For several years, John had struggled with breakthrough pain, inflammation, and a host of chronic problems related to the progression of his rheumatoid arthritis (RA). His doctor suggested that John move from using a COX-2 inhibitor (a prescription-strength, nonsteroidal anti-inflammatory drug, or NSAID) to an opioid for better pain control. “This is the next step to help you,” the doctor said. “But these are narcotics, and they are addicting. I don’t know that I’m ready to go in this direction,” replied John. “There is a big difference between pain management and addiction,” said the doctor. “I’m prescribing these medicines to relieve your pain, not to get you high.”
What are opioids?
Chronic pain causes suffering and disability that can seriously impair a person’s quality of life. Opioids—also known as narcotics—are drugs that can help relieve such distress by blocking pain signals from reaching the brain. Drugs in this class are only available by prescription and are often sold in combination with other pain relievers, such as acetaminophen. Some examples of opioids are morphine (brand names Kadian, Avinza, and others), hydrocodone (found in Vicodin, among others), oxycodone (found in OxyContin, Percocet, and others), and codeine.
Opioids are considered safe and effective medicines for treating pain caused by different types of arthritis. But people with arthritis and their health-care providers are often reluctant to consider narcotics for pain treatment for a variety of reasons, including concerns about psychological and physical dependence. Doctors may also shy away from prescribing these drugs because they fear close scrutiny by—and the potential for sanctions from—licensing agencies, colleagues, and hospital review boards. And people who are living in pain may worry about loss of control and recoil from the stereotype of the drug addict living on the margins of society.
Some people are also reluctant to try an opioid because of the contempt they have already encountered from health-care providers who dismiss their pain. One woman said, “I have a hard enough time now when I go anywhere—the dentist, the gynecologist, the podiatrist—you name it. These professionals may understand acute pain, but they don’t understand chronic pain. They really don’t want to take the time to listen. My symptoms are heard as whining and random complaints. If they find out that I’m taking a narcotic for my pain, I’ll likely get labeled an antisocial drug-seeker. I have a hard enough time living with pain without having to deal with doctors, nurses, and technicians who become my judge and jury.”
Unfortunately, drug-seeking individuals without legitimate pain concerns do find their way into doctors’ offices, and this group of people can lead practitioners to become hypervigilant about narcotic misuse and addiction. Out of this caution, doctors can develop a tendency to “overcorrect”, leaving well-meaning patients on guard and defensive.
Treating chronic pain
Over the last decade, more sophisticated treatment regimens have been developed for chronic pain, which is defined as pain that persists over a long period, generally six months or more. Chronic pain is different from acute pain, which is usually sharp and begins suddenly. Acute pain is a useful signal that something has gone wrong in the body and needs assessment. Usually, a health-care professional is able to identify the source of the acute pain and provide definitive treatment.
However, for people with chronic pain, there can be a disconnect between the origin of the pain and the pain experience. Alternatively, there may be an ongoing cause of pain in the body (as is the case with arthritis). The goal of chronic pain treatment is to relieve a person’s pain and improve his day-to-day functioning and quality of life. A measure of success in this situation is when the person who has been living with chronic pain is able to say, “I have my life back.” Getting there, though, may require the use of strong drugs—including opioids.
Treating chronic pain requires a comprehensive approach that includes drug and nondrug therapies. People who have chronic pain may take nonopioid medicines, including NSAIDs such as ibuprofen (Advil, Motrin IB), naproxen (Aleve), or the COX-2 inhibitor celecoxib (Celebrex). A person may also take anticonvulsants for neuropathic (nerve-related) pain and muscle relaxants for muscle spasms.
These drugs are often used in conjunction with nondrug therapies such as physical therapy, exercise, and alternative approaches (such as heat and cold, massage, acupuncture, and electrical stimulation). Experienced and caring health-care practitioners will always treat a person first with these conservative options, keeping in mind the goals of pain relief and increasing quality of life.
If these more conservative forms of pain management aren’t effective, then a doctor may consider prescribing opioids.
Effective treatment with opioids is a collaborative effort between the person taking the medicine and his doctor, since doses must often be adjusted to best manage pain and minimize side effects. If you take an opioid, it’s also important to work with your doctor to monitor your emotional state and pick up on any warning signs that you’re developing dependence on the drug. The definitions in the next section can help you recognize whether trouble lies ahead.
Talking the talk
When talking about the use—and potential abuse—of prescription opioids, there are a few important terms to keep in mind.
Substances. Problems or side effects related to the use of substances are called substance-related disorders. Substances may include illegal drugs, legal ones such as alcohol or nicotine, prescription and over-the-counter medicines, and toxins such as poisons and pesticides.
Addiction. Addiction is marked by a craving for a substance to trigger a feeling of euphoria, or intense pleasure (also known as a “high”); drug-seeking in the absence of physical discomfort; and, in the case of prescription drug addiction, manipulation of the prescriber to obtain drugs.
Signs of addiction that doctors will watch for include unexplained deterioration of day-to-day functioning, inconsistent response to dosing regimens, preoccupation with medicine use, a preference for medicines with a high reward value, and rejection of nondrug treatments.
Intoxication. Defined as the direct physical effects of a substance on a person’s central nervous system, intoxication can develop during or shortly after use of the substance. Symptoms of opioid intoxication include constricted pupils, drowsiness, slurred speech, and difficulty paying attention or remembering things.
But intoxication and addiction don’t necessarily go hand in hand. As one woman told her doctor after trying a prescription opioid, “That medicine just makes me feel like I’m drunk, and I don’t like it.” While the woman felt intoxicated, she did not report addictive behavior. And while some people experience an initial “high” with opioid intoxication, many report the effect to be unpleasant.
Substance abuse. Substance abuse is marked by obvious impairment or distress as a result of taking a drug or other substance, leading to problems at work, school, or home. Substance abuse can place a person in physically hazardous situations, cause legal problems, and significantly disrupt his social and personal life.
For example, a doctor received a phone call from one of his patients, who had received a DUI (driving under the influence) charge while medicated on an opioid patch. The man who had been arrested asked the doctor to “give him an excuse” for the legal problem, but the doctor rightfully refused. This situation is an example of a substance-abuse problem that requires a close reevaluation of the risks and benefits of using that opioid, particularly since the patient had been educated about the effects of using the patch. He’d been told that the possible side effects of slowed response time, drowsiness, and impaired judgment make driving while wearing the patch dangerous.
Physical dependence. Physical dependence is perhaps the most important term to understand. In the context of pain management, it cannot be overstated that physical dependence is different from addiction. This distinction can be confusing, because opioids can produce both physical dependence and addiction. People who are treated with opioids often become physically dependent on the drugs, but only occasionally develop addiction.
Two of the main signs of physical dependence are tolerance and withdrawal symptoms, which are common in people who take opioids and certain other drugs, such as corticosteroids.
A person shows signs of tolerance to a drug when he needs to take greatly increased amounts of it to achieve the same effect. Stated another way, if continuing to take the same amount of the drug produces a markedly lessened effect in the person’s body, he has developed tolerance.
Opioids have several main effects and side effects, and tolerance is expected, though with individual differences. Some tolerance can even be a good thing. For example, tolerance to the side effects of drowsiness and nausea is common and desirable. However, tolerance to the side effect of constipation can lead to a host of GI problems.
Withdrawal occurs when a person stops taking a drug after prolonged, heavy use. The concentration of the substance in the person’s body drops sharply, triggering unpleasant symptoms that are usually the opposite of the effects of the drug. Withdrawal can be avoided by tapering, or gradually reducing the amount you take of the drug.
Pain doctors and treatment teams carefully evaluate their opioid-taking patients for signs of dependence—and draw clear lines between physical dependence and addiction. People who can’t adhere to a prescription schedule and insist on taking their medicine in certain forms or by certain routes, such as insisting on injections, show signs of moving toward addiction. (For more potential signs of addiction, see “Is It Pain Relief or Addiction?” on page 27.)
Walking the walk
There is no doubt that taking opioids increases the likelihood for substance abuse problems. Many individuals also report an increase in depression and anxiety when taking them. These are challenging risk factors. People who use these drugs for pain relief must be educated on their value and enter into active, thoughtful, and ongoing evaluations of whether the drug continues to do them more good than harm. Chronic pain saps energy, so people who take opioids need to reserve some emotional and mental resources to monitor the benefits and complications of the medicine.
People who are considering beginning opioid treatment must also expect close and careful scrutiny from their health-care team. This assessment will include very personal questions about medical, mental health, and addiction history to evaluate pain, mood, and misuse risk factors.
Prescription of opioids is rarely a front-line intervention; the use of these medicines is considered only after other medicines have failed to alleviate pain effectively. Together, the doctor and patient develop a treatment agreement with appropriate levels of monitoring to assess the opioid’s effectiveness, any negative or side effects it causes, and any drug-taking behavior outside of prescribed treatment routines. The treatment plan concretely outlines the responsibilities and commitments of the person taking the opioids and his health-care provider.
A middle-aged man named Ralph told his story. “My pain has increased over the years, and oxymorphone was finally prescribed. I was given Web sites and handouts and had a thorough meeting with a nurse who taught me about these types of drugs. I learned main and side effects and how I might habituate or develop dependence to them.
“I studied like I was in graduate school, so I went into it with my eyes wide open. I was also told not to take it personally, but that my use of these prescriptions would be monitored because of the fine line between opioid dependence and addiction. I take my medicine bottles back to the doctor and do a urine screen for drugs at each visit. This was a little embarrassing at first, because I felt like they didn’t trust me. I’m certainly not a drug abuser, but I came to understand that the adverse effects of the drug can sneak up on you. They also told me that I should be very cautious about talking about the medicines with other people because of stigma, misunderstanding, and potential for misuse. I’ve never thought my pain was party conversation anyway.”
As the doctor told Ralph, “I’ll see you frequently, and at each visit we’ll go over the ‘4 A’s’: analgesia (how much pain you’re experiencing), activities of daily living (how well you are able to do basic daily tasks), adverse events and side effects (what negative effects of the drug treatment you’re encountering), and aberrant behaviors (where we’ll look at any signs of drug-related changes in your behavior). I add a fifth “A,” which is affect, or your emotional state. I always want to know how you are feeling.”
The main difference between people who benefit from opioid treatment and those who struggle with drug addiction is that addiction tends to constrict a person’s life. A person who is addicted to a drug increasingly focuses his energy on getting and consuming the drug, while the rest of his life suffers. But appropriate pain management doesn’t constrict a person’s life—it expands it. Finding a way to manage chronic pain can help a person function better in his own life.
Is it pain relief or addiction?
People who take opioids and their health-care providers should know what kinds of behaviors may be warning signs of progression toward drug abuse or addiction. While no one symptom on this list should be used in isolation to diagnose a substance abuse or dependence problem, a person who is experiencing several symptoms should have a more thorough addiction assessment.
A health-care provider needs to know a person’s overall pattern of behaviors, as well as his current and past history, to make a diagnosis of substance abuse or dependence. These behaviors may include the following:
■ Clock watching for the next dose
■ Demanding behavior related to drug administration
■ Being overly sedated
■ Asking for or demanding specific drugs
■ Adding over-the-counter drugs and alcohol into the prescription “mix”
■ Personality changes
■ Family concerns that center around the medicine
■ Any attempts to obtain the same, or a similar, prescribed drug outside the doctor’s office