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A patient once visited me. I had been treating him for several years. Although there was distant history of illicit drug use and use of methadone in the past, more recently he had been prescribed opiates for pain. He has a severe neurological disease that leaves him in chronic pain. When he uses pain medication, he is able to function and go to work. He does not use more medication than needed.
We were talking about addiction and he said “Doctor, surely there are two types of addicts. Some who use illicit drugs and as a result do nothing with their lives and others, like me, who use the medication in order to function”. He feels anyone who has a consistent use of an addictive medication is an addict. Certainly, if he did not get his medication he would have physical withdrawal symptoms. I am sure he would obsess over the lack of medication and might go to extreme measures to obtain the drugs. He might buy heroin on the streets. He might lie, juggle several physicians or forge prescriptions. To all persons who know him superficially, he is typical addict. He even identifies himself as one. However, the situation is more complicated
There is a great deal of confusion of what addiction is. The DSM is the official handbook for all behavioral health problems. It details the characteristics of all the various psychological diseases such as depression, schizophrenia as well as substance abuse. Over the past 40-50 years-the criteria for addiction has changed. In the first edition of DSM, addiction is defined solely by the presence of tolerance and physical dependency, which occur universally in chronic pain patients. Behaviors were not considered. Certainly, with these criteria, addiction will occur in everyone using opiate pain medication chronically.
In recent years the diagnostic criteria have changed. The official definition of addiction per the DSM 4, the current version of the DSM, is an improvement as it begins to looks at behaviors as well as physiologic consequences of the use of a substance. The definition is as follows:
A maladaptive pattern of substance use leads to clinically important distress or impairment as shown in a single 12-month period by 3 or more of the following:
3-The amount or duration of use is often greater than intended.
4-The patient repeatedly tries without success to control or reduce substance use.
5-The patient spends much time using the substance, recovering from its effects or trying to obtain it.
6-The patient reduces or abandons important social, occupational or recreational activities because of substance use.
7-The patient continues to use the substance, despite knowing that it has probably caused physical or psychological problems.
It is important to note that criteria one through five can still be seen in patients using opiates chronically for pain. Even though they are an improvement from prior criteria, they still fail to differentiate patients with addiction from those with chronic pain. For this reason, the American Society of Addiction Medicine, the American Pain Society and the American Academy of Pain Medicine have put out a collaborative definition of addiction and it is as follows:
Addiction is a primary, chronic, neurobiological disease with genetic, psychosocial and environmental factors influencing it development. It is characterized by behaviors that include one or more of the following:
1- Impaired control over drug use
2- Compulsive use (use when you do not want to use)
3- Craving for the substance
4- Use despite harm. (That is, the patient must recognize that the substance is impairing their overall ability to function and continue to use)
It is important to note that this last definition of addiction looks mainly at behavior and complex feelings, and does not consider the simple physiologic adaptations of tolerance and withdrawal. Item number four deserves more focus. If a person is more functional because of his use of pain medication, he is not being harmed by it. If he uses the medication as prescribed, without taking more medication than he intended, then there is no addiction. Most patients will not be craving for their drugs if they are on a steady dose and not in withdrawal.
Early in my career, I worked with an addiction medicine physician who felt that abstinence was a goal in and of itself. I have seen the results when people, stable on the use of an addictive substance, have undergone detoxification in order to reach the ideal of abstinence. It was not a good experience. Abstinence should not be the ultimate goal. Rather, optimal functioning in the physical, psychological and social domains should be that goal.
Nevertheless, just because there is a true physiological reason for pain, does not mean that it is okay to be using opiates. Many people with real disease often are worse off secondary to pain medication use. In many persons, the experience of pain is a learned stress response and not a nociceptive response (from pain pathways specifically. They could be experiencing increased pain (hyperalgesia), and rebound increases in pain and psychiatric symptoms. It can be difficult to determine who is better off and who is worse off. The intensity of pain is not a reliable indicator but needs to be considered in conjunction with the patient’s daily activity and their overall psychological functioning.
Nevertheless, some patients do better with chronic opiods. Currently for this population, Suboxone and/or methadone may be better options if all non-opioid treatments fail. Certain other opioids may also be beneficial but impractical to use in the current regulatory environment
People are not machines. On any given day, the patient may be tired, cranky, in a bad mood. We all have our bad days. So I ask you not to condemn a patient, who is taking these medications, because they are impaired from time to time. However, if the patient is over-sedated, irritable and/or depressed with any regularity, addiction may co-exist with the pain. If a determination is made that the patients overall condition is worse because of use of a pain medication, counseling and possible detoxification needs to be considered.
In sum, if you use a psychoactive substance, do not assume its use is wrong. Discuss with your doctor why you use the drug. Make sure he is comfortable with the concept of addiction and how to distinguish it from physical dependency. If necessary, discuss it with an addiction medicine specialist. Than, follow your instinct. It will usually be right.
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 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 the 2-5% 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 recreational. 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 potential addicts 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, other 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 strongly 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 them self, consider them self 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 tolerance 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.
Another 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.
We seem to be caught in a quandary. On one hand, chronic pain is so prevalent and doctors seem to undertreat it. On the other hand, there is an opioid epidemic because “bad” or “greedy” doctors were giving out too may opioids to the wrong people. So many lay people seem shocked when doctors have difficulty distinguishing between addicts and pain patients.
It is important to realize is that chronic pain is not the same as acute pain lasting a long time, different pasts of the brain are active.. The reason we have evolved pain is to motivate us to change our behavior so as not to exacerbate an injury. Acute pain works via a special pain pathway. Pain comes through the spinal cord, through several switch points, (where opioid medications work), and then onto the pain areas of the cerebral cortex (insula and secondary somatosensory cortices) where pain is actually experienced. This provides a strong motivation to remove ourselves from ongoing injury- (i.e.- when we pull out our hand from water that is too hot.)
Chronic pain, on the other hand, serves to motivate behavior that will avoid an exacerbation of an injury. We anticipate pain, become stressed and fearful and freeze up. This involves other areas of the brain such as those involved in memory, stress and anticipation. It is an emotional experience; the pain pathway, noted above, is quiet.
It is interesting to note that the pattern of brain activity in persons experiencing chronic pain is almost the same the pattern of activity in persons who are addicted. When scanned, the brain of an addict craving drugs looks like that of a chronic pain patient experiencing pain. Therefore, while the reasons for use at the beginning of both illnesses are different, after a while the physiology underlying suffering in both disease states is the same. This is why pain and addiction cannot be reliably differentiated.
I absolutely advocate treatment- even with long acting pain medicines if that becomes necessary (Suboxone & Methadone). These medications are what work in addiction and the CDC has recommended them for intractable pain as well. Yet, many doctors continue to use short acting agents for chronic pain. They rightly point out that no study has shown long acting agents to be better than short acting agents. Of course, one reason for this is that no opioid pain medicine has ever been shown to be beneficial once 90 days have passed. So of course- neither type is superior or inferior in their lack of effectiveness
Over recent years, there has been an epidemic of opioid use and drug overdoses. This has been met with increasing scrutiny of physicians with the result of the physicians being more reluctant to prescribe opioid medications. The CDC came out with recommendations against opioids for chronic pain treatment in 2016. It is clearly harder to be prescribed such medications. Yet, the chronic pain patients cry foul. Why should we suffer from not being able to get the meds we need because others are abusing their medications?
Underlying this complaint is the assumption that the opioids are helping these patients- that they are part of the solution of being more functional or in less pain. As I will explain- this is most often not the case. It turns out that the opioids result in increasing pain in a process referred to as Opioid Induced Hyperalgesia (OIH)
Most pain patients are aware that pain meds are habit forming. One often has to take more meds to get the same level of relief and one will have withdrawal if medication is missed. Many patients are prescribed longer acting drugs to minimize the risk of withdrawal; this is often helpful. However, even though withdrawal will result in increased pain, this is a separate issue from OIH.
It has long been recognized that patients on opioids have an increased sensitivity to pain even when they are not in withdrawal. In scientific studies, patients on opioids and normal controls have been subjected to the same painful stimulus (often by submersing their hands in painfully cold water or have a non-injurious heat stimulus applied to their skin.) Invariably, the patients who take the opioids rate the pain higher. It is not because they are dramatic; studies of their brain function show that the pain centers of their brain are more active than those not on opioids. The pain impulses have been magnified, not blocked. This is call HYPERALGESIA.
Recently, we have discovered the mechanism for this. Opioids stimulate immune cells that live in the brain. These immune cells in turn cause the nerves to make more of a molecule called glutamate and less of a molecule called GABA. These changes alter how nerves communicate and cause irritability and allow more pain impulses to get through the brain’s pain filters. The pain experience with resultant suffering is increased. The nerves also make less Serotonin; this can cause depression.
Increased activity of the immune cells, or neuroinflammation, can also be caused by alcohol use, cocaine and amphetamine use. THC, but not CBD, also increases inflammation. Even methadone and Suboxone can increase inflammation. Other long-term consequences involve impairment of neurogenesis: the growth and integration of new nerves cells into the brain. This may lead to impulsiveness and even dementia and memory loss.
Of course, when there is withdrawal superimposed on hyperalgesia or chronic pain, the pain is even worse.
Sedatives like Xanax and Ambien also cause problems. These drugs work by reducing brain activity; this includes pain. Many pain patients are aware of reduced pain when they take these meds. However, as these drugs wear off, the brain becomes more active; this includes the pain pathways. Pain is magnified. Alcohol will do the same thing.
I have found that most patients who suffer from chronic pain have significant reduction, if not complete resolution, of pain after the weaning process is complete. The neuroinflammation has resolved and a sense of well-being is restored.
Studies agree; no study using opioids that has lasted greater than 6 months has shown either reduced pain or increased function in those using opioids. That is why the medical field is appropriately more reluctant to prescribe them.
In truth, a small fraction of patients still suffer but they are only a small fraction. Perhaps, neuroinflammation and withdrawal were not major issues in these patients. Chronic use of Suboxone or methadone may have some benefit.