INFO - Addiction and chronic pain

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The National Pain Foundation

Last updated: 08/01/2005

By P. Schneider, MD, PhD

" Addiction and Chronic Pain " :

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 (ie, 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 (ie, 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 (eg, nausea and sedation will lessen) but not to others

(eg, 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.

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 or www.bn.com.

References

1. MDs struggle to treat chronic pain. The Quality Indicator Compendium on

Pain, Nov. 2002, pp. 9-10.

http://www.painconnection.org/MyTreatment/MyTreatment_Addiction_and_Chronic_Pain\

..asp

Not an MD

I'll tell you where to go!

Mayo Clinic in Rochester

http://www.mayoclinic.org/rochester

s Hopkins Medicine

http://www.hopkinsmedicine.org

[Guest guest]

Fantastic article. I still havent seen my first post pop up yet. I have to agree

that the statement of pain being under treated is very much on the money