Addiction and Chronic Pain
By: Jennifer P. Schneider, PhD
Chronic pain, especially chronic pain unrelated to cancer,
is notoriously under-treated. In 1999, the American Pain Society surveyed 805
people who had chronic pain about the adequacy of treatment they received from
their physicians.1 More than 50% of the survey respondents had been in pain for
more than five years, and more than 40% of respondents with moderate-to-severe
pain could not find adequate relief. For most sufferers, the cause was
arthritis or back disorders. Almost half of the 805 patients had changed
doctors at least once. The most common reasons for changing doctors were
•too much pain (42%),
•didn't know a lot about pain management (31%),
•the belief that the doctor didn't take their pain seriously
enough (29%), and
•the doctor's unwillingness to treat their pain aggressively
(27%).
Only 26% of those respondents who had "very
severe" pain reported taking opioids (i.e., narcotics— the strongest pain
relievers available) at the time of the survey.
Opioids are medications derived from morphine or chemically
similar drugs created in the laboratory. They are the most effective pain
relievers we have. Opioids have been used to treat pain for thousands of years.
The most commonly used opioids are morphine, oxycodone, hydrocodone, fentanyl,
hydromorphone, and methadone. All except methadone are short-acting
medications. If your pain is present around the clock, you are likely to do
better with formulations that are released slowly in the body, lasting longer
before you need another dose. Morphine, oxycodone and hydromorphone are
available in pills that need to be taken only once or twice a day, and in rare
cases, three times. Fentanyl is available in a patch that lasts two to three
days after it is applied to the skin. Hydrocodone is available only in a
short-acting form in combination with aspirin or acetaminophen.
The Myths Surrounding Opioids
Why are some physicians reluctant to treat chronic pain with
opioids – the most effective available class of medications for treating pain?
It's for the same reasons that many patients fear strong pain medications – the
many myths surrounding the use of opioids. These myths include:
•using opioids means you are a bad or weak person,
•opioids damage the body,
•people who use opioids are likely to become addicted, and
•the body gets used to the opioid dose, which then needs to
be increased again and again in order to continue getting pain relief.
Every one of these beliefs is incorrect. Below we'll go over
the facts one by one and see what the reality is.
Myth – Using opioids means you are a bad or weak person
Fact – Opioids are just another drug treatment for pain
Over and over again, when I've suggested an opioid to
suffering patients, they say, "Morphine! That's a dangerous drug. My
family would think I'm an addict," or "Methadone? That's what heroin
addicts use. Not me!" Because opioids can be abused, their legitimate use
for pain has become stigmatized. As a result, too many people suffer with pain.
Myth – Opioids damage the body
Fact – Opioids are very safe drugs when used as directed
You may be surprised to learn that the American Geriatric
Society has determined that opioids are safer for older people than
anti-inflammatories (NSAIDS) such as ibuprofen or naproxen. NSAIDs can increase
the blood pressure, cause gastrointestinal bleeding, and damage the kidney.
Opioids do not — opioids do not damage any organs. They do have some side
effects, such as nausea and sedation, but these effects rapidly diminish as you
continue using the drugs. Other side effects, such as constipation, don't
lessen with time, but can be prevented or minimized by taking stool softeners
and bowel stimulants on a regular basis. Some men on high doses of opioids
experience decreased testosterone levels, but this hormone can be replaced by
using a testosterone gel or patch.
Myth – People who use opioids are likely to become addicted
Fact – Most people who are treated with opioids do not
become addicted
Addiction is a psychological and behavioral disorder. Addiction
is characterized by the presence of all three of the following traits:
•loss of control (i.e., compulsive use),
•continuation despite adverse consequences, and
•obsession or preoccupation with obtaining and using the
substance.
As an addiction advances, the person's life becomes
progressively more constricted. The addiction becomes the addict's number one
priority, and relationships with family and friends suffer. The addict's inner
life becomes filled with preoccupation about the drug. Other activities are
given up. Life revolves around obtaining and using the drug. This constriction
is an important characteristic that distinguishes use of a drug by an addict
from its appropriate use by a patient with chronic pain. Patients who take
opioids for chronic pain hopefully expand their life, the opposite of what
happens with addicts. Pain patients feel better and are able to increase their
activities. They may begin gardening, going to movies, playing with children
and grandchildren, and many are able to return to work.
A patient who is addicted to drugs may keep increasing the
dose without discussing it with the doctor, might repeatedly use up the
medications early, go to several physicians for opioids and lie about seeing
other doctors, might inject their oral or topical drugs, or sell drugs to get
money with which to buy other drugs. These behaviors are not typical of most
pain patients.
Most pain patients taking opioids are not addicted to drugs.
What is true of them is that they usually become physically dependent on the
drug. Physical dependence has nothing to do with addiction. It simply means
that a habituated user will experience certain symptoms if the drug is stopped
abruptly. For opioids these withdrawal symptoms can include: anxiety, irritability,
goose bumps, drooling, watery eyes, runny nose, sweating, nausea and vomiting,
abdominal cramps, and insomnia. Withdrawal from morphine starts six to 12 hours
after stopping the medication and peaks at one to three days. Longer-acting
opioids, such as methadone, have a slower onset of these symptoms, and they are
less severe than with shorter-acting drugs such as morphine and hydromorphone.
Withdrawal symptoms can be avoided simply by tapering the drug dose over
several days.
Myth – Opioid dosages will have to be increased because the
body gets used to the drug
Fact – Significant tolerance to the pain-relieving effects
of opioids is unlikely to occur
Tolerance means that a person needs more medication to
continue getting the same effect. This is also true of addiction. With time,
the addict needs more of the drug to obtain the same mood-altering effect. This
is why cigarette smokers tend to increase the number of cigarettes they smoke.
When opioids are taken for chronic pain, tolerance develops to some of the
opioids' effects (e.g., nausea and sedation will lessen) but not to others
(e.g., constipation and pain relief will continue as long as a patient takes
the opioid). Unless the source of your pain progresses, as is true of many
cancer patients, you are likely to remain on the same dose that gave you
adequate pain relief when you first took the drug.
Tips for Getting the Treatment You Need
The treatment you need depends, first of all, on the
diagnosis, so ask your doctor whether he or she is satisfied (s) he has
finished working up your problem. For example, the solution to severe ongoing
knee pain might be surgery to replace a knee joint damaged by osteoarthritis.
You will need to be evaluated by an orthopedic surgeon. If medications are the
key to treatment and non-opioids have not given you enough pain relief, ask
your doctor what (s) he thinks about a trial of an opioid. Some doctors will be
uncomfortable with this approach. You can also ask your doctor for referral to
a pain clinic, where various options are available, including injections and
medications. If you have been addicted to alcohol and/or drugs in the past,
your doctor will be understandably reluctant to prescribe opioids. In that
case, it would be worthwhile to get a consultation with a pain specialist who
also understands addiction. A pain specialist with training in addiction can
figure out a treatment plan that will provide you with pain relief but also
addresses safety so as to minimize your chances of relapsing. This plan may or
may not include opioids, depending on what substance you were addicted to, how
long you've been clean and sober, and what you are doing to maintain recovery.
If you have an active addiction as well as severe chronic pain, you will need
addiction treatment before a physician will even consider treating your pain
with opioids.
You can learn more about the various treatments for chronic
pain, including medications, physical modalities, surgery, psychological
approaches, and alternative treatments, by reading my book, living with Chronic
Pain (2004). The book also addresses the issues relating to pain and addiction.
Jennifer Schneider, MD, PhD, practices pain medicine and
addiction medicine in Tucson, Arizona. She is the author of Living with Chronic
Pain (2004), available from www.amazon.com.
References
1. MDs struggle to treat chronic pain. The Quality Indicator
Compendium on Pain, Nov. 2002, pp. 9-10.
http://www.nationalpainfoundation.org/articles/134/addiction-and-chronic-pain
