Is it Pain or is it Addiction?

While ICDO doesn’t specifically treat chronic pain conditions, it is worthwhile to discuss the important link between Opioids, Pain, and Addiction.

Opiates have been used for thousands of years and even then, it was recognized that people could become dependent on these drugs and have a difficult time trying to stop using them. Prescription drugs, mistakenly referred to as prescription narcotics, are the #1 choice for new illicit drug users because they are readily available. Prescription drugs are second only to alcohol, cigarettes, and marijuana in frequency of abused drugs.

Opiates vs Opioids

What are Opioids?

With so many of them out there, talking about opioids can be confusing. Opioids are a family of drugs that have morphine-like effects. The primary medical use for prescription opioids is to relieve pain. Opiates are drugs that are derived from the opium poppy. These include opium, codeine, morphine, thebaine and heroin. Opioid means “opiate like” and refers to modern pain medication that are synthetically derived, but chemically similar to, opium. The synthetic drugs include methadone, Oxycodone (Percocet and Oxycontin), Hydromorphone (Dilaudid), Hydrocodone (Hycodan), Fentanyl (Duragesic), Meperidine (Demerol), buprenorphine, Tramadol, and Tapentadol. Opioids can also produce a high, making them prone to abuse. Some people use opioids for their ability to produce a mellow, relaxed high.

opioids_diagram

Methadone and buprenorphine (the active ingredient in Suboxone) are opioids prescribed to treat addiction to other opioids – they are the only approved opioid medications for opioid addiction. It is NOT acceptable to give an addicted patient any other opioid such as morphine, oxycodone if they are addicted.

Chronic Pain vs Addiction

Most people use medications appropriately for pain, however, there is considerable overlap between chronic pain and addiction and a significant “grey area” between the two. Some, but not all, people start treating pain, only to end up with an addiction to prescription medication. The psychological and physical cycle is vicious.

addiction_dependency

Even in patients who are very motivated to cut down on their opioid medication, it is very difficult to taper down because the withdrawal symptoms are excruciatingly uncomfortable.  Opioid withdrawal symptoms include:

  • Runny nose
  • Watery eyes
  • Nausea, stomach cramps, vomiting, diarrhea when things get bad
  • Extreme joint pain
  • Extreme muscle aches, sometimes with uncontrollable spasms.
  • Extreme agitation, restlessness, and anxiety, sometimes panic attacks
  • Severe depression, often associated with thoughts of self-harm
  • High blood pressure and racing heart
  • Goose bumps
  • Hot and cold chills
  • Sweating
  • Dilated pupils
  • Yawning
  • Untreatable Insomnia
  • Intense cravings

dependence_cycle

It should be noted that withdrawal from opioids always includes significant pain, particularly at the site of old injuries or surgeries, making some patients believe that their original pain is getting worse and “they need the medication” as “it’s the only thing that works.”  What most patients worry about is the first two weeks or so of feeling deathly ill.  What physicians worry about is Post-Acute Withdrawal, which can happen weeks or months later and is associated with insomnia, anxiety, and severe depression, often with suicidal thoughts.  Unfortunately, those patients who return to using opiates are at high risk of unintentional overdose at this time because their tolerance has decreased during the time they have not taken any medication.

 

Those At-Risk of Becoming Addicted to Opioids

Risk factors for addiction in the chronic pain patient include:

  • Family History of addiction
  • Personal history of addiction (drugs and alcohol)
  • Psychiatric history
  • Bipolar, depression, OCD, schizophrenia, ADHD, and chronically anxious
  • Smoking
  • History of sexual abuse
  • Legal problems
  • Age 16-45
  • Aberrant Behaviours – Medical professionals use certain tell-tale signs, in addition to regular drug screening, to help determine which patients are not and require treatment for addiction. The following is a comparison of patients with chronic pain to those with an addiction.

Clinical Features

Patients With Pain

Patients Addicted to Opioids

Compulsive drug use Rare Common
Crave drug (even when not in pain) Rare Common
Obtain or purchase drugs from nonmedical sources Rare Common
Obtain drugs through illegal activities Absent Common
Escalate opioid dose without physician consent Rare Common
Supplement with other opioid drugs Unusual Frequently
Demand specific opioid agent Rare Common
Can stop use when effective alternate treatments are available Usually Usually Not
Prefer specific routes of administration No Yes
Can regulate use according to supply Yes No
Run out before end of prescription or “lose” prescriptions No Yes
Have urine drug screens positive for other drugs No Frequently
Medication is used to treat non-pain conditions (such as anxiety and depression) No Frequently

 

Signs of Opioid Addiction in Chronic Pain Patients

Being able to tell the difference between pain and addiction is challenging, in fact, many physicians find it difficult to differentiate the two.  That is because Pain and Addiction can happen along a continuum.  Most pain patients will become physically dependent on pain medication, even after 3 or 4 weeks.  This does NOT mean that all pain patients will become addicted, even if they are physically dependent on their medication, but it does make it harder to know when you are treating pain, addiction, or both.

It is challenging to know the difference between pain and addiction.  The following list may help you decide.

Telltale Signs of Addiction to Pain Medication

  • Mood swings/bad temper/agitated
  • Overwhelmed
  • Tension in the home
  • Out of control arguments
  • Bored
  • “Foggy headed”
  • Not completing necessary tasks
  • Worried about being left alone
  • Others express concern
  • Close friends/family with drug/alcohol problems
  • Feel others keep them from getting what they deserve
  • Legal problems
  • Attended AA or NA before
  • Borrowing medications
  • Lending medications
  • Buying medication from street sources
  • Multiple doctors/Multiple Pharmacies
  • Consumed by need to get pain medication
  • Emergency Room visits to get pain control
  • Emergency calls to doctor’s office
  • Showing up at the doctor’s without an appointment
  • Impatient with doctors
  • Much time spent obtaining, using, scheduling medication
  • Need for higher doses of medication for pain
  • Taking medication differently than prescribed
  • Taking pain medication when not supposed to
  • Running out of medication early
  • Counting pills to see how many remaining
  • Concern about people judging about pain medication
  • Treating anxiety, depression, agitation, energy, stress with pain medication
  • Craving for medication to cope
  • Thoughts of self-harm

Remember, there is NO evidence to suggest that long term opiate use is helpful for “chronic pain.” There IS evidence to suggest that there are significant harms with long term opiate use. Some patients have both pain and addiction – they are not mutually exclusive.  It takes an experienced physician to be able to treat both.

If you would like to find out your risk for Opioid addiction, take this Quiz:

https://turntohelp.com/self-screening/