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Opiate Dependence Resulting From Treatment of Chronic Pain

75 million Americans suffer from chronic pain and most are prescribed opiate drugs to help manage their pain.In the past 10 years opiate use has increased markedly.In fact, from 1997 to 2005 major opiate sales rose over 90%.This widespread use of potentially addictive opiates has caused problems for many patients.The purpose of the next few pages is to help familiarize you with the risks of and alternatives to long term opiate use.

To tell if your opiate medication is effectively treating your pain, answer these 3 questions:

  1. Is your pain totally or mostly relieved, or at least significantly better?
  2. Is your function maintained or improved?
  3. Are the side effects (constipation, fatigue, mental clouding, respiratory depression, nausea, sedation, euphoria or dysphoria, and itching) tolerable?

If you answered yes to all three of these questions then you do not need to read any further, this is successful opiod treatment and needs no intervention.If you answered no to any of these questions, you are not alone.Many people who began opiate treatment for pain have fallen down the same rabbit hole, and need to change their method of treating their pain to improve their functioning and overall satisfaction with life.

Opiate medications are good for treating acute pain (initial, short term pain like that following surgery or severe injury) and terminal (malignant) cancer pain, but are not effective for treating chronic pain (long term pain lasting more than 6 months).The most problematic side effects of long term opiate use are tolerance and hyperalgesia.

Hyperalgesia is an increased sensitivity to pain, which may be caused by damage to nociceptors (sensory receptors that react to potentially damaging stimuli by sending nerve signals to the spinal cord and brain causing the perception of pain) or peripheral nerves. Various studies of humans and animals have demonstrated that primary or secondary hyperalgesia can develop in response to both chronic and acute exposure to opioids. This side effect can be severe enough to warrant discontinuation of opioid treatment.A common scenario is that a patient is prescribed an opiate during the acute phase of pain and then continues the opiate through the chronic phase in which pain is usually less, but because of opiod induced pain the perception of pain is distorted.This patient is now treating pain caused by the opiate, with more opiate.

Tolerance of the drug naturally occurs with long term use of opiates, requiring more of the drug to get the same effect.Hyperalgesia compounded by tolerance means the dose and number of doses per day has to continually increase.The increasing doses of opiates lead to decreased levels of functioning as side effects increase.Many patients report increased depression, frustration, anger, social isolation, dependence on others, and overall dissatisfaction with life.

Some Common Mood Altering & Potentially Addictive Opiate Drugs

(this is not a complete list)

Brand Name

Generic Name

Hycodan Hydrocodone/Methylbromide
Tussionex Hydrocodone bit/Chlorphreneramine
Actiq Oral transmucosal fentanyl citrate
Demerol Meperidine
Dilaudid Hydromorphone
Duragesic Fentanyl
Kadian Morphine sulfate
Methadone Methadone
MS Contin Morphine sulfate
Oxycontin Oxycodone
Oxyfast Oxycodone
Percocet Oxycodone/Acetaminophen
Percodan Oxycodone/Aspirin
Tylox Oxycodone/Acetaminophen
Lorcet Hydrocodone/Acetaminophen
Lortab Hydrocodone/Acetaminophen
Norco Hydrocodone/Acetaminophen
Subutex Buprenorphine hydrochloride
Suboxone Buprenorphine hydrochloride + naloxone
Tylenol/Codeine Acetaminophen/Codeine
Vicodin Hydrocodone/Acetaminophen
Vicoprofen Hydrocodone/Ibuprofen
Darvocet-N Propoxyphene/Acetaminophen
Darvon Propoxyphene
Stadol NS Butorphanol tartrate
Talwin NX Pentazocine

Some Other Common Mood Altering & Potentially Addictive Medications

(this is not a complete list)

Type Brand Name Generic Name
Amphetamines Adderal Amphetamine aspartate/Sulfate
Dexedrine Dextroamphetamine
Barbiturates Fioricet/Codeine Butalbital/Codeine/Acet/Caffeine
Fiorinal Butalbital/Aspirin/Caffeine
Phenobarbital Phenobarbital
Benzodiazepines Ativan Lorazepam
Dalmane Flurazepam
Halcion Triazolam
Klonopin Clonazepam
Librium Chlordiazepoxide
Restoril Temazepam
Serax Oxazepam
Tranxene Clorazepate Dipotassium
Valium Diazepam
Xanax Alprzolam
Hypnotics (for sleep) Ambien Zolpidem titrate
Lunesta Eszopiclone
Sonata Zaleplon
Muscle Relaxants Soma Carisopropodol
Equagesic Meprobamate/Aspirin
Stimulants Concerta Methylphenidate
Ritalin Methylphenidate

Mel Pohl MD, 2008. A Day Without Pain, Central Recovery Press, Las Vegas NV.

Indications of Problematic Opioid Use

  1. Taking more medication, more often than was prescribed by the physician
  2. “Doctor shopping”, or attempting to get prescriptions from multiple doctors.Also, repeated episodes of “lost” prescriptions
  3. Aggressively complaining about the need for higher doses or requesting specific drugs.An overwhelming focus on opiates during doctor visits that impede progress with other issues regarding pain management
  4. Hoarding or saving drugs during periods of reduced symptoms
  5. Taking pain medication to deal with other problems such as stress
  6. Stealing or borrowing medications from other patients
  7. Engaging in concurrent abuse of related illicit (illegal) drugs or alcohol
  8. Family members or others expressing concern about a person’s use of pain medication

Is opiate addiction the same as opiate dependence?

Yes and no.Opiate dependence and opiate addiction both result in withdrawal symptoms upon discontinuation of use. For this reason, both are initially treated the same way.Treatment involves education as to why chronic opioids are likely to maintain pain, detoxification, treatment of pain with non-opioid analgesics and other complimentary and alternative medicine, psychological support, coordination of care, and promotion of healthful behaviors. Detoxification alone is rarely sufficient.

The psychology of drug dependence is powerful and must be taken into account.

For the opiate addict, additional addiction treatment is necessary to avoid future relapse with the drug.The risk of addiction needs to be understood and built in to all treatment using potentially addictive drugs.

Opiate Addiction

Risk factors for addiction can be considered in three categories:

  1. Psychosocial factors
  2. Drug-related factors
  3. Genetic factors

The highest risk for addiction arises when risk factors in each category arise together. Pain patients with no genetic predisposition, no psychosocial factors, and taking stable doses of opioid for the treatment of severe pain in a controlled setting are unlikely to develop addiction. On the other hand, patients with a personal or family history of substance abuse, displaying one or several psychosocial factors, are at risk of developing addiction.

Ballantyne, J.,LaForge, S.(2007). Opioid dependence and addiction during opioidtreatment of chronic pain.Pain 129 (2007) 235–255

Signs of Addictive Use

  1. Continued use despite harmful consequences
  2. Withdrawal from family, friends, or other social activities
  3. Ignoring responsibilities such as work, school, family
  4. Increasing dose, number of doses, extending use without doctor approval
  5. Becoming defensive when confronted
  6. Being overly sensitive to normally sensitive situations
  7. Personality changes; energy & mood suddenly change
  8. Doctor shopping; visiting numerous doctors and ER’s to get prescriptions
  9. Forgetfulness
  10. Ignoring appearance/personal hygiene & changing eating and sleeping habits

Complimentary & Alternative Medicine (CAM) Treatment

CAM’s do work, there are volumes of experiences and research to support them.The reason they are not more popular is that they take time and effort to work.Sustained effort is required to maintain sustained change.The pill is reliable, although imperfect, in it’s effect;it only lasts a few minutes to a few hours.Medication has been the therapy of choice in treating pain for one reason – it is easier for the patient and the doctor.It requires no work on the part of the doctor to write the prescription or on the part of the patient to take the pill.However, in light of the rising epidemic of opiate induced problems, CAM’s are increasingly being used by doctors and their patients for relief from pain, return to functioning, and increased life satisfaction.

CAM’s work well when used along with non-opiod medications.These non-opiod medications, some originally used for other conditions, are helpful in managing pain.

Non Opiod Medications

Drug Class

Brand Name

Generic

Anticonvulsants Neurontin Gabapentin
Topamax Topiramate
Tegretol Carbemazepine
Depakote Valproic acid
Lyrica Pregablin
Antidepressants Elavil Amitryptilline
(Tricyclics) Norpramin Desipramine
Pamelor Morpramine
(SSRI/SNRI) Effexor Venfalxine
Cymbalta Duloxetine
NSAIDS Celebrex Celecoxib
Advil, Motrin Ibuprofen
Naprosyn, Aleve Naproxen
Indocin Indomethacin
Relafen Nabumetone
Muscle Relaxants Robaxin Methocarbamol
Baclofen Liorisal
Skelaxin Metaxalone
Flexeril Cyclobenzaprine
Xanaflex Tizandine
Topicals Zostrix Capacins
Lidoderm patches Lidocaine

Mel Pohl MD, 2008. A Day Without Pain, Central Recovery Press, Las Vegas NV.

For many pain patients, their pain becomes part of them.It defines them.It consumes their identity.In other words, they become their pain.But their pain is not who they are – it is simply the pain they feel.Chronic pain does not go away.But it can be diminished and controlled.The person can take control of their life back.Chronic pain does not have to mean chronic suffering.Many pain patients have learned to give up the opiates and manage their pain by using these techniques.When they do they report moments, days, even weeks, without pain.They report decreased levels of pain.They report increased ability to engage in joyful activities.They are able to live without the constant distraction of pain.They get control back from the helplessness of chronic pain, and so can you.

Following is a list and brief description of some Complimentary and Alternative Medicine (CAM) treatments from Dr Mel Pohl’s book, A Day Without Pain.These techniques are used in chronic pain treatment programs.Consider this a smorgasbord of options to pick and choose from.They work best when several are used in conjunction with one another.For more information about these treatments please ask your health care provider.

  • Exercise.When you are inactive your body becomes de-conditioned, which can add substantially to your pain.Exercise helps pain by decreasing weight and taking pressure off joints and vertebrae, increases flexibility which decreases stiffness and aches, builds strength to take pressure off joints and bones, increases serotonin levels which improve mood and blocks perception of pain in the brain, and strengthens the heart and circulatory system.Many chronic pain patients are resistant to begin an exercise program, fearing the movement will cause more pain.However, in reality – it is the lack of movement that causes more pain.
  • Nutrition. Eating “junk foods” is easy to rationalize when you are not feeling well.But eating healthy foods like green leafy vegetables, lean fish & meats, fresh fruits, and whole grains leads to being and feeling healthy which helps fight pain sensations.
  • Meditation & Imagery. When people meditate they can increase the amount of natural painkillers in their body and produce pleasurable brain chemicals.
  • Chiropractic therapy. Many patients report a reduction in pain with the use of regular chiropractic manipulations.There are hundreds of different techniques and manipulations used by chiropractors.
  • Physical therapy. Physical therapists use many different modalities to treat pain.They include manipulation, traction, therapeutic exercise, functional training, patient education and counseling about movement and body mechanics, ice & heat therapies, electrical currents, and other new techniques to remove adhesions.
  • Stretching, Pilates, Yoga, & Tai Chi. All of these methods work to improve pain on many levels;body awareness, mindfulness, core strengthening and awareness, postural balance, increased range of motion, spinal stability, stress relief, improved circulation,weight reduction, and inner peace.
  • Acupuncture. Acupuncture is thought to relieve pain by increasing release of endorphins (brain chemicals related to euphoria and happiness).Studies show that acupuncture is especially effective at relieving neck and low back pain.
  • TENS (Transcutaneous Electrical Nerve Stimulation). TENS units are small battery operated devices that produce a signal to interrupt pain transmission to the brain.They can be worn externally or implanted by a surgeon.
  • Massage & Aromatherapy. Massage relaxes tight muscles and tissues and improves oxygenation, circulation, and blood flow to painful areas.Aromatherapy claims to stimulate the brains limbic system awakening and strengthening the body’s self-healing chemicals.It works the same way as smelling freshly baked chocolate chip cookies makes you hungry!
  • Cognitive restructuring and psychotherapeutic therapy. Thoughts profoundly affect mood and the perception of pain.Cognitive restructuring of negative thinking about pain improves a sense of power and control over the pain and reduces the perception of pain.It also decreases muscle tension associated with the emotions of pain.
  • Hypnotherapy. Relaxation suggestion therapy can help change behaviors, like nail-biting and smoking.It is also helpful in treating depression, PTSD (post traumatic stress disorder), phobias, fears, anxiety, stress, and sleep disorders. It is helpful in treating pain by addressing the physical and mental aspects of pain.
  • Biofeedback. People are taught to control some normally involuntary processes such as muscle tension, blood pressure, and the perception of pain with the use of electrodes from a measuring device.
  • Support groups. People who experience chronic pain find that their pain is lessened when shared with other people who have the same experiences they do.When treating addictive opiate use, 12 step groups are the primary source for social and recovery support.For the non-addicted, chronic pain support groups are commonly held in hospitals and pain management centers.

Substitution Therapy

Medications such as Buprenorphine (Subutexand Suboxone) and Methadone are being prescribed by some physicians to treat some opiate dependent patients.The rationale motivating this therapy is to replace the addictive opiate medication with a less harmful synthetic opiate medication and eventually taper the patient off the drug completely.The problem with substituting one drug for another is that the patient becomes dependent upon the replacement drug and has difficulty tapering off the low doses of the medication.In most reported cases of Suboxone therapy the duration of Suboxone use has exceeded the time spent abusing.There is no evidence based data to suggest when or if substitution therapy can be discontinued.

These medications may be effectively used for 1 to 5 days during the medically supervised acute detoxification period, but long term use of these medications is only appropriate for a small percentage of the population.There are two situations where substitution therapy is beneficial:

(1)Once all other treatment options have genuinely been exhausted, it may be necessary to maintain a patient on a small dose of a substitution medication.

(2)The other appropriate use for substitution therapy is for palliative care (end of life care).Although it would be unusual to diagnose opioid misuse during treatment of terminal pain, this is not because terminally ill patients do not experience problems related to opiate drugs, but rather that it is not seen as problematic if they do.For them, the primary goal of treatment is palliation, not functionality, and therefore a substitution medication may provide better quality of life than continuation of high doses of opiates.

Naltrexone is another medication sometimes used to treat opiate dependence.Naltrexone is an opiate inhibitor that blocks the effects of the opiates.It does not have any pain relieving effects.It is used as a deterrent to taking opiates since any euphoric effect will be blocked.Again, using this substitution drug does not address the underlying problem; it shifts the dependence to another medication.Simply discontinuing the use of this medication, or any of the substitution medications, will reverse its effects.

References

  • Ballantyne, J. (2007).Opioid Analgesia: Perspectives on Right Use and Utility. Pain Physician 2007; 10:479-491• ISSN 1533-3159
  • Ballantyne, J., LaForge, S.(2007).Opioid dependence and addiction during opioid treatment of chronic pain.Pain 129 (2007) 235–255
  • Ballantyne, J.(2007).Opioid Misuse in Oncology Pain Patients.Current Pain and Headache Reports 2007, 11:276–282
  • Cicero,T., Inciardi, J., & Muñoz, A. (2005). Trends in Abuse of OxyContin® and Other Opioid Analgesics inthe United States: 2002-2004.The Journal of Pain, Vol 6, No 10 (October), 2005: pp 662-672.
  • Cummings, J.(2009).Chronic Pain Management.Lecture and accompanying written Materials, September 27, 2009.
  • Mendelson, J., Flower, K., Pletcher, K., Galloway, G. (2008). Addiction to Prescription Opioids: Characteristics of the EmergingEpidemic and Treatment With Buprenorphine.Experimental and Clinical Psychopharmacology 2008, Vol. 16, No. 5, 435– 4411064-1297/08/$12.00 DOI: 10.1037/a0013637
  • Modesto-Lowe, V., Johnson, K., Petry, N. (2007).Pain Management in Patients with Substance Abuse:Treatment Challenges for Pain and Addiction Specialists.The American Journal on Addictions, 16:424–425, 2007, DOI:10.1080/10550490701525566
  • Pohl, M. (2008).A Day Without Pain.Central Recovery Press, Las Vegas, NV.
  • Streltzer, J., Johansen, L. (2006). Prescription Drug Dependence and Evolving Beliefs About Chronic Pain Management. American Journal of Psychiatry 163:4,
  • April 2006
    Wikipedia.http://en.wikipedia.org

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