How do they treat prescription pain pill addicts who are genuinely in pain?

I’m talking about someone who has a genuine condition that causes them pain, but they’ve taken their pill popping to excessive levels. Complete abstinence (like they do with other drug addicts) doesn’t seem to be a viable option here. When they send them to Rehab, what do they do about that?

In my mother’s case, the pills to which she had become addicted weren’t even doing anything for the pain: they made her woozy without touching the pain at all, because they were for the wrong diagnosis.

The doctor who realized she’d become addicted to them cut her off cold turkey and told my father to ignore her insults, as “it’s the addiction talking”. They tried other treatments for the underlaying ailment and gave her painkillers from a different family: this different painkiller worked for the actual pain and did not make her woozy or prevent her from cursing us, insulting us, crying, yelling and, well, generally being extremely unpleasant to be around. This all happened while she was also depressed, so it’s not particularly easy to pinpoint a time when she stopped yelling that we were torturing her and moved to being quietly down; eventually the doctors were able to solve the physical problem (it had been a herniated disc all along) and, once she was able to walk again, she got out of the depression too.

There’s a note on her medical history to avoid that particular family of painkillers for her.

I think they do give them opiates in some situations, but there are lots of non-opiate options for multi-modal pain management, especially in hospitalized patients (it wasn’t clear to me whether you were talking acute pain or chronic pain).

  • NSAID’s and steroids (for inflammation causing pain)
  • Tylenol
  • anti-seizure type drugs, e.g., Lyrica (decrease reactivity of spine and brain; decrease wind-up pain, hyperalgesia, allodynia, etc.)
  • anti-depressants (modulate central processing of pain)
  • adrenergic agents (e.g. clonidine)
  • IV lidocaine drip (most often used for during/after abdominal surgery or similar)
  • lidocaine patches
  • capsaicin cream for arthritic joints
  • epidural or spinal anesthesia/analgesia - can be intermittent, constant drip, or patient-controlled
  • one-off injections or continuous infusion of local anesthetic over nearby nerves
  • local injections of steroids for inflammatory conditions such as arthritis
  • physical and occupational therapy for maximizing functionality and compensation for damaged areas

There are also several opiate-type drugs which have non-opioid-receptor mediated effects, such as tramadol, and drugs like buprenorphine which glom on to the mu opioid receptor but only excite it partially, producing less euphoria while retaining some analgesic effects.

In veterinary medicine, ketamine CRI’s (constant rate infusions) are not infrequently used post-op for painful procedures such as amputations, often in combination with opiates and lidocaine (a so-called MLK drip is morphine-lidocaine-ketamine in one bag); I don’t know how common that is in people. Neurokinin-1 antagonists, used in animals and people as anti-emetics, are also starting to be used in animals for their anti-inflammatory properties (I have a cat whose arthritis has been bothering her less since I started her on regular Cerenia), but I don’t know if that application has crossed over in to human medicine yet. It’s still gaining traction in the veterinary community.

This is actually not a terribly uncommon situation. For example, many palliative care patients with cancer need to use huge doses of narcotics simply to be comfortable from day to day. They are addicted, but the word “addict” in such a case is obviously non-pejorative.

If something comes up which is expected to cause these patients more pain, or is already causing them more pain, e.g. surgical procedure, transient pain flare due to treatment (e.g. radiation), etc., there is no reason that their dose of narcotic can’t be increased; and, it will be. Additionally, as mentioned by horsetech, there are a whole slew of non-narcotic options to manage pain.

In any case, the bottom line is that there is generally no limit on how much narcotic a patient can receive - if they’re having pain, simply increase the dose (or add in, or switch to, a different narcotic, i.e. some of the tolerance to narcotics is agent-specific. So, a patient using high doses of morphine, for example, may respond well to a rather modest dose of, say, hydromorphone (Dilaudid))

Tolerance to analgesia isn’t the same as addiction- not that anyone really uses addiction any more, the preferred term is dependence or misuse.

The cancer patient who requires 10 times the normally fatal dose of morphine just to stay comfortable has developed a physiological tolerance to morphine without the psychological “addiction”. They don’t want the morphine to"feel good" they want the morphine to make the pain bearable. In the rare cases when there is an actual cure for the pain these people can usually stop the huge doses of morphine without any problems, and don’t require treatment for addiction- once their physical need is gone they don’t have the psychological need for it.

The recreational pill popper has the psychological craving, physical withdrawals and tolerance, without the physical pain stimulus- not a good combo.

When you have actual pain, addiction isn’t a major issue- it is when the pain goes and the need for the painkilers persists, or when there never was pain to start with, thats when you have the issues.

Moderate to severe acute pain may often require opiates. Same for malignant pain. Opiate addicts (past or present) should not be deprived of opiates in these situations when other modalities have failed or are not appropriate. Any issues of addiction re-activation or detox can be addressed when the need for opiates is over.

Where the problems arise are in situations where opiate addicts are given opiates for chronic, non-malignant pain. This type of pain tends to not respond well to opiates in the long run anyway, so it really is a bad idea to use them in this setting. Other modalities should be employed as first, second, third, fourth, and even fifth choices, before considering opiates in this setting.

I was on opiates for about 9 months before I had a knee replacement. Four months after my surgery I quit taking them cold turkey. It was 10 of the most miserable days of my life. I had real pain. The medicine worked, but I was most definately addicted to them. If I had different life situation, and less responsibility, I would probably still be popping pills to this day.

That’s one of a number of reasons why many docs are now saying that using opiates for degenerative arthritis is not a good idea.

Cochrane Library

What about, say, diabetic neuropathy? The pain is chronic and it tends to get worse over time — are opiates still considered the best thing to alleviate it? Are any of the electronic devices for pain management an option for people in that situation?

It was a lifesaver for me. Tramadol had side effects that affected me mentally that made it prohibitive. The opoids helped with the severe pain and the resulting depression.

While the withdrawls were horrid, I was at least able to function and live a reasonably normal life.

Opiates are not considered good for neuropathy. They tend to stop working in a short time, requiring higher and higher doses. Eventually the patient ends up on huge doses of opiates, and has just as much pain as they had before starting on them.

Meds like amitriptylene, gabapentin, and pregabalin seem to work much better.

Join the club. I was on morphine for six months for sever lumbar pain. Finally had surgery, but had to stay on the stuff for another month.

My doc gave me a six-week taper-off schedule. Finally I got to the week ehere was supposed to take a reduced dose every other day.

On the skipped day, I felt awful, so I said, “What the hell” and decided to go cold turkey.

It was like the flue times ten. I stayed in bed for12 days wishing I’d die, but no such luck, and I finally was able to get up a do things. It was 15 days before I felt completely alright. Certainly one of the worst experiences in my life.

Now I understand those movie scenes where they lock an addict in a room while the suffers, moans and screams.

Sometimes it is difficult to tell if someone has a “genuine condition” that can cause pain: fibromyalgia and chronic fatigue system being two that come to mind (although there are supposed to be so-called “trigger” points establishing the diagnosis of fibromyalgia). This weeks’ issue of Time magazine has several articles concerning intractable pain. One possibility is a nerve stimulator implanted which overrides the pain sensation, and, instead, produces a tingling sensation, which is far better (but not perfect, of course). TENS units have been used for years, but I don’t think the medical evidence shows they are very effective.

If you want a detailed reading outside of the medical literature, pick up this week’s Time.