get evaluated for for years. So I asked him about getting evaluated for ADHD and he first was VERY discouraging, saying that everyone grows out of the hyperactivity and has problems with their attention as they age (I'm early 40s) and they'd only give me an antidepressant to treat it anyways. When I told him I wasn't interested in medication for it, but I know there are other treatments to help manage it he was suddenly thrilled and the CBT therapist can evaluate me!
Of course next he tells me the CBT is because he wants to give me DOXEPIN for my insomnia and I have to try a bunch of other things before insurance will pay for it. It's a tricyclic antidepressant, and all my pain meds are more strongly contraindicated than they are for Ambien. I can't imagine why he thinks this is somehow going to be better for me, so I think maybe he's just someone who thinks all pain patients need to be on an antidepressant. To be clear, there's a zero percent chance I'm taking another antidepressant after all the horrible experiences I've had in the past. So if he still wants to push it at my follow-up in 2 months, I'll be looking for a new Dr again. But at least maybe I'll finally get my ADHD evaluation after years of searching.
P.S. He also told me with zero context or questions that the burning pain in the soles of my feet that developed about 1½ years ago is hyperalgesia due to my pain meds. No chance it's another symptom of my chronic illness that causes many assorted neurological symptoms. No test for diabetes or B12 levels. No consideration of any other possibility, it can only be caused by my pain meds. 💀💀💀

I recently am off my mental health meds basically because I had a surgery and forgot to take them. I’m very lucky that it’s been two weeks and I haven’t felt any side effects except actually maybe a bit of depersonalization… I’ve been mostly on (and sometimes off) meds for 33 years. Holy crap. I’m 42 now. I’m feeling okay for now but want to be realistic and know that I may need treatment, again. (ADHD, bipolar, depression, anxiety, OCD) I would like to avoid pills if possible and try only ketamine (or maybe mushrooms). I’ve done on clinic ketamine treatments in the past (the shot type) and I had incredible results for my mood with them that lasted 1-3 months, each. The experiences were amazing and very intense. I know the Yale study recommends twice a week for three weeks for most efficacy however, the experiences were so conscious bending (which I like but also… and maybe I would do the one where you have therapy after- this was just the treatment) I don’t think I can experience so many psychedelic parties in my head within such a short amount of time. I will consider it and might- but was wondering how the at home treatments compare? I imagine the “trips” are less intense because of the delivery of the meds and I can’t imagine the govt letting me trip balls in my own home as a medical treatment, but hey- times are changing. Has anyone tried both or know how the experience as effectiveness might compare?
EDIT: My doctor knows I’m off the meds. We had an appointment. I had my tonsils removed and swallowing anything was very painful and I was on oxycodone and didn’t make a plan to remember to take my meds and my mom didn’t remind me. Shit happens. I’m okay. I’m taking this as an opportunity to explore other routes for treatment since I’m already off them. My bipolar might be misdiagnosed. I don’t have hypo manias. I could be bipolar 2 but symptoms overlap from all of these diagnoses so it’s hard to know what’s what sometimes. Since I’ve been on meds for 33 years (on and off but 80 percent on) this is a good opportunity for me. Just wondering about the actual psychedelic experience intensity of having in home treatments vs in clinic.
Thank you!!

I’m asking for a friend - I found this per Department of transportation’s official government website:
“The DOT testing at HHS-certified laboratories is a 5-panel drug test regimen. As of January 1, 2018, the ‘Opiates’ category was renamed ‘Opioids’:
Marijuana (THC) Cocaine Amphetamines Opioids Phencyclidine (PCP) Under ‘Opioids’, previously ‘Opiates’, DOT testing will continue to include confirmatory testing, when appropriate, for Codeine, Morphine, and 6-AM (heroin). We added initial and confirmatory testing for the semi-synthetic opioids Hydrocodone, Hydromorphone, Oxycodone, and Oxymorphone to this Opioids group. Some brand names for the semi-synthetic opioids include OxyContin®, Percodan®, Percocet®, Vicodin®, Lortab®, Norco®, Dilaudid®, Exalgo®.”
All that in short to ask, does kratom fall under one of these or qualify as any of these? Specifically the Opioids part? I know Mitragynine/7-HO-Mitragynine is molecularly different than all the other opioids.
Has anyone been tested with a 5-panel drug test who uses kratom? Have you ever had a false positive for any other opioid from using kratom?
Thanks in advance for any info 🙏

I used to have great results with Oxycodone, which I take at a very small dosage of (5mg) for pain after my treatments.
But recently, Oxycodone has been making me feel really cruddy. Like the pain goes away for a couple hours, but from the time I take it, I am extremely groggy… and moody to the point I almost feel depressed when I take it.
So I just asked my doctor if we can switch over to Hydrocodone (10mg) instead. She said it lasts longer and doesn’t cause so much moodiness.
Typically I hear that people prefer Oxycodone for pain relief because it’s more potent and so it helps them a lot better.
I am curious if you guys experience these same side effects? If it weren’t for the moodiness and sadness I get… It would work just fine! But I can’t stand that feeling!!
Note: I have chronic pain from my autoimmune disease, however, I only take pain medication because of the horrible side effects from my biologic treatments (so they are as needed only)

I am working with a GI specialist and a handful of other Drs to figure out some health issues I have been dealing with. One major problem, that is becoming exponentially worse and more frequent, revolves around my stomach. I will be going along my day, feeling fine, and the upper part of my stomach, (my guess is around the fudus/ cardiac sphincter area by how it feels) starts to become painful and swollen. My stomach fills with gas and the only relief I get is when I am able to release the gas. Burping can provide quick relief, but the gas in my stomach refills. The longer this goes on the more difficult it becomes to relieve the pain and bloating. Food can make the pain worse, but if I don’t eat there is nothing in my stomach to absorb the extra acid that is creating the gas. Toast can help, but it can also hurt. During an episode I will take dicyclomine, Pantoprazole, Zofran, GasEx, Pepto, metaxalone, marijuana oxycodone and oxymorphone- all Dr approved. Yet I am still left in Intense pain, bedridden, with a hot pack on my tummy. Last night I considered going to the ER, but since I am already working with specialists I can’t imagine how another uncomfortable trip to the ER would be beneficial. All that said, and understanding this is complicated, I am looking for advice about what food I should try, to help reduce the acid and extreme bloating that seems to be causing, or is related to, much of the pain. I have determined that during an episode, I cannot eat any raw vegetables, few raw fruits, meat, most dairy, things that are fatty or acidic. Old school Campbells chicken noodle soup can be helpful, but I really need more options as, at times, this has lasted over a week. Thank you all for the advice, in advance! Let’s hope tomorrow is a better day!

Hello, I'm from Europe and I've been addicted to oxycodone. I was addicted to about 80mg a day taken several times either by insufflation or orally. I also had liquid oxynorm. I abused the medication for about 5 months. I got help from my psychiatrist in the beginning but he finally decided to give me a morphine substitute. He told me that methadone is a very strong product for the body and that subutex too. He said that in Switzerland we have "sèvre long", according to my information it is a complete agonist compared to subutex which is a partial with naltro. He said that's it's a better alternative.
Now what is the difference between takin extend release morphine vs methadone or subs for opioid disorder. And how it will affect me vs my consomation of Oxy. How the extend release gonna be calculated vs my oxy immediate release?
Thanks you very much in advance .

I found posts like this helpful before my surgery so thought I’d share mine. I came down with a stomach bug & also a kidney infection during these two weeks, so I’ll say it was a slightly atypical recovery since it’s hard to separate which shitty parts were the surgery vs the other things. Despite how hard it was at times I am glad I did it.
Day 0: felt mostly fine following surgery. Alternating liquid oxycodone with liquid Tylenol. Was very tired, slept a lot. Ate yogurt successfully. Tried mashed potatoes and do not understand this common food recommendation. I thinned them out multiple times but still felt that potatoes are just too sticky a food, I needed my tongue to move around my mouth to eat them but my tongue was swollen and painful.
Day 1: still felt pretty okay. Wasn’t sleeping too much, spent most of the day on the couch but also easily took a shower and got the mail etc. Set alarms even through the night to not miss meds. Was super hungry. Yogurt again, then boldly ordered a French onion soup and Mac n cheese from Panera bread. (Let the croutons get super soggy in the soup). This absolutely slapped. No regrets. Later, some ice cream and Gatorade. Fairly good day with minimal pain.
Day 2: miserable as fuck. Despite the humidifier on constantly and sipping ice water consistently, my mouth felt so dry. Swallowing felt like knives. Only ate a milkshake, the act of using muscles to swallow was so painful as well. Talking hurt. Tongue still felt so swollen and sore. I could barely stand to get out of bed and needed a lot of help.
Day 3: even worse. Honestly this day is hazy. Like 2 day yet worse. Didn’t even feel okay enough to watch tv, just slept and drank water and slept more.
Day 4: woke up feeling suddenly a lot better. First day with no oxycodone, just Tylenol. Even went to an event where I did a lot of talking, and did some grocery shopping at target. Felt so human! I cooked lasagna soup, which sounded perfect but was too hard to eat. In retrospect, I went too hard. My two young kids came down with stomach bugs and started vomiting so I tried hard to avoid getting sick.
Day 5: back to feeling like day 3. Maybe I would have felt like this anyway but I wish I hadn’t pushed myself so much on day 4. I just ate a milkshake and was back on the oxycodone on a regular routine. I also developed a cough which was extremely painful. Talking hurt a lot. I called the surgeon because I wondered if I could take anything for the cough but he acted like I was drug seeking. I meant like “can I use my albuterol” but i was so upset and delirious I didn’t ask that, just asked what I could take and he clearly seemed to take it a different way. Started sleeping basically upright, which did help. My tongue at this point still felt really painful. I tried eating scrambled eggs but again, not realizing how much I rely on my tongue moving around in my mouth to even eat a soft food like that.
Day 6: felt a little better but learned my lesson and took it easy. Ate applesauce and ice cream and a couple gatorades, stayed on my pain meds routine. Talking didn’t hurt much, as long as i was quiet and didn’t say much. Watched a lot of tv and took it easy.
Day 7: this was the day i was originally supposed to return to work. I did not. I woke up with chills in the middle of the night. I had a fever and body aches and felt like garbage. I seemed to catch the norovirus my family had and had significant digestive issues. Throat pain was like knives. This was the day I first needed a spit cup. I had to text to communicate. Talking hurt so bad. Swallowing anything hurt. I tried so hard to stay hydrated but sometimes all I could muster was putting water in my mouth, leaning my head back to let it reach my throat then let it spill out my mouth. It hurt so bad.
Day 8: sweating through my sheets with a fever. Chattering teeth. struggled to even get out of bed to use the bathroom. I wondered if it was related to the stomach flu or the surgery (spoiler, it was neither). Throat pain was so awful still. Still struggling to swallow anything. Talking still very painful. Had absolutely no appetite at all. I called the surgeon again who said this could all be normal. He did say, if I wanted, I could go to the ER. Not like “you should” but like “idk what you want me to do” kinda way. This day I said a thousand times I deeply regretted getting this surgery.
Day 9: woke up with very obvious UTI symptoms (fever, chills, frequent urge to urinate without going, cloudy urine). I went to urgent care and was diagnosed with a kidney infection and got an antibiotic. Throat pain however, much reduced! Not gone but manageable. Ate a milkshake this day, soup, and yogurt.
Day 10: woke up with just minor pain, returned to work (from home) and managed okay with Tylenol as needed. Still felt yucky with fever and body aches. Ate my first “real” meal, chipotle burrito bowl. Couldn’t eat much though, my tongue still felt weird so took very small bites and chewed a lot.
Day 11: still feeling very tired and shitty but throat pain not terrible. Tylenol as needed. Tongue still feeling kind of bad. It hurts a lot to yawn! I had a jimmy John’s sandwich and it was pretty easy to eat though.
Day 12: calling this my first day of normalcy. Very little pain, not very tired, generally feeling good. I think I took a Tylenol once after I had been talking for a while and started hurting. I wasn’t looking at my throat regularly but I did this day and it just looked, pink and normal. I guess I lost scabs at some point but couldn’t tell you when, I never felt anything I clearly recognized as losing a scab.
Day 13-14 (now): feeling good. Some very mild discomfort but is not interfering with my life at all. My tongue mobility still isn’t totally there - reaching to my back teeth is uncomfortable. And swallowing, while it doesn’t exactly hurt, can feel weird and sometimes even a little difficult like I’m re-learning how to swallow. It still hurts when I yawn. I do also have some mild discomfort, particularly if I’m talking a lot.

" " So many people today are very quick to claim 'expertise" in cannabis this or that. Myself I have never claimed cultivation superiority or any superiority really. I have worked independently to create a means to best understand modern hybrid cannabis. The extent to which we as a society understand the effects of cannabis are largely based on anecdotal evidence from users many of whom are not sincerely passionate about cannabis and about being accurate and honest in their review if it's effects. In addition, we orient these effects characteristically by sativa vs indica, but today's cannabis is extensively hybridized.
When I say hybridized I am saying one genetic strain crossed over another. Landrace genetics brought into the lab taken from their endemic environment is an heirloom, not a hybridized plant. It is modified through control of lighting and control of the environment like humidity to amplify it's desirable properties. Also remember the "desirable Properties" this cannabis has been developed to achieve on the modern market was to enhance the psychoactive nature and intensity with which the cannabis gets a person high.
There has been no real work done on targeting cannabis using genetic modification and hybridization in the same way we controlled for potency but in order to produce for example a strain specifically used for Alzheimer's. Rather people who have Alzheimer's report anecdotally when they experiences positive effects from a product or strain. Even the FDA referenced social media posts recently in 2024 to find colloquially accepted and anecdotally reported medicinal benefits/ successful Therapeutic application of cannabis.
After they found that Hippies Disappointment by The Stanley Brothers caused a quelling of seizure activity in Children suffering severe neurological abnormalities like Dravets Stndrome and they used that to create the only pharmaceutical made to date derived directly from cannabis that they would do more towards uncovering the other miraculous applications of cannabis.
They also know that their synthetic pharmaceuticals marketed as far back as 1987 like Dronnibinol (Marinol) and Cassameat. So really by lessening restrictions on study of CBD dominant low THC cannabis they're not risking much because they've been doing these THC, CBD, and other cannabinoid derivations for decades themselves. Yet they still have not either supported a company to do so or themselves pursue a medicinal cannabis strain specifically oriented to treat a particular condition.
Cannabis today is as medicinal as the strain itself is inherently therapeutic for the individual using it. This varies wildly from phenotype to phenotype and even varies wildly for example between sativa vs sativa. Two Sativas of 60/40 sativa lean can have completely different experiential profiles. This is easily exemplified is.comoaring a 60/40 hybrid that is expressively dominant (not necessarily dominant overall) meaning it is the face of the sativa leaning characteristic of that terpene profile is Terpinolene.
Comparatively ocimene is another characteristic Terpene of sativa that isn't necessarily dominant overall but is expressively dominant of sativa characteristic, specifically carrying from terpinolene containing Sativas in that ocimene Sativas are typically of south American descent and terpinolene of Asiatic decent.
This isn't even bring into the equation the extensive intensification of psychoactivity due to the effects of hybridization and the fact Myrcene is present as dominant 50% of the time the fact is we have now a market highly dominated By Myrcene dominant profiles, this has intensified the psychoactivity in many instances and in other instances depending on how myrcene appears in the profile and what type of beta Caryophyllene is present has increased sedative effects of the beta Caryophyllene, even for example in a Sativa with Beta Caryophyllene like Blue Dream.
My protocol is helping at least Me.and those who see it and taken it seriously enough to understand it understand the still largely unknown synergistic benefits of cannabis in the market today is a huge opportunity for people to learn and be the people who figure out the deep secrets of cannabis the FDA IMO knows is present in cannabis. by understanding how the strains vary and understanding this through the Terpenes and cannabinoids, I am able to begin associating patterns and expression of certain compounds either alone at a particular level for example or paired together not only indicate this experience or that but with enough data can aid me in correlating the experiential effect to the strain most likely making that happen or strains, however it may be. Taking that information one could more easily attempt.to grow cannabis which is specifically oriented to address one type of condition for another.
I don't mean using the potency of THC for pain Management as this is a well known and IMO one of the more understood aspects of cannabis that more Than potency causes pain reduction. We now also know though that synergistic implications play a role in that analgesia as well because the anti inflammatory benefits of CBD particularly paired at desirable levels of THC produce better analgesia than just amplifying the THC potency. I think it would also be interesting to see the effect of Myrcene on pain given that increasing it at certain ranges causes heavy CB1 activity, but it heavily supported by evidence indicating analgesic applications.
A lab study of lab rats that were injected intra peritoneally and subcutaneously were shown to exhibit non reward seeking pathway analgesia on par with prescription opiates, and against, it did so using a novel pathway which didn't cause the addictive reward seeking behavior seen in morphine and oxycodone for example. So given that sort of implicit contraindication, it would be interesting to see the parabola for the data of Myrcene increasing and how it effects pain management vs increases psychoactivity. At a certain point the psychoactive intensity for.many like myself becomes overwhelming and makes the experience unpleasant.
There is a lot of possibility in the way I have laid out Terpological Protocol specifically. And I have laid it out intentionally as a work in progress always evolving with new knowledge, undefined end date longitudinal anecdotally supported experiment to create a protocol to better understand the cannabis today and use that to create the cannabis of tommarow as corny as it sounds.
The cannabis of today is focused on potency, even the companies focused ON Terpenes are still all about how potent the cannabis is. And my hypotheses about the illicit market leaning toward sativa because of people preferences and dealers meeting those demands can be evidenced in people avoiding lower THC and Indica smelling cannabis.
Some beautiful cannabis like Buckeye Purple is absolutely totally purple no green at all nice sparkling crystals but is between 10-15% and sold terribly at Grow West here in Western Maryland and i cant imagine it sold well elsewhere. I enjoyed and people who understand weed more deeply than potency enjoyed it, like purple Obeah. Also very low THC compared to High Test only at around 15% but is dominant in linalool with a crazily unique floral PUNGENCY. But people miss these jewels focusing on only getting as blasted as possible as quickly as possible, the chazzed banger crowd.
So that's that . . . .. hope it opens your mind up a little and make ya Wana dig into my content.
Don't break the law while your breaking the law
Advoc8 always Meduc8 Daily

I’m a 43 year old male living in San Francisco and was diagnosed back in high school with mitral valve prolapse (which they discovered via a really faint heart murmur). At the time, it was decided to wait and see and eventually the murmur went away. As I changed doctors over the years, no one seemed concerned.
Over the past few years, I’ve been noticing that my tiredness has increased and I was getting increasingly winded walking upstairs but attributed that to getting older (and to recently diagnosed sleep apnea). During my physical back in August, my primary care physician was listening to my heart and said “woah”. He gave me his stethoscope and let me listen and sure enough, there was a significant murmur that sounded like “thump, squish, thump” surely indicating that my prolapse had re-emerged with a vengeance.
After a few tests (including an EKG, Echocardiogram, and a Transesophageal echocardiogram), I was confirmed to have myxomatous degeneration (FED) with severe mitral regurgitation with anteriorly directed eccentric jet. Essentially, because my mitral valve was enlarged, blood was shooting back up in the wrong chamber of my heart instead of into my body causing it to have to work harder.
I met with my cardiologist and he explained that it wasn’t emergent meaning I wouldn’t have to get it addressed immediately but that I would need to eventually and the younger I am, the faster I’ll rebound. I decided to wait a couple months to get past the holidays while we did some more tests to confirm if my valve and repairable and get on the surgeon’s schedule.
Finding a surgeon
My cardiac doctor referred me to the chief of cardiac surgery for Kaiser in San Francisco and we had a consultation with him. He was super nice and informative but explained that he only did a method with a full sternotomy (meaning, they crack open your breastplate and go in from the top). I had done some research and knew there were alternative approaches that were minimally invasive and had to ask if that was something he supported. He said no but he has a colleague that does that and if I’d like to consult with him, he’s happy to help set that up. He talked through what he saw as the advantages to his method and downplayed the differences between the “normal” method and the minimally invasive method but ultimately, I was leaning towards a minimally invasive. This was a big lesson to me – you really need to do your own research (which isn’t easy!) to at least understand your options. Doctors will almost always defer to what they feel most comfortable with because that’s how they are trained (which totally makes sense if you think about it – you want someone who trains on fixing what you specifically have the more experience they have in it, the higher chance of success). I think overall though, I was a bit disappointed that they pigeon holed me into a method without at least explaining the options.
After my consultation with the second surgeon, it felt right on all levels and he not only specialized in mitral valve repairs (which is what I needed), he also could do either method and felt equally comfortable with both. He said that many doctors do around 10 of these a year and he does 2 a week which, while maybe not 100% accurate, sounded great. I found that it’s really hard to get good solid information on hospitals and doctors with respect to how they rank in specific surgeries but was able to at least gain minimal confidence that Kaiser here in the Bay Area had a solid program.
So I went through a couple extra tests to confirm I was a good candidate for the minimally invasive port approach to repair my mitral valve (essentially a couple of scans). Everything was set for my surgery in early Feb.
As we were leading up to my surgery, I found my level of anxiety increasing. First, there was a question of getting things set up at work to cover my absence. I have a somewhat stressful job (probably because I mostly make it that) but was trying to balance taking enough time off to recover but also not be gone for too long. I came to the conclusion that without knowing what recovery would look like, I would take a recommended 12 weeks off (my company has a generous medical leave policy) so it was nice to know that I would have a long runway to recover.
Second, there was the unknown of what recovery would look like. What would it feel like when I woke up? How much pain would I be in? How long would that last? Etc. There weren’t a ton of resources that provided the level of detail I was interested in to feel like I could have an idea of what recovery would look like and that was a bit scary for me.
Oddly, I wasn’t super anxious with the surgery itself. I felt pretty comfortable with my surgeon and knew that I just had to trust that they knew what they were doing. It was more of the unknown following surgery that gave me pause. Of course, you have moments where you think about things going wrong and not waking up after being put out but those were minimal in my overall emotional process. As the surgery date got closer, evenings is where my anxiety peaked but as the day approached, I was just ready to get to the other side.
Day of Surgery:
My call time for surgery was at 5am. After going through some quick things during the admitting process, my husband and I went up to the cardiac surgery floor and waited to get check in. Once there, a nurse set me up with an IV catheter (which would get heavy use over the next week) and asked me to change in to my scrubs. They took a full inventory of the belongings I brought with me but on advice of others, I didn’t much of anything except my clothes and my phone. Luckily, I lived locally and would have visitors pretty regularly so if I needed anything, they could bring it. They did advise me to bring my CPAP machine which I did (but in practice, I ended up not using it because most nights I slept a bit elevated which helped; well, that and the drugs).
After I changed into scrubs, they put in in a bed with a warm blanket and wheeled me to a pre-op room. One of the nurses asked me if I had any questions while another shaved all my body hair around the surgical sites. Note, if you are a guy, I’d recommend trimming your arm hair down because you’ll get a lot of blood draws and IV so when they pull off the tape, it can be a bit painful and they didn’t shave my arms because that wasn’t near an actual surgical site).
Then the surgeon came over and asked how I was doing. He also asked if that he can’t repair my valve and needed to replace it, what I wanted to replace it with (a biological or mechanical valve). I wasn’t expecting to make that decision there and felt like I had to make a snap decision but in our original consult, I had asked about what happens if they can’t repair and they talked through the options. For me, they said that a biological valve would calcify quickly and because I was young, it would almost certainly mean that I’d need to get the surgery again within 5-10 years whereas a mechanical valve would last me a really long time. So in my head, I knew a mechanical valve was the right choice for me and I confirmed that with the surgeon when he asked me that morning. But! I encourage you to understand all the permutations of what can happen and the pros and cons of each. Talk to your surgeon beforehand to get comfortable with the possible outcomes so you aren’t making decisions right before going into surgery.
They made me say goodbye to my husband and wheeled me into the OR which was quite the site (it was my first surgery). They transferred me to the table and my anesthesiologist was there and started making small talk with me. I remember two sentences before I was out.
I would later learn the surgery went pretty quickly by most standards – I was out around 7:30 and everything was done by 10:30ish and the surgeon called my family around 11:15 which is when I was transferred up to the ICU.
My next memory was a few doctors over me telling me it was time to wake up. My brain was sort of with it but it didn’t feel connected to my body. As I was coming out of my anesthesia, I remember my mouth being really dry and feeling the breathing tube. They were trying to get me to breathe on my own and they would do so by turning down the oxygen in my breathing tube. I’m semi conscious at best and recall the machines alerting when I wouldn’t be breathing and they would all tell me to breathe and I’d start breathing again. I think they had to turn up the oxygen once in that process so it took two attempts to get me breathing again.
I remember my mouth being so dry and uncomfortable and the machine alerts would always snap me back to reality. By 3:30, my tube was able to come out. When they were ready to take it out, I remember them saying to cough which, after heart surgery, is no easy feat. I can’t say it was painful when they pulled it out but it was definitely uncomfortable and it felt like there were a lot of stuff attached to the tube. I was able to give the meakest cough but they eventually got it all out on one long pull.
From there I was gaining more and more consciousness and was aware of my surroundings a bit more although I couldn’t really talk or do much with my body other than point or give a thumbs up.
As I regained more consciousness, I was able to see what all I had coming out of me. I had two lines – one on the right side of my neck and another on my lower left side of my neck. I also had a small tube coming out of my right peck and a larger chest tube coming out of my right peck that would be with me for a while and was meant to drain fluid in my chest. I had about a 3 inch scar under my right peck (which is where the port was that they did the surgery) and in my groin which is where they put me on bypass. I also had a catheter to help drain my bladder.
They tried to get me out of the ICU as quickly as possible but all in all I was there for about 24 hours so I spent the night. It was nice because you essentially have a dedicated nurse who constantly helping to manage your pain (although you are still a bit out of it). I had a challenge with being nauseous as I was coming off the anesthesia and with the pain meds so even though they pumped me full of anti nausea medicine, it was a constant balance of managing either my pain or my nausea. Because of the nausea, they wouldn’t really give me water because they didn’t want anything in my system to throw up but they would occasionally give me ice chips which were godsends. I did end up throwing up a little bit at one point but it was very minimal. I think my body knew it would be painful to have anything substantive come up so it was a little spit up. But I always kept the tub close.
Before they could move to the regular ward, they removed the smaller tube in my breast (which wasn’t painful because they ablated the nerves in my surgical site – which I recommend as it apparently helps minimize a lot of the pain). I think they also removed the lines in my neck (but those could have been removed before I woke up – I can’t recall).
They also make you sit up into a chair and then also go for a walk before they move you. It felt like a herculean mental effort to transfer to a chair but when I did it, with the assistance for the nurses, it was easier than I thought. The walk was a bit tougher for me. I was able to walk ok but I started to tremor and shake uncontrollably (like I was cold; but I wasn’t cold). I’d come to learn those are called “pain tremors” or “pain shivers”. I wasn’t actually in that much pain but they said that your body is in so much stress that it doesn’t know how to react. It got so uncontrollable they had to lay me back down and give me more pain meds. It also has to do with my body purging the remaining the anesthesia and sounded like the pain meds were interacting with that.
Despite that, they were ready to move me to my own room on the hospital floor and there was an aggressive nurse who couldn’t get me out of the ICU fast enough.
Regular recovery.
24 hours after arriving in the ICU, I was being transported by wheelchair to my normal hospital room where I would spend the next few days. Overall, I expected to be in the hospital 4-7 days hoping that my relative youth would put me on the early end of that.
Once I arrived in my regular room, it was a pretty standard routine of being woken up at 6:30am, getting my blood drawn for labs, and a nurse coming in every 4 hours to check my vitals to give me medication. They would tell me what medications they were giving me but honestly, there were so many that it was hard to keep track. There were checks on my pain and if I ever said I was in pain, they were pretty open with pain meds (Oxycodone and Tylenol) but they weren’t always volunteering the Oxy which I think is a good thing. You need to be honest and proactive about telling them your pain level but also be mindful that you’ll eventually need to wean off of them (and by eventually I mean after you leave the hospital).
Sitting in the hospital room is sort of miserable (to no one’s surprise). I was able to get to the bathroom on my own (and it certainly got easier each day). I almost always had pee in a container so they could measure my output. I had a really tough time peeing early on and they were going to put the catheter back into my bladder but I definitely didn’t want that so I made sure I peed and once I got through the initial hurdle, it got a little better.
The first time I tried to walk, I got the same pain tremors again so I had to cut my walk short but after that, it settled and I was able to walk fairly regularly. They told me walking is the most important thing I could have done and I was surprised the nurses didn’t force it more but given I had visitors to help me and I was tired of sitting in the room, I tried to walk around the floor 2-3 times per day.
Each day someone from the surgical team would pop in and ask how I was doing. One of the bigger pains (literally and metaphorically) is that they keep your chest tube in for quite a while to help drain fluid in your lungs. The nurses measure every few hours and it’s the last thing (aside from your IV) that they pull out of you. It’s pretty uncomfortable and leads to a dull pain in your chest and shoulder. The pain meds help but it makes it difficult to get truly comfortable. In addition, you have a plastic box with tubes that you have to carry around anywhere you go while it's in. I believe they took it out on Friday for me so it’s with you for a couple days (to ensure the drainage is winding down).
One thing I wasn’t aware of is that they were going to put me on blood thinners for three months following the surgery. Because I was getting a repair vs. a replacement, I didn’t think I’d need blood thinners (you’re on them permanently with a replacement as I understand). Blood thinners are high maintenance – you have to watch what you eat and drink and they require multiple blood samples to make sure you stabilize in the right range of “thinness”. Luckily, my hospital covers traveling nurses to visit you at home to check for you but that’ll happen at least twice a week for a few weeks until you settle. But all things considered, I can manage that .
Overall, I was in the hospital for 5 full days, including my surgery. I went in on a Tuesday and was able to go home on Sunday which I was told is pretty quick. There was a possibility that I would have been able to go home on Saturday but they were putting me on blood thinners and my levels weren’t right so they wanted to get that closer to normal. When I was able to go home was a complete mystery to me and everyone I asked would give a different (or non) answer. I’d learn that the on call doctor helps make that decision so when they come around once a day, ask them questions on the criteria for going home as they are best suited to help you know).
Home
About 1 week out from the surgery I was home about 4 days and overall I’d say my recovery was going pretty well. It was hardest early on but each day gets better as your body stabilizes. I hadn’t had any issues with walking (I was able to take a 30 min / 1.3 mile walk my second day home) but I definitely have to take a slower pace and have some breaks.
You get sent home with some pain meds to help manage but not quite as powerful as what you had in the hospital . I’ve found that most of my pain is in my breast area near the surgical sites. It’s certainly manageable but feels both tight and pinchy at the same time. As I mentioned, they ablated my nerves around the site which I think substantially helps minimize pain there but you can certainly feel the pain underneath the numbness and the mobility in my right arm is much more limited and I’m much more sensitive to it.
Sleeping was challenging at first but I made sure to have a healthy dose of pain meds before bed so I could sleep easier and that’s helped a lot.
I’m about a month out from surgery as of this week and I’d still say it’s going well. One of the frustrating parts of the process is that they don’t really give you any granularity as to what your recovery will look like (and anything they give you seems geared towards a full sternotomy and not a minimally invasive approach). Of course recovery is different for everyone but it would have been helpful to get a sense of the average recovery.
I’m pretty mobile and able to go where I want and walk decent amounts of time. I found that the pain was pretty manageable during the day but at night, it would escalate. I took some sort of pain meds before I went to bed to make sure I didn’t have flare ups at night but I’ve mostly stopped those within the past week. The biggest annoyance I have (and it can get significant) is a fairly intense burning sensation I have around my shoulder, back, and arm. It’s not constant but it flares up after a lot of movement (or a day of moving) and it’s like having really bad sunburn under your skin which makes it hard to concentrate or do a whole lot. I think it’s caused by my nerves growing back (the sensitivity is where I have feeling on one side and numbness on the other). My visiting nurse also tends to think I have some muscle inflammation. I know that the nerves take 4 months to a year to grow back so I’m hoping the burning doesn’t last that long but we shall see.
Now that I’m far enough out, I feel like I’m able to start living my life pretty normally (except going back to work – I probably could go back to work if I really needed to but that would be pushing it). I can’t say that I feel an differently after the surgery. I’m guessing that’s best left to a time when I’m fully, fully recovered (back at work, etc.). I am still a bit winded walking up stairs though.
It’s really strange to process everything that happened to me. Oddly, I get flashes of guilt that pop up, almost akin to survivor’s guilt which is really weird (and somewhat baffling) but thankfully they are fleeting. The doctor said that going on bypass messes up your endocrine system so you get all sorts of feelings and emotions. I can’t say I’ve experienced the crying and depression that others said are common (although depression and I are old friends) so that’s been good. There’s a large part of me that wants to go back to doing everything normally but I know I still have to take it easy – I’m learning that I’m not great and allowing myself to fully heal.
I hope this helps a little to demystify the process for some folks.

They all seem to effect me differently in how long they last and how potent they are. Hydromorphone was the least effective for me out of the 3 which isn’t supposed to be the case. So I am just wondering at your experiences in differentiating the 3. As well as if different companies of the same drug made a difference maybe because of fillers. Thank you
I would say equivalent for those 3 in my experience for the same intial effect was 10 oxy, 10 hydro and 5-6 morphone.
Morphone lasted the least amount of time with almost the same initial effect as oxy, oxy had the strongest intial effect while lasting medium, hydro had a smaller intial effect but lasted a bit longer for me.
My individual issue is hEDS and Crps type 2 from damage to the long thoracic nerve and lattisimus Dorsi. My main problem is the thermoregulation/parasympathetic issue that causes body spasms/burning/throbbing at the same time or it’s just pain without that being very tight and achy with electric Like shock feelings. Body feels one of the 2 ways depending on several factors.

After stopping chemo in August due to partial response and extreme weakness/no quality of life, my mom’s doctor recommended in the Nee Year we move her into Hospice. Literally 2 days later, we’re in the hospital due to a bowel blockage (she has an ileostomy). After reviewing the CT scan results, the doctors are saying the blockage isn’t physical, and is instead caused by her bowel slowing down due to pain management (oxycodone). This wasn’t a scenario we were prepared for or heard of. The hospital is getting us in touch with general surgery regarding options, but recommended we continue comfort care vs considering surgery. This option likely means she may pass in a few days due to narcotics causing respiratory decline.
I’m not sure if I have a point to the post outside of - has anyone experienced their loved one passing due to this situation? A bowel obstruction with an ileostomy and no “physical” obstruction, caused by narcotics/pain management, which then causes the downward spiral?

The following summary was created with the Recall Browser extension, you can save this summary to your own knowledge base or create your own here.

Dr. Sean Mackey (00:00:00)

• Dr. Sean Mackey) is a medical doctor and a PhD who is the chief of the division of pain medicine and a professor of both anesthesiology and neurology at Stanford University School of Medicine.
• Pain is a complex and subjective experience that serves to keep us away from injury or harm.
• Pain is both a sensory and an emotional experience and is incredibly individual.
• Chronic pain affects about 100 million Americans and costs about half a trillion dollars a year in medical expenses.

Pain, Unique Experiences, Chronic Pain (00:06:13)

• Pain is a complex and subjective experience that serves a crucial role in keeping us away from injury or harm.
• Pain is both a sensory and an emotional experience.
• Pain is incredibly individual and can vary significantly from person to person.
• Chronic pain is a persistent pain that lasts for more than 3 months and can have a significant impact on a person's life.
• Chronic pain affects about 100 million Americans and costs about half a trillion dollars a year in medical expenses.

Pain & the Brain (00:13:05)

• Pain is not simply a physical sensation, but also involves emotional and cognitive components.
• There is no single "pain center" in the brain, but rather a distributed network of brain regions that contribute to the experience of pain.
• Brain-based biomarkers can be used to identify common brain networks that represent the experience of pain.

Treating Pain, Medications: NSAIDs & Analgesics (00:16:15)

• NSAIDs (nonsteroidal anti-inflammatory drugs) like ibuprofen and naproxen are not technically analgesics (painkillers).
• NSAIDs reduce inflammation and sensitization in the injured area and the spinal cord.
• Opioids are analgesics that can potentially cause harm if taken in high doses.
• The threshold for treating pain should be based on its impact on quality of life and daily activities.
• Common over-the-counter NSAIDs include ibuprofen, naproxen, and acetaminophen (Tylenol).
• Aspirin is not considered an NSAID but has anti-inflammatory and anti-hyperalgesic effects.
• It's important to balance pain relief with the potential delay in healing caused by NSAIDs.
• Individual variability exists in the effectiveness of NSAIDs, so rotating them can be beneficial.
• NSAIDs should be taken with food and plenty of fluids to minimize side effects.
• Talk to a doctor before taking NSAIDs if you have any underlying health conditions.

Inflammation, Pain & Recovery; Ibuprofen, Naprosyn & Aspirin (00:22:46)

• Prostaglandins are one of the main ways the immune system responds to injury and creates inflammation.
• Inflammation sensitizes the injured area, making it more sensitive.
• NSAIDs can help with pain and function but may delay the healing process.
• Balancing pain relief with healing is crucial, and the lowest effective dose of NSAIDs should be used.
• NSAIDs should be taken with food and plenty of fluids to minimize side effects.
• Individual variability exists in the effectiveness of NSAIDs, so rotating them can be beneficial.
• Aspirin in low doses (81 mg) acts as an antiplatelet agent and may benefit heart health.
• Higher doses of aspirin (325 mg) have anti-inflammatory effects similar to NSAIDs.

Caffeine, NSAIDs, Tylenol (00:30:19)

• Caffeine can potentiate the analgesic response and be effective for headaches and migraines.
• Caffeine can cause stomach irritation, so it's best to take NSAIDs with food.
• Tylenol (acetaminophen) is safe on the stomach but should not exceed 4,000 milligrams per day.
• COX-2 inhibitors like celecoxib are less irritating to the stomach but require a prescription.

Pain & Touch, Gate Control Theory (00:32:34)

• Gate control theory of pain: rubbing, shaking, or running water on an injured area activates touch fibers that send signals to the spinal cord, inhibiting pain signals.
• Kissing an injured area can reduce pain due to the activation of touch fibers and positive emotional salience.
• Transcutaneous electrical nerve stimulation (TENS) devices use electrical stimulation to activate touch fibers and reduce pain.
• The mechanism of action for mechanical interventions like rubbing or shaking occurs in the spinal cord, not at the site of the injury.

Pain Threshold, Gender (00:38:56)

• Pain threshold is the stimulus intensity that results in the onset of pain.
• Men generally have higher pain thresholds to heat stimuli than women, but there is significant individual variability within both genders.
• The difference in pain thresholds between men and women is often overstated due to the focus on group averages rather than individual variability.

Pain in Children, Pain Modulation (Pain Inhibits Pain) (00:44:53)

• Pain perception is influenced by beliefs, expectations, anxiety, and early life experiences.
• Pain inhibits pain, a phenomenon called conditioned pain modulation (CPM) or diffuse noxious inhibitory control (DNIC).
• CPM involves activating a brainstem circuit that sends descending pathways to the spinal cord, inhibiting pain.
• CPM may explain why some parents' reactions to their children's pain, such as smacking them, might inadvertently reduce the pain.
• However, ignoring a child's pain or sending the wrong message can have negative consequences.

Tool: Heat, Cold & Pain; Changing Pain Threshold (00:53:20)

• Cold reduces inflammation and slows nerve firing, reducing pain.
• Heat increases blood flow, relaxes muscles, and feels good.
• Individual variability exists in preferences for heat or cold.
• Cold should be used with caution to avoid frostbite.
• Numbing an area with cold can be effective in reducing pain.
• Regular exposure to safe pain, such as deliberate cold exposure, can raise pain thresholds through habituation.
• Cross-modality changes in pain thresholds are possible, but more research is needed.
• Cognitive control, such as avoiding looking like a wuss in front of an attractive person, can temporarily raise pain thresholds.
• Exercise can also increase pain thresholds over time by building inhibitory tone.

Tools: Psychology, Mindfulness-Based Stress Reduction, Catastrophizing (01:00:54)

• Mindfulness-based interventions lack specificity, granularity, and mechanistic logic.
• Attentional distraction engages specific brain networks and can reduce pain, but it may not be effective at night when people are trying to sleep.
• Non-judgmental acceptance of pain has been shown to be effective in reducing pain.
• Cognitive reframing about the meaning of pain can be helpful in managing pain.
• Catastrophizing pain can worsen the experience of pain.

Tool: Hurt vs. Harmed?, Chronic Pain (01:08:29)

• The distinction between hurt and harm is critical in pain management.
• Pain that is not causing harm does not need to be avoided.
• Chronic pain conditions are often complex and require more than just education.
• It is important to seek medical attention for pain that is getting worse or may be a sign of a serious medical condition.

Emotional Pain, Anger, Medication (01:12:38)

• Dr. Mackey does not distinguish between psychological and physical pain, instead treating all pain as pain.
• Pain is a sensory and emotional experience, so treating the whole person is important.
• Anger, especially anger in (simmering, self-contained), is associated with worse pain.
• Medications used for pain include antidepressants, anti-seizure medications, and anti-arrhythmia medications.
• A holistic approach that addresses the whole person, including psychological, physical, and social factors, is most effective in treating pain.

Tool: Nutrition & Pain; Food Sensitization & Elimination Diets (01:20:43)

• Nutrition plays a critical role in pain management.
• Identifying and avoiding trigger foods can significantly reduce pain.
• Elimination diets can help identify trigger foods.
• Food sensitization can occur after a gut infection, leading to chronic pain.
• Food sensitivity is a growing public health issue.
• Research is needed to explore how foods impact local and systemic pain responses.

Visceral Pain; Back, Chest & Abdominal Pain (01:28:45)

• Visceral pain is different from somatic pain.
• Visceral pain is more diffuse and has larger receptive fields compared to somatic pain.
• Visceral pain can cause referred pain to other areas of the body due to visceral-somatic convergence in the spinal cord.
• Examples of referred pain from visceral organs include:
  • Pelvic pain causing lower back pain.
  • Heart attack causing pain radiating down the left arm.
  • Abdominal surgery causing shoulder pain.

Referenced Pain, Neuropathic Pain; Stress, Memory & Psychological Pain (01:34:02)

• Referred pain is pain that is felt in a different location from the source of the injury or damage.
• Neuropathic pain is pain caused by damage to a peripheral nerve or the central nervous system.
• Neuropathic pain can have different qualities and characteristics, such as shooting, stabbing, shock-like, or burning pain.
• Stress can contribute to pain by impacting the end organ or tissue.
• Chronic stress can lead to chronic pain.
• Early life events and injuries can sensitize individuals to future pain vulnerability.
• Pain can be associated with memory, and stress can trigger pain in areas previously injured or affected.

Romantic Love & Pain, Addiction (01:40:23)

• A study explored the intersection of romantic love and pain perception.
• The study found that being in love significantly reduced pain, with a correlation between the intensity of love and the level of pain relief.
• The brain circuits involved in romantic love and addiction were found to be similar, suggesting that the early phase of a romantic relationship engages the same reward circuitry as addiction.
• Attentional distraction was also found to be effective in reducing pain, but it worked on different brain circuits compared to love.
• The strength of a romantic relationship a year later was found to be correlated with the love-induced analgesia and brain activity in the caudate nucleus and insula.

Endogenous & Exogenous Opioids, Morphine (01:48:57)

• Endogenous opioids are natural painkillers produced by the body.
• Higher endogenous opioid levels may lead to less emotional reactivity.
• Morphine was the first exogenous opioid derived from the poppy, and medicinal chemists have since created variations of morphine and purely synthetic compounds like oxycodone.
• The use of poppies for pain relief has a long history.
• Opioids can positively transform people's lives by relieving suffering and improving quality of life, but they can also destroy lives due to addiction.
• Opioids should be treated as a tool to be used in certain circumstances and not as a first-line agent.
• The opioid crisis is a complex issue that requires a nuanced approach, considering both the benefits and risks of these drugs.

Opioid Crisis, Prescribing Physicians (01:53:17)

• Opioid crisis is often attributed to overprescribing of opioids.
• Opioids can be beneficial for pain management when used appropriately.
• Overprescribing occurred due to lack of education among physicians about pain management and alternative treatments.
• Some physicians overprescribed due to marketing messages and lack of alternatives.
• A small group of physicians engaged in illegal activities related to opioid prescribing.
• Fear of legal consequences led many physicians to abruptly stop prescribing opioids, leading patients to seek illicit sources.
• Current opioid crisis is driven by illicit fentanyl.

Opioids & Fentanyl; Morphine, Oxycontin, Methadone (02:02:21)

• Fentanyl in street drugs is the primary cause of opioid-related deaths, not fentanyl prescribed by physicians.
• Compassionate opioid weaning can be successful for patients who want to reduce their opioid use.
• Commonly used opioids include morphine, oxycodone, fentanyl, Tramadol, hydromorphone, and methadone.
• Opioids work by binding to opioid receptors in the periphery, spinal cord, and brain.
• Benzodiazepines are rarely used for pain relief, except in specific cases where anxiety contributes to pain.

Kratom, Cannabis, CBD & Pain; Drug Schedules (02:07:44)

• Kratom has opioid-like properties and is available over the counter.
• Some people find kratom helpful in reducing opioid use, but its safety and efficacy need further research.
• Cannabis) has been shown to reduce neuropathic pain in small studies, but large-scale studies show mixed results.
• Cannabis is not a uniform substance, and THC to CBD ratios and doses vary.
• Cannabis remains a Schedule One drug, which hinders research.
• Rescheduling cannabis) as a Schedule Two drug could facilitate research and regulation.

Pain Management Therapies, Acupuncture (02:18:12)

• Acupuncture is one of six broad categories of therapies for chronic pain.
• Acupuncture has been shown to activate peripheral adenosine receptors and engage different brain regions compared to sham acupuncture.
• The exact mechanism of acupuncture's pain-relieving effects is still not fully understood.
• Acupuncture can be effective for certain types of pain, but it's important to find a qualified acupuncturist.

Finding Reliable Physicians, Acupuncturist (02:22:19)

• To find reliable physicians or acupuncturists, seek recommendations from trusted sources such as primary care doctors or colleagues.
• Be cautious of inflated patient ratings, as they can be manipulated.
• Consider using an independent platform that provides genuine patient experiences and ratings to find the best healthcare providers.

Chiropractic & Pain Treatment; Chronic Pain & Activity (02:26:36)

• Chiropractic and acupuncture are different professions with distinct approaches to pain management.
• Acupuncture has shown some effectiveness in certain patients and circumstances, and is now covered by Medicare for back pain in patients over 65.
• Chiropractic care has mixed evidence for its effectiveness in treating low back pain.
• High-velocity chiropractic manipulations may pose a risk of vertebral artery dissection, especially in the neck.
• Chronic pain often leads to reduced activity and deconditioning.
• Physical therapy and rehabilitation are crucial in addressing chronic pain by helping patients safely engage in activity and improving biomechanical issues.

Physical Therapy & Chronic Pain; Tool: Pacing (02:31:35)

• Physical therapists play a vital role in chronic pain management by providing rehabilitation, goal setting, and education on body mechanics.
• Pacing is a critical tool in managing chronic pain, involving setting small, incremental goals for physical activity.
• Avoid overdoing activities on good days and recognize that bad days are normal.
• Consistency in pacing helps prevent the negative reinforcement cycle of pain and inactivity.
• Effective pain management involves collaboration between different healthcare providers, including primary care doctors, pain psychologists, and physical therapists.

Supplements: Acetyl-L-Carnitine, Alpha Lipoic Acid, Vitamin C, Creatine (02:36:35)

• Acetyl-L-Carnitine:
  • Improves mitochondrial health.
  • Studied in the Sydney trials for diabetic neuropathy.
  • Shown to improve nerve conduction velocity.
• Alpha Lipoic Acid:
  • Has antioxidant and calcium channel modulating properties.
  • May benefit neuropathic pain.
  • Can cause stomach upset.
• Vitamin C:
  • Prophylactic use may reduce the likelihood of nerve pain after surgery.
• Fish Oil (Omega-3s):
  • Beneficial for chronic pain.
  • May reduce the viscosity of the blood, increasing the risk of bleeding.
• Creatine:
  • Shown some benefit in fibromyalgia and other conditions in small studies.

Pain Management, Cognitive Behavioral Therapy (CBT), Biofeedback (02:42:25)

• Pain psychology and behavioral therapy can help with maladaptive coping and thought processes related to pain.
• CBT involves recognizing unhelpful thoughts and patterns, interrupting them, and teaching goal setting, pacing, and relaxation techniques.
• Biofeedback provides closed-loop feedback to help individuals learn to calm down the sympathetic nervous system.
• Mindfulness-based stress reduction and acceptance and commitment therapy are other tools used by pain psychologists.
• Empowered relief is a brief intervention developed by Dr. Mackey's partner, Beth, that condenses 8 weeks of CBT into 2 hours.
• Digital platforms and online treatments are being developed to make pain management tools more accessible.

National Pain Strategy, National Pain Care Act (02:48:32)

• Dr. Mackey) co-led the development of the National Pain Strategy, a strategic plan for transforming pain assessment, care, education, and communication.
• Full implementation of the National Pain Strategy would make a significant difference in the lives of people living with pain.
• Concerned citizens can help advance the implementation of the National Pain Strategy by contacting their representatives and writing letters.
• Dr. Mackey's nonprofit organization, Pain USA, aims to advance the implementation of the National Pain Strategy and use high-quality data to inform pain care and treatments.

The following summary was created with the Recall Browser extension, you can save this summary to your own knowledge base or create your own here.

Dr. Sean Mackey (00:00:00)

• Dr. Sean Mackey) is a medical doctor and a PhD who is the chief of the division of pain medicine and a professor of both anesthesiology and neurology at Stanford University School of Medicine.
• Pain is a complex and subjective experience that serves to keep us away from injury or harm.
• Pain is both a sensory and an emotional experience and is incredibly individual.
• Chronic pain affects about 100 million Americans and costs about half a trillion dollars a year in medical expenses.

Pain, Unique Experiences, Chronic Pain (00:06:13)

• Pain is a complex and subjective experience that serves a crucial role in keeping us away from injury or harm.
• Pain is both a sensory and an emotional experience.
• Pain is incredibly individual and can vary significantly from person to person.
• Chronic pain is a persistent pain that lasts for more than 3 months and can have a significant impact on a person's life.
• Chronic pain affects about 100 million Americans and costs about half a trillion dollars a year in medical expenses.

Pain & the Brain (00:13:05)

• Pain is not simply a physical sensation, but also involves emotional and cognitive components.
• There is no single "pain center" in the brain, but rather a distributed network of brain regions that contribute to the experience of pain.
• Brain-based biomarkers can be used to identify common brain networks that represent the experience of pain.

Treating Pain, Medications: NSAIDs & Analgesics (00:16:15)

• NSAIDs (nonsteroidal anti-inflammatory drugs) like ibuprofen and naproxen are not technically analgesics (painkillers).
• NSAIDs reduce inflammation and sensitization in the injured area and the spinal cord.
• Opioids are analgesics that can potentially cause harm if taken in high doses.
• The threshold for treating pain should be based on its impact on quality of life and daily activities.
• Common over-the-counter NSAIDs include ibuprofen, naproxen, and acetaminophen (Tylenol).
• Aspirin is not considered an NSAID but has anti-inflammatory and anti-hyperalgesic effects.
• It's important to balance pain relief with the potential delay in healing caused by NSAIDs.
• Individual variability exists in the effectiveness of NSAIDs, so rotating them can be beneficial.
• NSAIDs should be taken with food and plenty of fluids to minimize side effects.
• Talk to a doctor before taking NSAIDs if you have any underlying health conditions.

Inflammation, Pain & Recovery; Ibuprofen, Naprosyn & Aspirin (00:22:46)

• Prostaglandins are one of the main ways the immune system responds to injury and creates inflammation.
• Inflammation sensitizes the injured area, making it more sensitive.
• NSAIDs can help with pain and function but may delay the healing process.
• Balancing pain relief with healing is crucial, and the lowest effective dose of NSAIDs should be used.
• NSAIDs should be taken with food and plenty of fluids to minimize side effects.
• Individual variability exists in the effectiveness of NSAIDs, so rotating them can be beneficial.
• Aspirin in low doses (81 mg) acts as an antiplatelet agent and may benefit heart health.
• Higher doses of aspirin (325 mg) have anti-inflammatory effects similar to NSAIDs.

Caffeine, NSAIDs, Tylenol (00:30:19)

• Caffeine can potentiate the analgesic response and be effective for headaches and migraines.
• Caffeine can cause stomach irritation, so it's best to take NSAIDs with food.
• Tylenol (acetaminophen) is safe on the stomach but should not exceed 4,000 milligrams per day.
• COX-2 inhibitors like celecoxib are less irritating to the stomach but require a prescription.

Pain & Touch, Gate Control Theory (00:32:34)

• Gate control theory of pain: rubbing, shaking, or running water on an injured area activates touch fibers that send signals to the spinal cord, inhibiting pain signals.
• Kissing an injured area can reduce pain due to the activation of touch fibers and positive emotional salience.
• Transcutaneous electrical nerve stimulation (TENS) devices use electrical stimulation to activate touch fibers and reduce pain.
• The mechanism of action for mechanical interventions like rubbing or shaking occurs in the spinal cord, not at the site of the injury.

Pain Threshold, Gender (00:38:56)

• Pain threshold is the stimulus intensity that results in the onset of pain.
• Men generally have higher pain thresholds to heat stimuli than women, but there is significant individual variability within both genders.
• The difference in pain thresholds between men and women is often overstated due to the focus on group averages rather than individual variability.

Pain in Children, Pain Modulation (Pain Inhibits Pain) (00:44:53)

• Pain perception is influenced by beliefs, expectations, anxiety, and early life experiences.
• Pain inhibits pain, a phenomenon called conditioned pain modulation (CPM) or diffuse noxious inhibitory control (DNIC).
• CPM involves activating a brainstem circuit that sends descending pathways to the spinal cord, inhibiting pain.
• CPM may explain why some parents' reactions to their children's pain, such as smacking them, might inadvertently reduce the pain.
• However, ignoring a child's pain or sending the wrong message can have negative consequences.

Tool: Heat, Cold & Pain; Changing Pain Threshold (00:53:20)

• Cold reduces inflammation and slows nerve firing, reducing pain.
• Heat increases blood flow, relaxes muscles, and feels good.
• Individual variability exists in preferences for heat or cold.
• Cold should be used with caution to avoid frostbite.
• Numbing an area with cold can be effective in reducing pain.
• Regular exposure to safe pain, such as deliberate cold exposure, can raise pain thresholds through habituation.
• Cross-modality changes in pain thresholds are possible, but more research is needed.
• Cognitive control, such as avoiding looking like a wuss in front of an attractive person, can temporarily raise pain thresholds.
• Exercise can also increase pain thresholds over time by building inhibitory tone.

Tools: Psychology, Mindfulness-Based Stress Reduction, Catastrophizing (01:00:54)

• Mindfulness-based interventions lack specificity, granularity, and mechanistic logic.
• Attentional distraction engages specific brain networks and can reduce pain, but it may not be effective at night when people are trying to sleep.
• Non-judgmental acceptance of pain has been shown to be effective in reducing pain.
• Cognitive reframing about the meaning of pain can be helpful in managing pain.
• Catastrophizing pain can worsen the experience of pain.

Tool: Hurt vs. Harmed?, Chronic Pain (01:08:29)

• The distinction between hurt and harm is critical in pain management.
• Pain that is not causing harm does not need to be avoided.
• Chronic pain conditions are often complex and require more than just education.
• It is important to seek medical attention for pain that is getting worse or may be a sign of a serious medical condition.

Emotional Pain, Anger, Medication (01:12:38)

• Dr. Mackey does not distinguish between psychological and physical pain, instead treating all pain as pain.
• Pain is a sensory and emotional experience, so treating the whole person is important.
• Anger, especially anger in (simmering, self-contained), is associated with worse pain.
• Medications used for pain include antidepressants, anti-seizure medications, and anti-arrhythmia medications.
• A holistic approach that addresses the whole person, including psychological, physical, and social factors, is most effective in treating pain.

Tool: Nutrition & Pain; Food Sensitization & Elimination Diets (01:20:43)

• Nutrition plays a critical role in pain management.
• Identifying and avoiding trigger foods can significantly reduce pain.
• Elimination diets can help identify trigger foods.
• Food sensitization can occur after a gut infection, leading to chronic pain.
• Food sensitivity is a growing public health issue.
• Research is needed to explore how foods impact local and systemic pain responses.

Visceral Pain; Back, Chest & Abdominal Pain (01:28:45)

• Visceral pain is different from somatic pain.
• Visceral pain is more diffuse and has larger receptive fields compared to somatic pain.
• Visceral pain can cause referred pain to other areas of the body due to visceral-somatic convergence in the spinal cord.
• Examples of referred pain from visceral organs include:
  • Pelvic pain causing lower back pain.
  • Heart attack causing pain radiating down the left arm.
  • Abdominal surgery causing shoulder pain.

Referenced Pain, Neuropathic Pain; Stress, Memory & Psychological Pain (01:34:02)

• Referred pain is pain that is felt in a different location from the source of the injury or damage.
• Neuropathic pain is pain caused by damage to a peripheral nerve or the central nervous system.
• Neuropathic pain can have different qualities and characteristics, such as shooting, stabbing, shock-like, or burning pain.
• Stress can contribute to pain by impacting the end organ or tissue.
• Chronic stress can lead to chronic pain.
• Early life events and injuries can sensitize individuals to future pain vulnerability.
• Pain can be associated with memory, and stress can trigger pain in areas previously injured or affected.

Romantic Love & Pain, Addiction (01:40:23)

• A study explored the intersection of romantic love and pain perception.
• The study found that being in love significantly reduced pain, with a correlation between the intensity of love and the level of pain relief.
• The brain circuits involved in romantic love and addiction were found to be similar, suggesting that the early phase of a romantic relationship engages the same reward circuitry as addiction.
• Attentional distraction was also found to be effective in reducing pain, but it worked on different brain circuits compared to love.
• The strength of a romantic relationship a year later was found to be correlated with the love-induced analgesia and brain activity in the caudate nucleus and insula.

Endogenous & Exogenous Opioids, Morphine (01:48:57)

• Endogenous opioids are natural painkillers produced by the body.
• Higher endogenous opioid levels may lead to less emotional reactivity.
• Morphine was the first exogenous opioid derived from the poppy, and medicinal chemists have since created variations of morphine and purely synthetic compounds like oxycodone.
• The use of poppies for pain relief has a long history.
• Opioids can positively transform people's lives by relieving suffering and improving quality of life, but they can also destroy lives due to addiction.
• Opioids should be treated as a tool to be used in certain circumstances and not as a first-line agent.
• The opioid crisis is a complex issue that requires a nuanced approach, considering both the benefits and risks of these drugs.

Opioid Crisis, Prescribing Physicians (01:53:17)

• Opioid crisis is often attributed to overprescribing of opioids.
• Opioids can be beneficial for pain management when used appropriately.
• Overprescribing occurred due to lack of education among physicians about pain management and alternative treatments.
• Some physicians overprescribed due to marketing messages and lack of alternatives.
• A small group of physicians engaged in illegal activities related to opioid prescribing.
• Fear of legal consequences led many physicians to abruptly stop prescribing opioids, leading patients to seek illicit sources.
• Current opioid crisis is driven by illicit fentanyl.

Opioids & Fentanyl; Morphine, Oxycontin, Methadone (02:02:21)

• Fentanyl in street drugs is the primary cause of opioid-related deaths, not fentanyl prescribed by physicians.
• Compassionate opioid weaning can be successful for patients who want to reduce their opioid use.
• Commonly used opioids include morphine, oxycodone, fentanyl, Tramadol, hydromorphone, and methadone.
• Opioids work by binding to opioid receptors in the periphery, spinal cord, and brain.
• Benzodiazepines are rarely used for pain relief, except in specific cases where anxiety contributes to pain.

Kratom, Cannabis, CBD & Pain; Drug Schedules (02:07:44)

• Kratom has opioid-like properties and is available over the counter.
• Some people find kratom helpful in reducing opioid use, but its safety and efficacy need further research.
• Cannabis) has been shown to reduce neuropathic pain in small studies, but large-scale studies show mixed results.
• Cannabis is not a uniform substance, and THC to CBD ratios and doses vary.
• Cannabis remains a Schedule One drug, which hinders research.
• Rescheduling cannabis) as a Schedule Two drug could facilitate research and regulation.

Pain Management Therapies, Acupuncture (02:18:12)

• Acupuncture is one of six broad categories of therapies for chronic pain.
• Acupuncture has been shown to activate peripheral adenosine receptors and engage different brain regions compared to sham acupuncture.
• The exact mechanism of acupuncture's pain-relieving effects is still not fully understood.
• Acupuncture can be effective for certain types of pain, but it's important to find a qualified acupuncturist.

Finding Reliable Physicians, Acupuncturist (02:22:19)

• To find reliable physicians or acupuncturists, seek recommendations from trusted sources such as primary care doctors or colleagues.
• Be cautious of inflated patient ratings, as they can be manipulated.
• Consider using an independent platform that provides genuine patient experiences and ratings to find the best healthcare providers.

Chiropractic & Pain Treatment; Chronic Pain & Activity (02:26:36)

• Chiropractic and acupuncture are different professions with distinct approaches to pain management.
• Acupuncture has shown some effectiveness in certain patients and circumstances, and is now covered by Medicare for back pain in patients over 65.
• Chiropractic care has mixed evidence for its effectiveness in treating low back pain.
• High-velocity chiropractic manipulations may pose a risk of vertebral artery dissection, especially in the neck.
• Chronic pain often leads to reduced activity and deconditioning.
• Physical therapy and rehabilitation are crucial in addressing chronic pain by helping patients safely engage in activity and improving biomechanical issues.

Physical Therapy & Chronic Pain; Tool: Pacing (02:31:35)

• Physical therapists play a vital role in chronic pain management by providing rehabilitation, goal setting, and education on body mechanics.
• Pacing is a critical tool in managing chronic pain, involving setting small, incremental goals for physical activity.
• Avoid overdoing activities on good days and recognize that bad days are normal.
• Consistency in pacing helps prevent the negative reinforcement cycle of pain and inactivity.
• Effective pain management involves collaboration between different healthcare providers, including primary care doctors, pain psychologists, and physical therapists.

Supplements: Acetyl-L-Carnitine, Alpha Lipoic Acid, Vitamin C, Creatine (02:36:35)

• Acetyl-L-Carnitine:
  • Improves mitochondrial health.
  • Studied in the Sydney trials for diabetic neuropathy.
  • Shown to improve nerve conduction velocity.
• Alpha Lipoic Acid:
  • Has antioxidant and calcium channel modulating properties.
  • May benefit neuropathic pain.
  • Can cause stomach upset.
• Vitamin C:
  • Prophylactic use may reduce the likelihood of nerve pain after surgery.
• Fish Oil (Omega-3s):
  • Beneficial for chronic pain.
  • May reduce the viscosity of the blood, increasing the risk of bleeding.
• Creatine:
  • Shown some benefit in fibromyalgia and other conditions in small studies.

Pain Management, Cognitive Behavioral Therapy (CBT), Biofeedback (02:42:25)

• Pain psychology and behavioral therapy can help with maladaptive coping and thought processes related to pain.
• CBT involves recognizing unhelpful thoughts and patterns, interrupting them, and teaching goal setting, pacing, and relaxation techniques.
• Biofeedback provides closed-loop feedback to help individuals learn to calm down the sympathetic nervous system.
• Mindfulness-based stress reduction and acceptance and commitment therapy are other tools used by pain psychologists.
• Empowered relief is a brief intervention developed by Dr. Mackey's partner, Beth, that condenses 8 weeks of CBT into 2 hours.
• Digital platforms and online treatments are being developed to make pain management tools more accessible.

National Pain Strategy, National Pain Care Act (02:48:32)

• Dr. Mackey) co-led the development of the National Pain Strategy, a strategic plan for transforming pain assessment, care, education, and communication.
• Full implementation of the National Pain Strategy would make a significant difference in the lives of people living with pain.
• Concerned citizens can help advance the implementation of the National Pain Strategy by contacting their representatives and writing letters.
• Dr. Mackey's nonprofit organization, Pain USA, aims to advance the implementation of the National Pain Strategy and use high-quality data to inform pain care and treatments.

Nasal Nalmefene spray for opioid overdose to enter the world of prehospital medicine.
"Compared to naloxone, nalmefene binds with higher affinity at the mu opioid receptor, the receptor subtype involved in breathing, and is about four times more potent. Although structurally similar, nalmefene is a methylene analog of the opioid receptor antagonist naltrexone without the hepatic side effects, whereas naloxone is derived from oxymorphone."
​
"Nalmefene, which has an onset of action of 2.5 to 5 minutes, provides long-acting reversal of opioid-induced respiratory depression because of its long half-life (more than 10 hours)"
vs.
"Intranasal naloxone, which has an onset of action of about 2 minutes, has a shorter half-life of approximately 2 hours, or about 1.24 hours when administered intramuscularly."
​
Very cool! Are any agencies using this already?

Hi, all. About 5 mos post multi-level lumbar laminectomy. Been on oxycodone for about 10 mos.Pre op, was taking 10-325 3-4 times/day. For first month or so post op was taking 10-325 4-6 times/day. Unfortunately, I am in more pain post op than pre op so likely going to need a double lumbar fusion. I then went down to 10-325 4 times/day - sometimes I would take 3, sometimes 4, and 5 if i was doing something such as an hour dinner with my wife - i can't really sit. At one point, went down to 5-325 4 times/day but that didn't work, so went back up to 10-325 4 times a day.
The effectiveness had been wearing off slowly, but the last two weeks it's fallen off a cliff. It was taking over an hr and a half to kick in and when it was bad it would only work for an hour until i started feeling it getting worse again, so j would take another 10, yet trying not to with all my strength because of the shortage fear. I had an appt with pain management dr last week and explained that what we're doing is no longer working. He said he would put me back on 10-325 4-6 times a day so i can take 20 mgs when i needed it, and that he wouldn't go any higher than that if that didn't work When i asked about extended release (not necessarily Ocycontin) he said they wouldn't provide bang for the buck and I wouldn't get the kind of relief i would get taking 20mg of oxycodone, even though i cant always take 20 under his script. I was shocked bc my understanding of extended release drugs is that they maintain the pain reduction so you don't have to have an hr or so of pain when the immediate release stops workin. Thus, I am dumbfounded by his statement.
I didn't push the issue because i have a now 5th and 6th opinion to determine how i am going to proceed with respect to surgery and i should know by mid-Feb what I am going to do. but, what if the degradation of effectiveness continues and i don't make it to surgery. He said you treat the problem not the symptom which i agree with, but that doesn't always work as evidenced by my failed laminectomy. And him saying he won't increase the dose and doesn't think extended relief wil benefit me leaves me out in the cold if the oxy effectiveness continues to decrease. A spinal cord stim is on the table but won't be decided until after my upcoming appointments.
Anyone have similar experience and been told extended relief won't help you as much as immediate release, yet the immediate release isn't working like it used to and your dr tells you it will likely stop working too. What do you do then ? When did you switch to ER and what did your dr say regarding effectiveness of ER vs immediate release ? Thanks.

I had a diskectomy on Monday. I was prescribed 5mg of oxycodone every 6 hours, and 1000mg of Tylenol every 6 hours. I was in a lot of pain that night and called them, and they said I could take 10mg of oxycodone every 4 hours. I did that, and it helped some, but I was still in a lot of pain. They prescribed 10mg of flexiril 3 times a day.
With that, I've been able to get enough pain relief to sleep. It seems that I can't take the flexiril during the day because it knocks me out. I've also been able to get away with pivot taking 5mg of oxycodone every 6 hours during the day. I'm still in pain, but since I'm awake, I can handle it. I'm used to being in pain.
It's Thursday afternoon, and I have 8 oxycodone left. I was originally given 30. I called and asked if I could get a few more to get me through the weekend since I was having to take the 10mg at night. She said she'd have to check with the surgeon, but they're usually wanting you to kind of start tapering off of it. So now I'm waiting on a call back.
I had my fucking spine sliced into 3 days ago! My leg and hip aren't hurting me at all, so I'm pretty sure the surgery was a success, but I'm still having a lot of back pain. Getting up and down is really painful. Going to the bathroom is rough. I'm trying to walk around a bit. If I walk a little bit, my pain decreases, but it gets worse if I walk too much. If I sit or lie down too much, the pain gets worse. I'm still working on finding my happy medium with how much I'm moving around vs. sitting still and of course, that changes as I start to heal.
I'm just frustrated that I can't get adequate pain relief. I feel like I've been using the oxycodone very conservatively. I just want to get through this without being in constant unbearable pain. Is that too much to ask?

Story:
After Josip Broz Tito was executed in 1951 by Soviet spies, the Socialist Federal Republic of Yugoslavia becomes the battleground for a proxy war between the USSR and the United States. The latter seeks not only to repel the enemy power but also aims to establish secret laboratories in the area for the Homo-Deus project, intending to enhance human biology for military purposes.
Darko Kurtovic, a 17-year-old Serbian youth, is chosen as a test subject once the Yugoslav Liberation Front, a puppet army of the Americans, takes over his orphanage. Hours after being separated from his friends, the protagonist arrives at the Detention and Reeducation Center of Srebrenik in Bosnia and Herzegovina, now used as a laboratory for the Homo-Deus project. After undergoing sufficient physical conditioning and befriending other abducted youths, American scientists immobilize him and inject a prototype serum they have been working on. This triggers a rewriting of Darko's DNA, granting him, after a month of extreme illness and intense hallucinations, superhuman enhancements in all physical abilities equivalent to a century of continuous training for a normal person. He also gains regenerative qualities and heightened senses. However, the disadvantage is that to prevent the mutation from fatally tensing his muscles, he must consume opium or derivatives regularly.
Months later, with some combat and infiltration training, Darko witnesses the invasion of the laboratory by the Titoist Civil Defense of Yugoslavia. He joins their ranks along with fellow mutants once the battle ends, resulting in the destruction of the Detention and Reeducation Center of Srebrenik by a Yankee artillery attack. From then on, the player can choose how to deal with General Jefferson Smith, the mastermind behind the Homo-Deus project. Options include joining the Yugoslav People's Army (controlled by the KGB) at the cost of them eliminating the partisans (easy route) or continuing in their ranks. However, the protagonist faces the time limit imposed by his opium addiction, and delaying allows the U.S. army to deploy more and better super soldiers. The enemy can be defeated by either assassinating the general or stealing secret documents only obtainable from other research centers and leaking them to the international press, a task requiring an extreme level of military intelligence about the invaded territory.
Various nationalist groups emerge due to increased ethnic tensions following the Yugoslav leader's execution, influenced by NATO. The protagonist has the option to join Serbian paramilitaries, leveraging his origin. This requires undertaking missions involving drug trafficking and terrorism, receiving an unlimited supply of opioids from that faction. By doing so, the paramilitary leader discovers that the Americans use Serbian civilians as laboratory rats, leading to the faction breaking its alliance with the U.S after an internal war of Pro-Yankees vs Anti-Yankees.
Gameplay:
The game will incorporate stealth elements from Assassin's Creed and shooting and healing mechanics from the S.T.A.L.K.E.R. series. Players must extract bullets with a knife and subsequently apply bandages.
The presence of a variety of psychoactive substances allows addiction for certain drugs, impacting mental health along with grotesque violence, untreated extreme pain, and lack of human contact. Improving mental health can involve consuming psychedelics in calm environments, socializing, etc. The game includes diverse substances such as alcohol, tobacco, cannabis, LSD, mescaline, magic mushrooms, amphetamines, methamphetamine, cocaine, opium paste, morphine, heroin, codeine, and oxycodone, with prices based on the difficulty of obtaining them in Yugoslavia at the time.
The open-world game gradually unlocks as enemy territories are conquered.
Players can acquire armor capable of reducing bullet impact at the expense of breaking over time, with each faction having its own.
Running on Unreal Engine 5, the game simulates realistic material physics, destructible environments, and a plausible consequence system; player actions, such as damaging structures controlled by their militia, killing comrades, civilians, or innocent animals, affect reputation within the faction, potentially leading to expulsion or execution.
The dynamic society system simulates realistic hierarchies and interactions among civilian NPCs and members of armed groups. This includes NPC's ability to construct and gradually repair structures, resembling a simplified war-focused version of Dwarf Fortress's procedural system.
Historians and Yugoslav citizens of the era will be hired to ensure historical and cultural fidelity, including lesser-known details like Yu-Mex music and the Mexican Revolution cinema popularized by Tito's regime. In-game events leading to real-life instant death, such as a gunshot to the brain or heart or drug overdose, reflect the consequences realistically.
There will be a hyper-realistic large and small-scale war strategy system that depends on military officials, tactical commanders, and personal psychology for every soldier. NPCs possess personal traits affecting the gameplay experience, with procedural generation defining characters' physical, psychological, and psychiatric well-being.
Realistic biology includes habits determining health and physical performance, complemented by complex psychology. Circumstances like religious/transcendental experiences, lifestyle (including substance use), loss of loved ones, and other procedural factors affect NPCs physically and psychologically.
RPG components include dialogue options, an upgrade system for armor and weapons akin to S.T.A.L.K.E.R Call of Pripyat, aesthetic possibilities influencing NPC interactions, and an editor allowing customization of military gear and armor similar to Escape From Tarkov's. Difficulty scaling increases weapon damage for both the player and enemies. There will be a realistic mode that penalizes poor or excessive eating, unhealthy sleep patterns, failure to apply alcohol before bandaging wounds (risk of infection), and exacerbates consequences of routine drug use and dependency. Cannabis may remove dialogue options requiring mental agility more frequently, and alcohol further increases the risk of cancer, cirrhosis, and other pathologies, while amphetamines or methamphetamine more frequently induce depression, schizophrenia, or psychosis, etc.
By the way, I wrote this text originally in Spanish, I used ChatGPT 3.5 to translate it, so if there's any error or hard-to-understand sentence please let me know.