I have blogged on the topic of pain twice, once on coping with the emotional aspects of pain and then on the topic of coping with physical pain. Lately I've been thinking about another aspect of pain, the idea that we may become addicted and the role that plays in how individuals with chronic pain use their pain meds.
The Idea of Addiction
Let's face the truth here, many people who suffer from chronic pain regardless of source are given short-acting opiates to deal with the pain. Short-acting opiates can be anything from Tylenol 2's to Percocets, Vicodin, etc. Unfortunately for us, there has been a huge increase in the number of reports of abuse of these medications. Perhaps it's because pain is a subjective thing. When you report pain to your doctor, they can't tell visibly that the pain is there, they can't deny that you are feeling pain. Thus it would be easy for a person seeking pain meds to go to a doctor and "pretend" the pain symptoms are there just to get access to the drugs. Not to mention that drugs such as percocet, oxycodone, and Vicodin have a high retail value on the streets. It's much easier to hide this type of addiction than it would be to hide an addiction to heroin or cocaine.
Due to the rise in abuse, doctors have become more aware of the dangers in prescribing these meds. Specialists tend to not want to prescribe pain meds as they usually don't see you on a regular basis to keep tabs on you. I had one doctor tell me that it would unethical of him to prescribe me anything for my pain but that he would send the recommendation back to my family doctor. But what if your GP didn't agree with the specialist's recommendation and denied it all together? It's a real problem.
A Chronic Pain Patient's Nightmare: Prescription Addiction Assessment
Prescription addicts are a chronic pain patient's worst nightmare. How so you ask? Well due to the individuals who abuse prescription narcotics, many individuals with legitimate needs for pain medication, cannot have access to the type and/or amount they may require.
An addiction is a psychological issue where the person is dependent upon a substance for their day-to-day functioning. Sometimes it's a mild addiction where the person can function and think about other things other than how to get their needs met. However, in the throes of addiction, individuals are motivated to find how and when their next source of meeting their needs will be. This becomes drug seeking behaviour. Doctors have come up with a list of common drug seeking behaviours which is often used in determining whether our complaints are legit or whether we are just looking to "score". This list has been put into the form of a Risk Assessment which the doctors can use to determine if we might be "drug seeking".
We can fit the profile of those who abuse prescription drugs. We complain of constant pain, and many health practitioners still believe that we are exaggerating. This is most likely due to the myth that us endo patients are nothing more than people who cannot handle normal menstrual cramps. Many of us who have been "around the block" long enough, know which prescription drugs are effective for us and we ask for them by name. This is listed as one of the red-flags of a drug-seeker. We are penalized for knowing too much. And many of us, despite our illnesses are still able to work, which means that we have the means to feed our addiction. Let me give you a personal example of how this has affected me:
I have been taking prescription narcotics on and off since I was in my mid-teens. I am allergic to NSAIDs (non-steroidal anti-inflammatories) which is the first line of pain meds that many doctors would prefer to use. So when a doctor offers me NSAIDs I will politely turn them down and say that I'm allergic to them, which is all too easy for an addict to say. It would be unethical for a doctor to prescribe you a medication for which you are allergic, so there is really no way of proving this statement. As I have taken so many narcotics, I tend to know what works best for me. I don't believe that this is drug-seeking a particular drug, but I think that it's useful knowledge that can save time and frustration over prescriptions that don't work. Unfortunately, when I say by name what works, I'm often met with resistance. Tylenol 2's or 3's are essentially useless to me, especially after being on and off oxycodone (percocet) for the past several years and having been on a high-dose fentanyl patch. Thus, when I go to the ER with pain complaints, and shoot down their first suggestion for either Naproxyn or Toradol, it's no wonder that I've been flagged as a potential drug seeker. Yet all I want, all anyone wants, is relief to their pain.
Addiction VS Tolerance
As said above, the addict is motivated to seek drugs based upon their psychological need. This is quite different than a naturally occurring physical dependency or the increase in pain medication tolerance levels that many of us chronic pain patients experience. Research has informed us that if you take any medication long enough, your body can become physically dependent upon it. I have experienced this first hand with my two year usage of fentanyl. This is a very strong drug that is given quite a bit to cancer patients. I had switched pain doctors and needed to come off the fentanyl patch. For two weeks, all I could do was lay in bed, shake and pace. I honestly didn't know whether I was going to make it through. That is the physical addiction. With short acting pain meds, research has also informed us that we tend to become used to the drug and require more of it in order to get the same amount of relief. This is what is known as tolerance. And it is naturally occurring all the time.
Chronic Pain Management in the Face of Addiction
As mentioned, many doctors have now become increasingly aware of the problem of prescription drug abuse and thus have limited their number of prescriptions that they give out. As a result, many chronic pain patients tend towards under-treating their chronic pain. The problem with this is that those pain signals travel through the Central Nervous System and over time, build up more and more pain receptors to match the number of pain signals. When the CNS is flooded with pain receptors, there is the likelihood that we are going to be sensitive to non-painful stimuli as a result of a hyper-stimulated CNS. Research has shown that chronic pain patients are less likely to become addicted to pain meds, as they try to conserve whatever pain meds they have left over in fears that they will not be able to get more for when the pain is even more severe.
I have experienced this in the past two weeks with my back, which I just found out is a torn spinal muscle. My doctor gave me a limited number of percocets, so I would use them scarcely. Even though the pain would be a 9/10, tears streaming down my face as I vomited from the pain, I would be thinking, "what if the pain gets worse and I need them more then?". So I under-treated my own pain. This is far from ideal pain management.
What really gets me is that I was approached by a lady who does services for people within their homes. Upon mentioning her pain to her customer, the customer, rather than offering her a tip offered her a bunch of pain meds. I think that this type of behaviour is a real problem and doesn't do anything to help out the image of those who are trying to access pain control through legitimate ways.
So what can we do?
We need to communicate with our healthcare team as openly and honestly as possible. Keeping a pain journal is a great way of showing the doctors that you take your pain seriously. For pain journals please see my post on coping with pain. As well, don't be quick to rule out your doctor's recommendations for alternative therapies. If you shoot down the doctors ideas before even giving them consideration, this can signal to the doctor that you aren't interested in trying all that you can do to relieve your pain. Consider going to pain management, sometimes it's best to go to the specialists who deal with what you have to put up with every day. Pain clinics exist for chronic pain patients to use. My posts on coping with emotional and physical aspects of pain have some good ideas for pain management as well.