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 805people who had chronic pain about the adequacy of treatment they received fromtheir physicians.1 More than 50% of the survey respondents had been in pain formore than five years, and more than 40% of respondents with moderate-to-severepain could not find adequate relief. For most sufferers, the cause wasarthritis or back disorders. Almost half of the 805 patients had changeddoctors 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 seriouslyenough (29%), and
•the doctor’s unwillingness to treat their pain aggressively(27%).
Only 26% of those respondents who had “verysevere” pain reported taking opioids (i.e., narcotics— the strongest painrelievers available) at the time of the survey.
Opioids are medications derived from morphine or chemicallysimilar drugs created in the laboratory. They are the most effective painrelievers 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-actingmedications. If your pain is present around the clock, you are likely to dobetter with formulations that are released slowly in the body, lasting longerbefore you need another dose. Morphine, oxycodone and hydromorphone areavailable in pills that need to be taken only once or twice a day, and in rarecases, three times. Fentanyl is available in a patch that lasts two to threedays after it is applied to the skin. Hydrocodone is available only in ashort-acting form in combination with aspirin or acetaminophen.
The Myths Surrounding Opioids
Why are some physicians reluctant to treat chronic pain withopioids – the most effective available class of medications for treating pain?It’s for the same reasons that many patients fear strong pain medications – themany 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 tobe increased again and again in order to continue getting pain relief.
Every one of these beliefs is incorrect. Below we’ll go overthe 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 tosuffering patients, they say, “Morphine! That’s a dangerous drug. Myfamily would think I’m an addict,” or “Methadone? That’s what heroinaddicts use. Not me!” Because opioids can be abused, their legitimate usefor 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 GeriatricSociety has determined that opioids are safer for older people thananti-inflammatories (NSAIDS) such as ibuprofen or naproxen. NSAIDs can increasethe blood pressure, cause gastrointestinal bleeding, and damage the kidney.Opioids do not — opioids do not damage any organs. They do have some sideeffects, such as nausea and sedation, but these effects rapidly diminish as youcontinue using the drugs. Other side effects, such as constipation, don’tlessen with time, but can be prevented or minimized by taking stool softenersand bowel stimulants on a regular basis. Some men on high doses of opioidsexperience decreased testosterone levels, but this hormone can be replaced byusing a testosterone gel or patch.
Myth – People who use opioids are likely to become addicted
Fact – Most people who are treated with opioids do notbecome addicted
Addiction is a psychological and behavioral disorder. Addictionis 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 thesubstance.
As an addiction advances, the person’s life becomesprogressively more constricted. The addiction becomes the addict’s number onepriority, and relationships with family and friends suffer. The addict’s innerlife becomes filled with preoccupation about the drug. Other activities aregiven up. Life revolves around obtaining and using the drug. This constrictionis an important characteristic that distinguishes use of a drug by an addictfrom its appropriate use by a patient with chronic pain. Patients who takeopioids for chronic pain hopefully expand their life, the opposite of whathappens with addicts. Pain patients feel better and are able to increase theiractivities. They may begin gardening, going to movies, playing with childrenand grandchildren, and many are able to return to work.
A patient who is addicted to drugs may keep increasing thedose without discussing it with the doctor, might repeatedly use up themedications early, go to several physicians for opioids and lie about seeingother doctors, might inject their oral or topical drugs, or sell drugs to getmoney with which to buy other drugs. These behaviors are not typical of mostpain patients.
Most pain patients taking opioids are not addicted to drugs.What is true of them is that they usually become physically dependent on thedrug. Physical dependence has nothing to do with addiction. It simply meansthat a habituated user will experience certain symptoms if the drug is stoppedabruptly. 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 hoursafter stopping the medication and peaks at one to three days. Longer-actingopioids, such as methadone, have a slower onset of these symptoms, and they areless severe than with shorter-acting drugs such as morphine and hydromorphone.Withdrawal symptoms can be avoided simply by tapering the drug dose overseveral days.
Myth – Opioid dosages will have to be increased because thebody gets used to the drug
Fact – Significant tolerance to the pain-relieving effectsof opioids is unlikely to occur
Tolerance means that a person needs more medication tocontinue 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. Thisis why cigarette smokers tend to increase the number of cigarettes they smoke.When opioids are taken for chronic pain, tolerance develops to some of theopioids’ 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 takesthe opioid). Unless the source of your pain progresses, as is true of manycancer patients, you are likely to remain on the same dose that gave youadequate pain relief when you first took the drug.
Tips for Getting the Treatment You Need
The treatment you need depends, first of all, on thediagnosis, so ask your doctor whether he or she is satisfied (s) he hasfinished working up your problem. For example, the solution to severe ongoingknee 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 thekey to treatment and non-opioids have not given you enough pain relief, askyour doctor what (s) he thinks about a trial of an opioid. Some doctors will beuncomfortable with this approach. You can also ask your doctor for referral toa pain clinic, where various options are available, including injections andmedications. If you have been addicted to alcohol and/or drugs in the past,your doctor will be understandably reluctant to prescribe opioids. In thatcase, it would be worthwhile to get a consultation with a pain specialist whoalso understands addiction. A pain specialist with training in addiction canfigure out a treatment plan that will provide you with pain relief but alsoaddresses safety so as to minimize your chances of relapsing. This plan may ormay not include opioids, depending on what substance you were addicted to, howlong 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 needaddiction treatment before a physician will even consider treating your painwith opioids.
You can learn more about the various treatments for chronicpain, including medications, physical modalities, surgery, psychologicalapproaches, and alternative treatments, by reading my book, living with ChronicPain (2004). The book also addresses the issues relating to pain and addiction.
Jennifer Schneider, MD, PhD, practices pain medicine andaddiction medicine in Tucson, Arizona. She is the author of Living with ChronicPain (2004), available from http://www.amazon.com.
1. MDs struggle to treat chronic pain. The Quality IndicatorCompendium on Pain, Nov. 2002, pp. 9-10.