Chronic Pain vs. Opiate Addiction

Great Debates
1

Many doctors underprescribe opiate-based drugs to patients out of fear of addiction. Certainly opiate addiction is a horrible thing to go through, but what about chronic pain sufferers? I’ve seen one or two people on this MB complain that doctors wouldn’t prescribe pain medicine for their afflictions.

So, what’s worse : constant pain or being hooked on pills for the rest of one’s life? The prospect of going broke trying to finance a Percocet habit doesn’t factor into the equation at all since the stuff is dirt cheap. So how about it gang? Should one have the right to become an addict if one so chooses?

2

What’s worse is having chronic pain AND addiction.

3

One should have the right to become an addict if one chooses, with or without chronic pain.

4

I know I’m going to cause a stir by saying this but here goes…most doctors are right when they hesitate to prescribe under these circumstances. Why? Because they are clued in to the type of personality that WILL become addicted. What really gets to me is the doctors who don’t, the ones who do “overprescribe” and allow their patients to become addicted. There are other ways to manage pain. I have no scientfic data on this only observation. It has been my observation with people who become hooked on prescription drugs after an accident or injury that they LOVED the stuff. Or they at least seemed to thrive on the attention they received by constantly talking about their pain. They seem to have the right personality for addiction. (I’m not really sure I’m saying this right.) While others become determined that their afflictions will not completely destroy the quality of their life.

This is not to say that most people can indeed use pain medication responsibly. I would imagine that as rule this is true. I’m just suggesting that doctors are hesitant, and a good one should be, about prescribing potentially addictive drugs.

Needs2know

5

I have to disagree with needs2know on the subject of there being an “addictive personality”, and on the subject of “most people using pain medication responsibly.” Most people, when they’re in pain, don’t give a rat’s derriere about, “Oh, I’d better not take too many of these, because I might get–ADDICTED.” Most people, I would even say 99% of people, will instinctively keep on taking the pills until the pain stops.

(Side note, not on pain necessarily: there was a woman who died from liver failure a while back because she drank an entire bottle of Nyquil. She had a cold, drinking the recommended dosage didn’t help, so she kept taking more, and more, and finally the acetominaphen overdose shut down her liver, and she died. Vicks said, with perfect justification, “well, geez, people, what do you expect?” and AFAIK there wasn’t even the hint of a lawsuit, a rarity these days.)

OK, back to opiates. AFAIK, I am one of the most normal, stable (seriously) people I know, and because of migraine headaches and Tylenol 3, I had a brief but exciting brush with opiate addiction.

Not much to tell–no exciting montages of needles and gray-faced addicts, just that a doctor gave me the single refill prescription as a stopgap, and when I found out I couldn’t get any more, I was FURIOUS. Standing there, on the phone with his receptionist. For about 10 seconds. Then I realized what was happening here, and I took a deep breath and explored other methods of migraine pain relief.

The point is, the reason opiates have been addicting people unintentionally for thousands of years is because that’s just the way they work. I loved that feeling of drowsiness that I got from Tylenol 3.

I also had surgery about 15 years ago, when they gave me a “pain pump”, which I didn’t think worked at all. I think they had the dosage set low enough so as not to seriously addict me afterwards, but it sure didn’t do much by way of actual “pain relief”. I still hurt, but I still remained absolutely conscious and totally focused on when the next 15-minute beep would come.

So even very small amounts of opiates can become addictive. Look at all the women in the 19th century who were addicted without knowing it to various “female tonics”, most of which contained laudanum, a tincture of opium.

To answer the OP, I think doctors all have to make a very tricky decision as to how much opiate will dull the pain, without leaving the patient a hopeless addict afterwards. And no, I don’t think the patient has the right to demand to be addicted, because otherwise I would have been able to demand that my prescription for Tylenol 3 be refilled, and that my “pain pump” be reset so as to knock me out.

While, generally speaking, I’m against lots and lots of government regulation, still I think that some laws are a Good Thing, and I think the laws regulating opiates are a Good Thing, too.

As for the “right to become an addict”, I’m sorry but no. People don’t live in an isolated bubble, just “me” and nobody else. What you do affects everybody around you, and what they do, affects you. You can go live on a desert island and be an addict and I won’t object, but don’t complain if the outside world isn’t too regular with your shipments of “supplies”.

6

Notthemama:

That is quite a chain of reasoning. Are you aware of how much freedom you are offering to give up by supporting this argument? Particularly, this “what you do affects everybody around you” bit. You didn’t even specify that I had to be harming anyone, just “affecting” them.

What if I live alone off of savings, and my addiction won’t hurt anyone? Then, is it okay? And who is to judge which “affects” are allowable and which ones aren’t?

Am I the final arbiter of what’s best for me, or are you? Or a doctor? Or the FDA?

I’m sorry to see that your freedom means so little to you–it means a lot to me.

-VM

7

In my pharmacology class last semester, the professor who lectured on opioids (who, in my experience, really knew his stuff) inserted this document at the end of his handout. (He didn’t make us sign it or anything; it was mainly just a summary of his sermon on the subject.)

–
My Opioid Contract and Promise of Y2K

I will TREAT TO EFFECT! I will prescribe strong opioid analgesics for my patients who are in severe pain. I will not use Mickey Mouse drugs like dextropropoxyphene, codeine, tramadol, or meperidine for a patient who is in SEVERE pain. I will use appropriate analgesics for all of my pediatric, regular, and geriatric patients.

I will NOT wait until pain becomes agonizing; none of my patients will ever wish for death because of my reluctance to use adequate amounts of effective opioids.

I know that less drug is needed to prevent the recurrence of pain than to relieve it. I will CONTINUALLY control severe pain. I believe that Patient Controlled Analgesia is both efficacious and odes not lead to serious toxicity or excessive use by the patient.

I am NOT OPIOPHOBIC! My pain patient will NOT suddenly be transformed into a narcotics abuser after I give him or her a dose of an opioid. In fact, I know that there’s a 30-fold higher probability of me becoming an opioid abuser than my patients. Here’s why:

Three studies (Medina and Diamond, 1977; Porter and Jick, 1980; Perry and Heidrich, 1982) followed 24251 hospitalized patients that were administered morphine for chronic pain. The results indicate that only 7 (0.0029%) became addicted. That is, all patients were physically dependent upon morphine in the hospital during treatment for severe pain–but this is OK! All patients were detoxified so that they were not physically dependent on opioids before discharge from the hospital. Only 0.0029% turned to compulsive opioid use after they went home.

I know that the estimated incidence of opioid abuse among health care professionals is 1%. Yessireebob, one of our classmates!

Doing the math, 1% is 34.5 times greater than 0.0029%. By the way, I also know that the national incidence of opioid abuse is about 0.38%.

SO, I will watch myself if I enter a subspecialty which is associated with a high incidence of opioid abuse (Medicine, Anesthesiology).

SIGNED, this 24 of March, 2000.

I tend to agree with Dr. Iwamoto here–any doc who leaves his patients in chronic pain because he fears addiction is committing malpractice. A lot of docs are jaded because they’ve been taken for a ride by a few drug seekers, but that’s no excuse.

Here at UK, we have a whole clinic devoted to pain management. Some of my classmates who did an elective there say that you wouldn’t believe the change in people’s lives when the docs in that clinic actually do something about pain that might have been plaguing them for years. I’m going to do an elective there ASAP.

Dr. J

8

“The right to become an addict” is a bit disingenuous. The phrase calls up images of people using their free will to make some sort of informed choice. Having witnessed it in action, I can assure you it is not so.

Pain is a powerful persuader, and if intense enough, it will make up your mid for you. Torture, whether it comes from within or without, is irresistable after a point for most people. For those who don’t believe it, I propose a simple experiment. You get your left arm, and I get the right. Put a pill of any kind in your left hand. Meanwhile I get to twist your right arm up behind your back and pretty much do whatever I want. The experiment ends when you decide to take that pill. Then, six hours later, we’ll do it again. Every six hours in fact.

My predictions for the outcome: Sooner or later, you will take that pill. I would be willing to bet that you will take it again six hours later, and again after that.

I am not arguing that the current system is the correct one. In fact, I agree that opiates are underprescribed. However I am arguing that people do not always “choose” to become an addict in any normal sense of the word “choice.” When severe pain is an issue, everyone has a breaking point. There are people who would not “choose to become an addict” who nevertheless will if given easy opportunity. The immediacy of pain can be enough to override the poorly realized possibility of greater harm later.

9

I have to disagree…there are some people who are careful with medication, I am one of them. I will not take more medication than necessary. I refuse to allow myself to become dependent on medication. I have been in constant pain before. My doctor was not in the least bit leary of giving me percoset, although I usually used hydrocodone because it could be prescribed over the phone. I took it only during the first few days of my recovery. Then sporadically later, opting to use something less effective but safer, like Advil. Perhaps I am one of the few.

We may have to research this. I’d like to know where the idea comes from that opiates are underprescribed. The several people I know who are or have been addicted to prescription drugs have not had the slighted hard time in obtaining them. And the several people I have known who were in terrible pain, have not had any trouble getting what they needed to manage it. Of course these people were/are dying of terminal cancer. Is there stats on this…I admitted to only having personal observation here…where is your info coming from?

Needs2know

10

Here are some:
http://www.bazelon.org/pall8art.html
http://hivinsite.ucsf.edu/akb/1997/04nurse/index.html#Cg
(85% of AIDS patients with pain undermedicated)
http://www.hhs.gov/news/press/pre1995pres/920305.txt
and
http://www.hospicepatients.org/hospic30.html
(admittedly anecdotal but makes some good points)

On a personal note, as an RN for seven years, I saw MANY people die in pain when there was absolutely NO reason for it, other than they had horrible doctors. I can remember begging doctors to let me give someone a little more morphine. OTOH, I saw deaths that were pain-free, and some undoubtedly hastened by high opiate doses.

Keep in mind that the OP mentioned chronic pain. This is quite different than a surgery or injury situation where you might need to be on PCA (patient-controlled analgesia) pump or some Tylenol #3 or Percocet for awhile.

neutron star, are you talking about people with terminal conditions, or people who might live indefinitely with chronic pain? My answer would be different in these situations. When someone is going to die soon, there is no reason to use the term “addicted” at all. They do develop a physical tolerance, and their dose will continually need to be increased. They are never going to try to get off of the morphine or fentanyl or whatever, and are never going to experience withdrawal.

I don’t think people who are not terminal but have chronic pain should be allowed to become addicted to opiates - because they will either:
a. End up dying
b. No longer get any pain relief due to tolerance and dosage limits
There are many other treatment options, and they should be fully pursued.

-sulla

11

Unless you’re planning on “living off savings, locked into an isolation chamber with door-to-door drug delivery”, yes, your addiction will affect the society around you. How are you planning on having your drugs delivered? UPS straight to your door? Most addicts have to leave the house to get drugs, not to mention food, not to mention paying a few bills to keep the lights turned on and a roof over their head.

If you’re an addict, every time you walk down the street, you have an impact on society, and society has an impact on you. That was my point about “living in a bubble”. You don’t live in a “vacuum”, you bounce off other people, and they bounce off you. We call this a “society” or a “civilization”. And yes, part of the price we pay for living in a CIVILIZED society is that we give up part of our freedom for safety. Together, we agree on what laws should be passed to protect the majority from the dangerous minority. That “agreement” is what constitutes a civilization.

The society around you is the final arbiter of what’s best for you. If you lived in late 18th century France, what the society around you would have decided was best for you was that when you turned 17, you would join Napoleon’s army and help him conquer the world. And if your body ended up rotting in a ditch somewhere in Upper Saxony, well, there were always more 17-year-olds. A new crop, coming along every year.

If you were an Israelite living in any time period, what the society around you would have decided was best for you would have been that the foreskin of your penis would be cut off when you were 8 days old. If you were a non-Jew living during the same time period, up until mid-20th century America, at least, what the society around you would have decided was best for you would have been that the foreskin of your penis NOT be cut off. As a non-Jew living in mid-20th century middle-class America, chances are good that your society decided that your foreskin SHOULD be cut off.

If “total and absolute freedom” means so much to you, I suggest you explore relocation opportunities in Colombia, South America. If you’ve got the life savings, babe, the sky’s the limit. Anything you want. But don’t come crying to Uncle Sam when the local warlord decides he wants a piece of your action.

People who live in a place without law, i.e. with “total freedom”, have to make their own law. Nature makes a few laws of her own, too. “Survival of the fittest”? “Nature red in tooth and claw”?

12

Nothemama:

Your reasoning is making me a little dizzy.

First, you mention decisions that societies throughout history have made for members, as if I had denied that this existed. I have not. However, showing its occurrence does not justify it nor provide evidence that it is right.

Second, you have reacted as if I said that society should have no ability to regulate the behavior of its members. Once again, I did not. However, I believe I went to some effort to point out that we should all have an interest in keeping society’s influence in our lives to a minimum.

Third, you seem to think that I have denied that my behavior can have any impact on society or its members. Once again, I did not. Everything you or I do has some impact on some part of society or its members.

My point is this:

  1. The mere fact that my behavior has an effect on people does not justify taking away my right to decide what goes into my body. First, you need to at least show that I am doing someone harm.
  2. The fact that some people who are drug addicts do harm to others does not lead to the conclusion that all drug addicts do harm to others. In fact, there is clear evidence that this is not the case. However, I am not arguing that drug addictions never lead people to do harm. What we can conclude is that if I become drug addicted, I may do harm to someone.
  3. From my standpoint, the fact that I may do harm to someone does not justify violating my right to control what goes into my body. Once you start thinking along these lines, where do you draw the line? If I buy a gun, I may shoot someone with it. If I buy a steak knife, I may stab someone with it. If I go for a walk in the woods, I may harvest a poisonous plant and kill someone with it.

I am sure you enjoyed carrying my points to ridiculous extremes, but you have not, in my mind, justified your categorical denial of people’s rights to eat what they want, even if it is an addictive drug, even if it is bad for them.

-VM

13

Notthemama: Sorry about the misspelling.

14

Thank you for the links sulla…This subject interests me. Naturally I would respect your opinion since you are a health care professional and I am not. But I do need to make a few observations about the links you have given me. The first one states that many HIV patients are undermedicated for pain even though the general cause of their pain is often undetermined. What I found interesting about the link also was that it stated this practice was especially so in patients who are substance users. Doesn’t this seem to be a logical approach for a doctor? Wouldn’t it be dangerous for a doctor to prescribe high powered opiates to a known opiate abuser?

The other link concerned the use of opiates as pain management after surgery. It stated that infants, children and the elderly were often undermedicated. This also made sense to me. I am not saying that it should be an accepted practice, only that I can understand the problems inherent with using opiates on small children and the very old.

The link concerning the use of opiates for the dying makes perfect sense to me. People should not have to die in pain. But let me ask you this…Is there a danger of overmedicating a dying patient and thereby hastening their death? Isn’t that sometimes exactly what happens?

So let me ask you this…as a health care professional have you not witnessed the abuse of pain medication? How is chronic pain defined? What types of maladies can cause or contribute to chronic pain? The personal experience I have seen is that back pain is perhaps one of the biggest culprits. This is also where I have seen pain medication used very irresponsibly. Isn’t there other methods for managing this type of pain? I also have to agree with you, and that is the point I was making to start with. Doctors should be hesitant about prescribing potentially addictive drugs to people who are not dying. Their lack of restraint could cause an even more serious problem. What do you think?

Needs2know

15

OOPs…I almost forgot one more question…please bare with me. In your work as a nurse have you also observed that some individuals seem to “tolerate” pain better than others? If so, do you think this ability is based on physiology or psychological factors? Perhaps a combination of both.

Just a little story…A couple of years ago I required surgery on a shattered ankle. Afterwards in recovery I was on a morphine pump. I was in a good little bit of pain but hated the way the morphine felt when it entered my hand. It burned something awful. I hate an IV in the top of my hand anyway. I think most people do. I complained and the nurse removed the IV and gave me Percoset. I still hurt like the dickens, but at least the IV was gone. The next day I went home from surgery. I was just miserable. The swelling was so great that I felt like my leg would explode. I called the doctor crying and told him, he allowed me to take two percoset and advil inbetween. I got a major buzz, my daughter still talks about it because my behavior scared her a little. That night was the only time I allowed myself to do that. I only double medicated myself twice that day. The next day I went back to the regular dosage. I was also using ice packs. Within two days I had stopped using the percoset altogether except when I really felt I needed it. Otherwise I used advil. That isn’t very normal is it?

16

Yes. This is called the double effect principle–giving large amounts of pain medication to terminally ill patients in severe pain, even though the patient’s death is a foreseeable side effect. Note the subtle difference between this and deliberately giving medication to cause the patient’s death, which makes all the difference in the world from an ethical and legal standpoint.

The problem is that you have your malingerers (people who make up or exaggerate pain to get drugs or some other gain) and you have your people in genuine chronic pain. Although we have some really nifty tricks that we use to distinguish the two, it’s impossible to do so perfectly. Therefore, you have to pick a side to err on. Would you rather have a few people getting strong opioids who don’t really need them, or a few people not getting strong opioids who are in severe pain? I choose the former, myself.

I also think that even if you have a non-terminal patient in severe pain, addiction should be a secondary concern to treating the pain. Since physical dependence on opioids is predictable and treatable, you can plan on it and get the patient off of them when it’s necessary.

Dr. J

17

Eh, sorry, Smartass, I don’t have time for this.

18

Notthemama:

I know exactly how you feel.

-VM

19

The doctor’s decision probably has a lot more to do with overing his own ass when prescribing opiates than the wellbeing of a patient. Avoiding that malpractice suit by the addict or the addict’s family makes the final decision. You’re best off looking for the doctor who will prescribe what you need than taking one opinion.

In the end, a street smart chronic pain sufferer will easily be able to score opiates on his own be it pharmacuticals or recreational drugs. I’d much rather have the potential abuser prescribed the proper amount to keep the pain away and off the street looking for drugs. Sounds a lot like the methodone solution to me.

20

Notthemama:

This is a common scenario which should never, ever happen. Being undermedicated with opiates not only causes undue suffering, it’s actually more likely to lead to addiction than if proper doses are given. As Notthemama so accurately described, the patient spends a lot of time waiting for the next dose, yearning for the next dose, and needing the next dose. The patient becomes fearful of not getting the next dose, or of not getting enough. Obviously, it’s difficult to recover from surgery if you’re so preoccupied with pain and drugs.

My favorite surgeon routinely prescribes “5 to 10mg Morphine every hour, as needed”. (Most doctors will let you give a maximum of around 2mg every few hours.) Now, a dose of 10mg every hour would likely kill the average person, but this doctor recognizes that sometimes a bolus of 10mg is needed to get pain under control. Sometimes a patient can go a few hours needing little medication, but have episodes where a big dose is needed. Sometimes a patient needs a steady 5mg every half hour. He leaves it up to the nurse, but he’ll be royally pissed off if he comes in and finds his patient’s pain is not being adequately controlled.

Other doctors are so clueless (or callous?) about pain that they assume a paralytic, such as Norcuron, is adequate to control pain. Norcuron paralyzes the muscles, rendering the patient totally helpless (he can’t even breathe, so he must be on a ventilator) but totally conscious and alert. This must be like being buried alive. Giving a patient Norcuron without also giving a liberal dose of Morphine and/or Versed (a benzodiazepine, like Valium) is cruel and unusual punishment. I don’t anger easily, but I will personally chew a new one on any doctor or nurse who inflicts this torture on a patient.

Most people have the idea that it’s better to do without pain meds. This is so wrong. This is like saying it’s better to tough out a life-threatening infection without antibiotics, because antibiotics are for weenies. One of the first things I do when my coronary artery bypass patients wake up after surgery is give them my speech about pain meds. (It would be better if someone let them know this stuff beforehand.) It goes something like this:

"I want you to let me know every time you start to hurt. Do not wait until you are already hurting pretty badly to let me know. If you wait, it will take a lot more medicine and a lot more time to get that pain back under control.

"You have an incision from the base of your neck clear to your belly, with three chest tubes poking into your guts. No matter how hard you try, if you don’t get enough pain medicine, you will not be able to breathe deeply. You will not get addicted to the pain medicine. I have never seen a patient in your situation get addicted to the pain medicine, but I have seen many patients die of pneumonia because they refused to take the pain medicine and they couldn’t breathe deeply.

“When you are in pain, your body (and your mind) gets stressed out. If you’re hurting, your body will spend all its energy trying to fight that pain. If this happens, your body will not have any energy to heal. You will get better much faster if you take the pain medicine.”

This deals with acute pain, though, which is an entirely different critter than chronic pain. Opiates are generally not the best thing to use in managing chronic pain as sulla pointed out earlier. There are other, better methods and new ones are being developed all the time.

Doctor J- I would love to have the opportunity to work with you.