Names and personal information of patients interviewed in this article have been changed to protect their privacy.
- John is a 52-year-old professional educator. During a rainstorm two years ago, John fell outside his office. Diagnostics from a neurologist and orthopedist revealed one herniated and one ruptured disc, plus complications from previously undiagnosed arthritis. Providers treated him with escalating interventions including physical therapy, anticonvulsants, higher doses of opioids and corticosteroid injections. Eventually, John had surgery for the back problems. He asked all his health-care providers, “If I need higher doses of medicine, won’t I have withdrawal symptoms when I stop taking them? Won’t that mean I’m addicted?” John’s health-care providers had varying responses to his questions about taking pain medicines.
- Marianne, 42, has an escalating and ongoing problem with Crohn’s disease. Her physician wants to prescribe an opioid medication in addition to a TNF inhibitor. Her childhood friend, who is in a recovery program for alcoholism, has insisted strongly that she not take the pain medicine. “It is too easy to get addicted to these kinds of medicines, and you really don’t want to deal with the problems that will cause.”
- Arthur is 66 and in long-term recovery for addiction to opioids that were prescribed originally for low back pain. Last year, he had a bout of shingles, a common viral infection that causes an intensely painful rash. He developed postherapetic neuralgia, a complication that causes ongoing nerve pain. His physician discussed prescribing opioid medicines to treat the pain, but Arthur said, “This is an absolute trigger for me. I’ve never relapsed and certainly don’t want to start these kinds of pain meds again.”
These three case studies have a common thread—taking pain medicine (opioids) can result in addiction. While prescription opioid addiction is a common tabloid headline when it sends celebrities spinning out of control, it also plagues those out of the spotlight who grapple with addiction behind closed doors.
Health-care providers wrestle with how best to treat the approximately 116 million Americans who live with acute and chronic pain. Their dilemma stems from the potential risks of long-term treatment, such as the development of drug tolerance, the need for escalating doses, increased pain sensitivity and addiction. Many patients are reluctant to take a prescribed opioid medication for fear of becoming drug dependent.
How common is the problem? Estimates of addiction among chronic pain patients vary widely, from about 3% to 40%. This variability results from insufficient research on outcomes, study populations and measures used to assess abuse and addiction. Addiction to prescription painkillers is widely misunderstood by the general population, which can be dangerous and frightening for patients dealing with pain. Where is the line between appropriate use and addiction to prescription pain medicines? How can patients stay on the right side of that line without suffering needlessly?
The contemporary practice of pain management for individuals follows basic guidelines established by the Joint Commission on Accreditation of Healthcare Organizations in its standards for pain control, as well as by the World Health Organization in its stepladder approach to pain treatment. In the past, some important terms have been inappropriately used to define the term addiction.
– Physical dependence is the development of a physical withdrawal syndrome following abrupt dose reduction. Physical dependence does not indicate the presence of an addiction but is a normal physiologic consequence of chronic use of medications.
– Tolerance is the normal physiologic response at the cellular level to chronic use of a medication that results in requiring more of the drug to elicit the same physical response.
– Substance abuse is defined as use of any illegal substance or inappropriate use of a controlled substance.
– Addiction refers to the chronic condition of an individual who is currently active in substance abuse that produces harm or dysfunction, or to someone who is in recovery from an addiction. Active addiction is frequently characterized by the presence of maladaptive, drug-seeking behaviors.
The word “pain” comes from the Latin poena, meaning a fine or penalty. It is defined as an unpleasant sensation that can range from mild, localized discomfort to agony and includes both physical and emotional components. The physical nature of pain results from nerve stimulation, known scientifically as nociception, which is the encoding and processing of harmful stimuli in the nervous system. It is the body’s private and personal ability to sense and respond to potential harm. Once stimulated, a nociceptor—a nerve ending that registers pain—sends a signal along a chain of nerve fibers via the spinal cord to the brain. Nociception triggers autonomic responses that result in the subjective physical experience of pain.
The emotional and affective experience of pain is described through the term “suffering.” In its broadest sense, it is the experience of unpleasantness and aversion associated with the perception of harm, or threat of harm, to an individual. Suffering rests at the opposite end of the continuum from pleasure. Brain structures, physiological responses and psychological processes are involved in both physical nociception and emotional suffering; their overlap creates difficulties and challenges in pain management.
“In my practice, about 30% of pain patients are primarily dealing with nociceptive distress, and the remaining 70% are principally suffering from the impact of the physical pain,” said Corey Waller, M.D., director of the Center for Integrative Medicine for Spectrum Health in Grand Rapids, Mich. He currently is president of the Michigan Society of Addiction Medicine and Chief of the American Society of Addiction Medicine’s Legislative Advocacy Committee. He said most pain specialists will take a pragmatic approach to pain, which he described as a “patient-centered pathway…and treat it as a primary medical problem. The key to interventional pain is held in good diagnostics. With accurate assessment, treatment can be well managed.”
The science of pain management has advanced significantly since the 1970s. Research in the last decade has provided the lion’s share of neurological findings in the field to the point that providers now can treat more from scientific evidence than from inclination. Medications are chosen based on their ability to afford adequate and rapid pain relief.
In Arthur’s case study, when he initially refused the prescribed opioids, his physician educated him on the need for a specific analgesic to interrupt his constant pain. Arthur countered the physician, saying, “I’m afraid of getting hooked and needing to detox. I’m afraid of withdrawal. I fear if I start with an opioid, I can’t quit, so I don’t want to take this kind of drug for any reason, even though you say I may need it for pain control.”
Arthur’s physician said, “I will prescribe, and you can take, these medicines for the briefest time needed to create an accurate and long-term treatment plan. Your pain is chronic, and anything less than the right plan will be inadequate to address it. In my experience, undertreating the problem is just as much another kind of problem that might force you to consider self-medicating the pain.”
Waller concurred. “Opioids are used to treat nociception for a relatively brief time. The current research says clearly that long-term prescription of opioids is not an effective answer to pain management because of their longer-term side effects. With patients who are prescribed opioids, safety has to be weighed against the physical pain and the impact it has on that person’s activities of daily living.”
There are pathways of treatment that address both pain and suffering, said Waller. “There are many myths to counter. Pain management requires a practical approach. When I first meet with a patient, we’ll talk about what has worked in the past, and if opioids are indicated, I will prescribe for three days to assess the nociceptive response. We’ll meet again and get good perspectives for longer term management. There are as many emotional as physical decisions to be made, and these require a great deal of activity from both the patient and provider. We look at contingency management strategies to address symptoms. I want to answer every question a patient has. A drug seeker is easy to spot and easier to address.”
“My concern for patients in pain is long-term control that supports autonomy and a good quality of life,” he said. “Comprehensive treatment involves multiple avenues, including physical therapy, behavioral health and psychotherapy and physical exercise. The use of opioids is one part of the entire treatment approach to find the patient’s ‘sweet spot’ to effective management.”
In John’s case study, surgery eventually was indicated for his back difficulties. He said, “I exhausted all other possibilities and courses of treatment. The first neurologist was very good. She said, ‘Let pain be your guide.’ The pain continued to escalate over time as I moved through all my different treatments. I limited the ways that I could move through the day until I was quite impaired. I was terrified of pain meds and the anesthesia associated with the surgery. The surgeon referred me to a pain specialist immediately following the procedure. I did need the medications, and was able to back off from them quickly enough that I felt OK. I did have some withdrawal symptoms, but got good reassurance from the physician that I wasn’t addicted.”
Said Waller, “There is no reason for a patient to be afraid to be anesthetized or medicated on an opioid. These drugs are helpful when used the right way. Surgically, pain medications are a necessity. Post-surgically, they just require very careful attention.”
What to expect from the treatment process
What should you expect when being treated by a pain management specialist?
“Be ready to be actively involved in the whole diagnostic and treatment planning process,” said Waller. “You’ll be asked to participate in all stages. While you may be given opioids for a brief time, your physician is going to look for longer-term solutions that will reduce the amount of any addictive pain meds prescribed.”
Plans should be made with only one doctor who will prescribe all pain medicines, preferably a physician who is board-certified in addiction medicine. You will be encouraged to maintain stability at home and in the workplace while dealing with pain management. You can expect to be prescribed behavioral and physical health treatments.
“Prescription of pain medicine is contingent on involvement in physical therapy and mindfulness exercise, like yoga,” said Waller. “The goal is to keep the patient active and engaged. Share all your questions and thoughts with your doctor; you won’t be fired or accused of being an addict.”
“A good pain management specialist will have an evidenced-based understanding of toxicology and risk and will be able to help you make informed decisions to reduce the suffering that physical pain causes,” he said. “I explain the treatment approach using the metaphor of ocean tides. We look for the rhythms of the tides and medicate storms, not waves. As a pain doctor, I am like the detective Colombo—always looking for the bigger picture and examining what’s missing from it.”
You also will be asked your goal for treatment. “I want the patient to guide my approach and tell me what changes can be made to help him or her live the best quality of life that can be imagined,” said Waller.
He said pain specialists are not afraid to treat patients with opioids, and good pain control can be achieved for most individuals. He reminds patients that there will be a periodic weaning from pain medications to assess the pain syndrome and level of individual functioning, and that there will be a reduction of opioid use to the minimum dose necessary to relieve pain while maintaining an effective everyday life. Patients can expect that nonpsychotropic medications (drugs that have an effect on mental state) will be used whenever possible without sacrificing effective pain relief.
All three case study patients were prescribed opioids in addition to other treatments. Marianne, the Crohn’s patient whose friend was opposed to opioids, sought two additional opinions, from a gastroenterologist and an interventional pain specialist, before agreeing to the prescription. Both she and Arthur incorporated pain management, including medication, into their health and wellness routines. John recovered successfully from his back surgery, was discharged from treatment and said, “I’ve learned my lesson and walk much more carefully on slick sidewalks.”
A version of this article was published in the April/May issue of Pain-Free Living. Subscribe.