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Pain Management and Addiction

For the patient that has a history of substance abuse, pain management carries significant risk, because narcotic pain killers (opioids) are extremely addictive.  It is a common misconception that the management of acute or chronic pain necessarily leads to addiction.  Taking mood-altering chemicals for management of legitimate pain in opiate-naive patients only results in addiction a small percentage of the time.  In most cases, pain management and addiction are mutually exclusive.  Nevertheless, some individuals do become addicted to pain medication, and for individuals with a history of addiction, taking narcotics for pain management can be a recipe for disaster.

Pain Management and Addiction

The specialty of chronic pain management in patients with a history of substance abuse lies at the convergence of psychiatry and general medicine.  Few topics in behavioral health are as controversial, or poorly understood.  While there is general agreement in the medical field that pain is commonly undertreated (both in addicts and the general public), state medical boards have nevertheless punished physicians who "overprescribe" (in the eyes of state regulators) controlled substances used to manage pain.  Physicians untrained in addiction and pain management often fear that patients will become "addicted" when taking prescription opiates, and often misinterpret the physical dependency produced by long-term opiate use with full blown addiction. As a result, pain is grossly undertreated in individuals with a history of addiction in the United States.  In addition to a fear of regulatory sanctions, "generalized opioiphobia" and a punitive view of addictions exacerbate the problem of physician under-treatment of pain. Doctors are also concerned about being "ripped off" by "doctor shopping" addicts or individuals who plan to divert narcotics for sale on the streets.  

Experts in pain management today suggest a simple and straightforward approach: treat pain patients appropriately for their symptoms and tolerance, and when they are at risk for addiction, recognize it as a coexisting disorder that must also be addressed. For example, how should a patient experiencing significant pain with a history of opiate addiction be treated? Assuming that the source of the pain is clear and verifiable, should this patient be denied pain relief because of their past? Probably not. The course of treatment may have to be modified, and increased dosages of medications will most likely be necessary due to preexisting tolerance, but providing adequate pain relief is the only humane course of action.

Healthcare providers are especially reluctant to treat pain issues the etiology (biological cause) of which can't be easily pinpointed (i.e. headaches, phantom pains from amputated limbs, neuropathy (nerve pain) etc.).  Crafty drug seekers know to use these complaints in order to obtain narcotics.  Nevertheless, in these situations healthcare providers must base their treatment decisions on the patient’s word in combination with their symptoms.  A patient’s behavior, posture, body language, facial expressions, energy level and demeanor can all be indicators of the level of pain he or she is experiencing.  Biological responses to pain include:

  • Tachycardia (increased pulse rate)
  • High Blood Pressure
  • Dilated Pupils
  • Vasoconstriction (Cold Hands or Feet)
  • Diaphoresis (sweating)
  • Hyperreflexia (overactive or over responsive reflexes)
  • Insomnia
  • Nausea
  • Diarrhea

The under-treatment or non-treatment of chronic pain can lead to addiction in it's own right, as individuals with addictive personalities when faced with severe pain will often turn to the streets to obtain narcotics for pain relief.

Patients with a history of addiction to any mood-altering chemical or experience should work closely with healthcare providers to monitor any course of treatment with narcotic medications, and watch carefully for signs of physical dependence and psychological addiction. For patients with a history of opiate addiction specifically, there should be a plan in place for detoxification from the narcotic medications following the course of pain treatment.  Once an individual has become physically dependent on opiates, cold-turkey detoxification is characterized by a severe withdrawal syndrome with symptoms including:

  • insomnia
  • nausea
  • vomiting
  • diarrhea
  • sneezing
  • yawning
  • chills
  • sweats
  • anxiety
  • depression

Understanding how patients respond to pain individually and treating them accordingly (and appropriately) is essential to effective pain management. It is not uncommon for patients who take narcotic painkillers for extended periods of time to actually become more sensitive to pain. In other words, their tolerance for pain (pain threshold) is diminished because their nervous systems have become dependent on "outside help' rather than their brain's natural processes for the management of pain.  This leads to perceptions and pain coping mechanisms that can obscure the true source and extent of any real or perceived pain.  The brain naturally produces opioid molecules as neurotransmitters and has receptors for these molecules to manage pain.  When opiates are artificially introduced into the system, the brain gradually learns to stop producing them on its own.  As a result, the opiate-addicted brain can take months and even years to return to proper functioning following opiate dependence.

Healthcare practitioners providing pain management should watch for the following:

Tolerance

Patients who are treated for extended periods of time with opiate-based pain medications are likely to develop a tolerance to the drugs.  This means that more of the drug is required to achieve the same effect.  The development of tolerance is inherent to extended use of all opioid medications.  

Physical Dependency

Physical dependence results from physiological changes that occur in the central nervous system when opiates are consistently introduced into the body.  The mind and body become accustomed to and reliant upon the drug, and when it is withheld from the system, severe withdrawal symptoms can occur.  Like tolerance, physical dependence is inherent to the ingestion of opiates over any extended period of time.

Pseudo-Addiction

In an effort to be free from pain, under-treated pain patients may exhibit many of the same symptoms and behaviors as true addicts.  This "pseudo-addiction" can be all but indistinguishable from the real thing.  For example, if a practitioner don’t prescribe a strong enough medication, a patient might take more than the prescribed amount of the medication they have on hand (under other circumstances, a telltale sign of addiction).  Or if short-acting opiates are prescribed for individuals with chronic pain conditions that require pain management round-the-clock, the pain sufferer may turn to the street to supplement their supply.  

Addiction

Drug addiction can be defined as continued use of a mood-altering chemical despite life damaging consequences.  Identifying true addiction in pain management patients is often complicated by the fact that patients in full-blown addiction are usually quite manipulative.  They will do or say whatever is necessary to obtain their drug of choice. The following behaviors are primary warning signs:

  • Using all of a prescription before the next refill (running out)
  • Requesting higher dosages or stronger drugs, especially over time following surgery or an injury, as pain should be diminishing
  • Requests for replacement prescriptions due to "lost", "stolen", "accidentally damaged" or "accidentally destroyed" prescriptions

Additionally, family members, patients and health care practitioners should look for the following:

  • *Continuing to abuse the drug despite significant adverse consequences: Patients that continue to abuse pain medications despite legal troubles, financial difficulties, social problems or family problems directly related to the use and abuse of the substance(s).
  • *Obsession: When a pain management patient obsesses about their medications, is constantly worried about running out etc.  They might become preoccupied with obtaining, using, recovering from, hiding, or glorifying their drug of choice, or otherwise obsess over some aspect of the drug.

Pain Management and Addiction Treatment

If you or someone you know may be having trouble with pain management and addiction, there are effective treatment methods available.  The most important aspect of treatment is to have a direct and open dialogue between the patient and the practitioner.  Both should be honest with each other about expectations and goals - but also about restrictions and limitations.  Patients can enter into structured treatment agreements or contracts with providers to manage dependency and still treat for pain if necessary.

When an addict needs pain control, precautions can be taken to help avoid unmanageability  Having a 3rd party dispense the medication, such as a family member or trusted friend, can go a long way toward preventing tolerance from spiraling out of control.  This method of medication management, and treatment agreements with providers often work well in conjunction with a plan for tapered reductions in the pain medication followed by a medical detoxification program if necessary.

For severe or repeated bouts with addiction to pain medication, structured treatment at a drug rehabilitation center may be indicated.  This type of treatment is usually preceded by medical detoxification

Addiction to painkillers affects millions of Americans, from all walks of life.  Anyone who is forced by surgery, illness, or injury to take pain medications for an extended period of time can become addicted.  Becoming educated about the addictive liability of prescription opioids is the best defense against the potential pitfalls of addiction when faced with the necessity for pain management. Vigilance is integral part of any responsible pain treatment program.

For additional information, check out:

http://www.medscape.com/viewarticle/448468_3

http://pain-topics.org/pdf/Tennant-PainSigns.pdf

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