The Progression From Pain Treatment to Addiction


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“I never tried to get high” is a typical statement I get from many patients who present to my office.  They may be using 40 pain pills a day, or seeing multiple physicians, or buying from the street; but, they never set out to get high.  Many are bewildered how they came to be in such a state.

 

I am not talking about patients who may be Pseudo-addicted because the pseudo-addicted patient’s pain is poorly controlled.  Pseudo-addiction refers to deviant behavior that emerges as patients try to get relief from poorly treated pain.  Many of them are identified as having an addiction problem.  However, any aberrant behavior disappears when their pain is adequately controlled. 

 

Rather, I am talking about people, with no prior history of addictive behavior, who started on pain medication in response to true physical pain.  The pain went away (at least partly) but their medication use persisted or even increased.   Why did this occur?  If you believe the experts, the emergence of true addiction from pain treatment is uncommon.  Studies were concluded 15 years ago and found that addictive behavior did not emerge when pain patients were maintained on opiates chronically.  So why are there so many of these people around? 

 

When the original studies were done, persons with a history of addiction were not included.  This made sense since the study want to examine the development if new addiction; inclusion of former addicts would confuse the issue.  The question remains, was there something about the studies that prevented the2-5% of the population with addiction potential from being included?

Studies indicate 1% of the general population abuses heroin and 5% of the population abuses opiates recreationally.   The incidence of addiction was far less than this in thepain studies.  One might conclude that something in the experimental design caused a lower incidence of addiction in these studies than is found in the population at large.  What could that be?

These studies were done in university settings and the patients had long histories of pain problems.  They had often been under the care on community-based doctors for quite some time.  They did not develop addictive behaviors.  I believe many of the pain patients destined to misuse medication were already identified and excluded from the pain studies.  Perhaps, the misusers were unwilling to travel to the university centers where these studies were done.   

However, the most important thing to realize is that the studies did not reflect what occurs in real life.  The pain patients were only followed for 3-6 months- not for years consistent with current episodes of treatment.  Also, many of the medicines used today were not part of the initial studies.

I believe that there is a definitive fraction of persons who will develop addiction from chronic opiate treatment.   Most chronic pain patients will not get into trouble.  However, the ones get into trouble are very difficult to care for.  They believe  they’re in pain and wonder why the medications do not work well.  Why do they need to take more medications than their doctors are willing to prescribe?  They never set out to abuse the drugs.  How did they get into this position?  They find themselves adrift with no one to turn to for treatment. 

 

Some of these patients are easily identifiable.  They develop overt misuse of medication.  They may buy from the street or see multiple physicians to obtain high amounts of pills. 

However, o
ther patients have more subtle manifestations of addiction.  They may not use more than the maximum amount allowed.  Yet, they are doing poorly.  They have persistent pain and are often depressed. They use too much one day and have to do without later in the month.  They may experience over-sedation at times.  They perform pooly at work, or fail to return to work.  They neglect their families.  The drugs have led to a decrease in function.   The drugs have become the problem.   

 

Why does this happen? One must understand how the opiates work in the brain.

Opiate receptors have a wide distribution in the brain and have multiple effects in different areas.  However, I want to focus on two of the major effects.

The first of these effects is to relieve true pain otherwise known a nociception.  Nociception comes from the activation of the normal pain pathways of the brain and spinal column.  Opiods block these nociceptive impulses.

The second effect is to stimulate the emotional centers of the brain.  The area affected are the Nucleus Accumbens and the Ventral Tegmental area.  When these areas are stongly stimulated, there is a "high" and a nodding out.  However, when these areas are only moderately stimulated, we will just experience a relief of depression and/or an increase in energy. 

Now many persons in pain have some degree of depression.  The depression may or may not have been caused by the pain.   Either way, the stimulation of the previously mentioned emotional centers will lead to some relief of their depression.  This is an effect separate from pain relief.

 

If this were the whole story, there would be no problem.  After all, what’s wrong with relieving depression?  However, there is a catch.  Tolerance to the anti-depressant effect may develop.  The patient had a great sense of well being when he started the medication; after a while, he feels less well.

 

The patient is not so analytical of the situation.  He only knows that he gets less relief from the medication.  What does he do?  He may ask his doctor for an increase or he may increase the pills himself.  He gradually increases the medication and now, he begins to develop tolerance to the pain relieving function of the medication.  He is in more pain

Of course, if he is using a short acting agent, the drug wears off in a few hours.  This worsens the pain, depression and irritability until he gets his next dose.

It is important to realize that there are people who suffer these withdrawal symptoms even while using the allowed number of pills.  The pills still wear off leading to depression, irritability and increased pain.

 

Another problem leading to opiate misuse is CHEMICAL COPING.  This is a term coined by Steve Passik PhD. to describe the use of pain medications when we are stressed out or depressed.  For example, let’s consider an employed person with mild to moderate chronic pain.  This person tolerates the pain most days and uses pain medication only on bad days.  Now lets suppose he had a particularly stressful day.  The person might come home and, because they are upset, they do not want to experience the pain they can usually tolerate.   They take a pain pill.  While they think they are taking the pill for pain, aren’t they actually taking the pill for emotional distress?  And what’s worse, the pill will relieve their emotional distress so they continue to take the pills for the wrong reason.

 

In many cases, the medication use increases in frequency.  Dosage often increases as well.  Finally, the person cannot obtain enough drugs to function optimally.  They realize that there is a problem.  They may turn to their doctors who usually do not have good insight into such situations.  Their family and friends don’t understand.  In fact, the patient blames himselfs, consider himself addicted and is very ashamed.  In a sense this is true, but the addiction should not be considered some type of moral failing.  They wound up in this situation because he had poor insight into the progression of his problems; he did not know what signs to look for. 

 

What signs should one look for?  The biggest telltale sign of a problem, in my opinion, is the regular use of medicines that are supposed to be used on an as needed basis.  When Vicodan is taken at 6 PM everyday, (others may take the medication regularly at bedtime and others when they awake) it may be the sign of a problem.  The medication should be taken based on how we feel and not based on the time of day.  Once, we have a routine of taking the medication at the same time each day, the meds are taken even it the pain is not that bad. 

By the time medications are used four times daily on an everyday basis, I would be even more concerned.  The medication is in the body around the clock leading to tolerlance and physical dependency. Withdrawal symptoms will be experienced when we stop the medication.  These withdrawal symptoms might even be experienced before the next scheduled dose.
 

Aother sign is taking the the medications secondary to stress.  Of course, it can be difficult to know when one is doing this.  Knowing how to differentiate pain from stress may take a degree of self-awareness that many patients do not have.  For this reason, I believe most people using pain medication regularly should have some counseling with someone knowledgeable in these issues.

 

For many persons, stopping the pain medication is the road to getting better.  However, some with pain still need to continue treatment with pain medicine.  This is a hard distinction to make; you need a doctor with the right knowledge and attitude.  Even then, mistakes may be made.  Many of my patients are intolerant to weaning and stay on their medications.  Others have come off; they may still have pain but they feel it’s the best thing they ever did.

 

Many reading here might be thinking of all the persons they know who have taken pain medications and have not gotten into trouble.  When I took pain medications after a surgery, I never felt euphoria.  That is because I didn’t have the susceptible brain.  Opiates do not cause the same degree of euphoria in different people.  Susceptibilities differ based on the presence of psychiatric illness, Adhd and genetic tendencies.   The patient who gets into trouble will have a susceptible brain, regular use of pain medications and, perhaps, a good dose of anxiety and/or depression thrown in as well.  


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