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 http://www.amazon.com.
1. MDs struggle to treat chronic pain. The Quality Indicator Compendium on Pain, Nov. 2002, pp. 9-10.