Chronic Pain

Pain is common but frequently under treated which leads to social costs such as “lost productivity, needless suffering, and excessive healthcare expenditures” but the concerns about addiction, fear of regulations and diversion seem to override those costs (8).  In “On Death and Dying” by Elisabeth Kubler-Ross, she states “There is not much sense in suffering, since drugs can be given for pain, itching, and other discomforts.  The belief has long died that suffering here on earth will be rewarded in heaven.  Suffering has lost its meaning” (17)  According to Dr. Joel J Nobel, cofounder, Emergency Care Research Institute, medicine’s purpose is to “prevent significant disease, to decrease pain and to postpone death when it is meaningful to do so” (18). Daniel Bennett, in his article “Breakthrough Pain: Treatment Rationale with Opioids” states “There is a quote by Dobrisa Cesaric that I would like to leave with you.”Some walk with their pain like an open wound for all to see. The others crush it into themselves and do not let it turn into tears of words." Remember to ask, believe, choose, and deliver to empower your patient for a better life and functional outcome” (21).  Primo Levi says ““If we know that pain and suffering can be alleviated and we do nothing about it, we, ourselves, are the tormentors” (21).  While these quotes on pain tell us many things, they don’t tell us how common pain is, what it is, why we have it, the costs of not treating it properly, and how it can be treated. 

 

How Common is Chronic Pain?

 Twenty percent of the adult population in developed countries lives with chronic pain.  Women and the elderly are the most common but children also have chronic pain.  Cancer accounts for 1-2% of adults in chronic pain.  Headaches and migraines affect less than 10%, neck and back pain 30%, and musculoskeletal and joint disorders cause about 30-40% of chronic pain.  In developing countries, pain in primary care is as prevalent as in developed countries (19).  Approximately 50-70 million people in the United States are under treated or not treated for their painful conditions (33).  Dr. Antonin and Dr. Beasley write that in a 1996 survey in Scotland 45% of the people who responded had chronic pain.  A follow-up survey was done in 2000 and 54% of the 1,608 people who responded had chronic pain.  Newly developed pain occurred in 8% of the people in those 4 years between surveys.  Annually, about 5% of the respondents recovered from chronic pain.  The findings of this survey are similar to the prevalence of pain in the United States (28).  90% of all diseases may have associated pain (34).  65 million Americans suffer painful disabilities (34).  75% or more of patients in hospitals suffer more pain than is needed (34). 

 

What is Pain?

There are two main types of pain: acute and chronic.  Acute pain signals damage or pending damage. Chronic pain remains after treatment and is no longer considered a symptom but can be considered a disease in its own right when the original cause of the pain has been removed or curative treatment is not possible (19).  There are psychosocial and physical changes that occur.  Chronic pain causes changes in the nociceptive system which cause signals of pain to the brain to become inappropriate (20).   Pain is an unpleasant and emotional sensory experience that warns us of actual or potential tissue damage.  Being unable to verbally communicate pain does not mean that it is not felt and does not need to be treated (23).  It is subjective.  What is painful to one person is not painful to another.  Stimuli that cause pain have the ability to damage tissue.  But sensations that are like pain but not necessarily unpleasant, like pricking, should not be called pain (23).

 

In acute pain, the nervous system acts to warn our bodies of danger of some sort.  In chronic pain however, the signals to the brain continue long after the danger has passed.  Chronic pain can stay long after the initiating condition is resolved.  There are many types and causes of chronic pain.  These include: headache, back pain, cancer pain, arthritis pain, neurogenic pain which results from nerve damage, and psychogenic pain which is not due to past injury or disease or visible signs of damage in the nervous system (24).

 

How Pain Works

Feeling pain is complicated.  Years of research has been done and there are still questions about what happens between when you hurt yourself and you verbally express that pain (27).  Severe pain is more attention grabbing and the location of the pain also has an effect on the perception of pain (27). 

 

There are types of pain aside from acute and chronic.  The main ones are: nociceptive, neuropathic, mixed and incident (or episodic) pain. The most commonly occurring pain is a mix of nociceptive and neuropathic pain which is referred to as mixed pain.  In pain that is incidental , the nociceptive pathways are activated quickly and dissipate quickly.  Incidental pain is different from breakthrough pain.  Breakthrough pain is pain that exceeds the baseline of chronic pain (12). Nociceptive pain is typically the aching or pressure feelings of pain.  Neuropathic pain centers in the nervous system.   

 

Chronic pain occurs due to the “gate theory”.  Simply put, the theory is that there is a mistake in the way the brain processes pain signals.  Pain signals are sent along the nervous system to the brain for processing.  The brain then sends signals back to the injury to sensitize the area and promote inflammation which in turns promotes healing by causing humans to be more careful of the injured area.  Healing chemicals are also sent to the site of the injury.  But, at times, the body signals itself that the injury is more painful and then the brain continues the cycle of increasing pain.  It seems that with chronic pain, some of the pain pathways stay open rather than close off, which leads to a cycle of increased pain.  Different types of sensations travel the pain pathway at different speeds.  Touch travels at about 200 miles an hour.  Acute pain at 40 MPH and chronic pain at speeds as low as 3 MPH.  The signal of pain travels to the spinal cord which releases chemicals called neurotransmitters to help it travel along to the brain.  Thoughts and feeling are also carried by neurotransmitters.  There are three neurotransmitters that ship pain along.  Substance P, NMDA and glutamate are the three.  If these three neurotransmitters did not exist, pain would be slow to reach the brain.  But in chronic pain there seems to be an overabundance of these neurotransmitters which causes pain signals to reach the brain more quickly.  Medications and other treatment methods can cause the level of these neurotransmitters to change.  The body itself has a way to alter the way these neurotransmitters flood the brain.  It forces the neurotransmitters through a pain gate in the spinal cord called the substantia gelatinosa of the dorsal horn.  Supporting the nervous system also helps this process by the fact that the better it works, the higher your threshold for pain can be (37).

 

Once the pain signal goes to the brain, the thalamus separates the signals it receives.  Not only does it receive pain signals, but it receives signals of hunger and thirst as well.  From the thalamus, pain continues on to the cortex and the limbic system.  The cortex is responsible for thought and the limbic system is responsible for emotions.  Together, these systems compare how serious the pain is, where it is, what to do and how to deal with it.  If it is not serious, the body then releases serotonin which causes it to relax, blood vessels dilate from their constricted state.  If the pain is serious, the body sends out norepinephrine, a form of adrenaline.  Norepinephrine is responsible for the “fight or flight” reflex. It causes vasoconstriction, your heart to pound, your muscles to tense and your nerves to become hyperactive as they wait to see what happens next.  Chronic pain begins here.  When the neurological system reacts and is not strong enough or it is too strong chronic pain can occur.  If it does not react strongly enough, your body does not release serotonin and therefore can’t relax.  This leads to the pain gate being left open or of more opening up.  As you become more alarmed those gates open and stay open.  This can lead to increased sensitivity in injured areas, which increases the cycle (37). 

 

Your body also releases its own natural opiates called endorphins, dynorphins, and enkephalins.  They are stronger than morphine but do not cause tolerance.  They fight substance P for space in the nerves to keep the pain signals from reaching the brain.  But when the amount of substance P is greater than the amount of endorphins etc. then it travels to the brain that much faster. 

After time, the pain gates cannot close due to the flood of pain signals running along them.  This leads to pain being “engraved” on the nerves that send the signals to the brain.  It is basically a memory that is a physical part of your anatomy (37). 

 

When the neurological system reacts too strongly, inflammation occurs and gets out of control.  Inflammation leads to greater sensitivity which restarts the cycle again.  Then it is no longer a symptom of pain but the cause of the pain. 

 

 Muscle spasms are another way the system can react too strongly to pain.  Some muscles spasms are purposeful in immobilizing the injured area.  But, when the nervous system reacts too strongly, it sets up a cycle of spasm-pain-spasm-pain.  These spasms can become permanent if ignored which leads to more pain (37).

 

The nervous system can improperly heal pain as well by creating imperfections in the nerves when they heal.  These imperfections then cause the nerves to erroneously send pain signals to the brain.  This is an explanation for phantom limb pain in amputees and why some people who are paralyzed can still feel pain in body parts that neither move nor respond to external stimuli (37).

 

Costs of Not Treating Chronic Pain

Annually, $120 billion are spent on or because of pain (34). Decreased functional status and quality of life result from under treating pain.  Many factors such as: “social, economic, political, legal and educational factors” contribute to the under treatment of pain.  Regulatory scrutiny, not understanding the differences between addiction and dependence, not knowing the regulations and a lack of medical knowledge of appropriate pain control also contribute to this problem (20).  Treating pain properly is the responsibility of the physician, but it is the responsibility of the patient to learn to properly advocate proper treatment for themselves.  Proper assessment and timely treatment are needed as is basing the dose and frequency of dosing of pain medication to the amount of pain, intensity of pain and length of pain.   Tolerance and dependence are normal parts of treatment and do not mean a patient is addicted to a medication (20). 

 

Treatment Options

 

Daniel Bennett states that there are five principles of treatment of chronic pain. 

Ask

Believe

Choose

Deliver

Empower

 

Doctors should regularly ask for an assessment of pain and function.  They should believe the impact and intensity of a patient’s pain.  They should choose therapies that are appropriate for the patient, deliver coordinating therapies such as medicine, diagnostics and intervention.  They also need to empower the patient and their support system in order to make changes available (21).

Patients in chronic pain experience a degree of pain at all times.  Those that are not in chronic pain who have a sustained level of pain medicines in their system may be at risk for increased side effects to the medicines.  Each medicine that has an analgesic effect has a “therapeutic window” that if passed leads to absorbing too much medication.  It is desirable to maintain a level of the medicine in the system (21).  Unfortunately, periods of increased pain can happen.  They can be sudden, intense and inconsistent (21). But increasing the dose of sustained-release medications can lead to drug toxicity (21).

 

People with chronic pain have more options now to deal with that pain than they had 20 years ago.  All medications have side effects though.  There are two things to keep in mind when using pain medications:

 

1.  Find the lowest dose that controls your pain to limit side effects.

2.  “Stay ahead” of your pain by having a regular schedule of taking those medications rather than taking them as needed for predictable pain. (22)

 

Many options exist to treat pain: medications, acupuncture, local electrical stimulation, surgery, psychotherapy, relaxation, meditation, and biofeedback are some options. (24)  Combining therapies is called a “multimodality approach”.  Eight broad categories can be combined to achieve pain relief.  These are: drug therapy, rehabilitation, anesthesia, neurostimulation, surgical, lifestyle changes, and complimentary and alternative medication therapies (29).

 

The following is a large excerpt from “MODEL POLICY FOR THE USE OF CONTROLLED SUBSTANCES FOR THE TREATMENT OF PAIN” by The Federation of State Medical Boards of the United States, Inc. 

 

 

The Board has adopted the following criteria when evaluating the physician’s treatment of pain, including the use of controlled substances:

 

1. Evaluation of the Patient—a medical history and physical examination must be obtained, evaluated, and documented in the medical record. The medical record should document the nature and intensity of the pain, current and past treatments for pain, underlying or coexisting diseases or conditions, the effect of the pain on physical and psychological function, and history of substance abuse. The medical record also should document the presence of one or more recognized medical indications for the use of a controlled substance.

2. Treatment Plan—the written treatment plan should state objectives that will be used to determine treatment success, such as pain relief and improved physical and psychosocial function, and should indicate if any further diagnostic evaluations or other treatments are planned. After treatment begins, the physician should adjust drug therapy to the individual medical needs of each patient. Other treatment modalities or a rehabilitation program may be necessary depending on the etiology of the pain and the extent to which the pain is associated with physical and psychosocial impairment.

3. Informed Consent and Agreement for Treatment—The physician should discuss the risks and benefits of the use of controlled substances with the patient, persons designated by the patient or with the patient’s surrogate or guardian if the patient is without medical decision-making capacity. The patient should receive prescriptions from one physician and one pharmacy whenever possible. If the patient is at high risk for medication abuse or has a history of substance abuse, the physician should consider the use of a written agreement between physician and patient outlining patient responsibilities, including

a. urine/serum medication levels screening when requested;

b. number and frequency of all prescription refills; and

c. reasons for which drug therapy may be discontinued (e.g., violation of agreement).

4. Periodic Review—the physician should periodically review the course of pain treatment and any new information about the etiology of the pain or the patient’s state of health. Continuation or modification of controlled substances for pain management therapy depends on the physician’s evaluation of progress toward treatment objectives. Satisfactory response to treatment may be indicated by the patient’s decreased pain, increased level of function, or improved quality of life. Objective evidence of improved or diminished function should be monitored and information from family members or other caregivers should be considered in determining the patient’s response to treatment. If the patient’s progress is unsatisfactory, the physician should assess the appropriateness of continued use of the current treatment plan and consider the use of other therapeutic modalities.

5. Consultation—the physician should be willing to refer the patient as necessary for additional evaluation and treatment in order to achieve treatment objectives. Special attention should be given to those patients with pain who are at risk for medication misuse, abuse or diversion. The management of pain in patients with a history of substance abuse or with a comorbid psychiatric disorder may require extra care, monitoring, documentation and consultation with or referral to an expert in the management of such patients.

6. Medical Records—the physician should keep accurate and complete records to include

a. the medical history and physical examination,

b. diagnostic, therapeutic and laboratory results,

c. evaluations and consultations,

d. treatment objectives,

e. discussion of risks and benefits,

f. informed consent,

g. treatments,

h. medications (including date, type, dosage and quantity prescribed),

i. instructions and agreements and

j. periodic reviews.

Records should remain current and be maintained in an accessible manner and readily available for review.

7. Compliance With Controlled Substances Laws and Regulations—To prescribe, dispense or administer controlled substances, the physician must be licensed in the state and comply with applicable federal and state regulations. Physicians are referred to the Physicians Manual of the U.S. Drug Enforcement Administration and (any relevant documents issued by the state medical board) for specific rules governing controlled substances as well as applicable state regulations.

 

One of the most underused therapies is opioid therapy.  This statement shows the under treatment of pain with opioids. “Research shows that many people who do not have adequate pain relief with narcotic analgesics are either receiving prescriptions that under treat their pain or are not following the recommendations for those prescriptions because they fear side effects. For example, a study from the University of California at San Francisco interviewed cancer patients in their homes and found that fear of side effects was a major cause of inadequate drug use. In addition, fewer than a third of patients had been prescribed both as-needed and around-the-clock pain drugs as recommended by current guidelines”(22).

 

Opioids

Severe, unrelenting pain is often treated with narcotics, which are the strongest pain relievers and are typically used as a last resort.  There are a variety of ways they can be taken: by mouth, injection, patches worn on the skin, an implanted tube in the spine or a pump in the abdomen.  These medications are typically used in conjunction with other approaches to dealing with pain (22). 

 

With proper use, medicines such as opioids, which are also known as narcotics, can be useful in treating pain.  People with chronic pain do not typically become addicted to them, but may have tolerance or physical dependency develop.  This is different from addiction however (25).   With careful monitoring, the risk of addiction is small.  Once the proper dose is found, increasing dosage is not continually needed. 

 

At times, when pain is under control, there is a possibility to lower the dose or taper off of an opioid with no withdrawal. (25)  For many with chronic pain, opioid medications used under proper guidelines is the most effective treatment for pain and the only way to get “significant” relief (27).

 

Goals for treatment should be set at the beginning of treatment with an opioid medication.  Physicians should monitor their patients’ use of opioid medications (28). There are drawbacks to using opioid medications such as long-term side effects so treatment should be done on a patient by patient basis (28).  There are no perfect opioid medications.  A perfect one would be easy to take, have no byproducts, be easily absorbed and have minimal side effects as well as provide steady relief (21).

 

 When choosing a medication to use, a doctor should consider the opioid that conforms best to the ideal and is best tolerated and effective for the patient (21).  A trial use of an opioid medication should precede continual use in order to show which medication is most effective (21). Success of a therapy is based on achieving the goals set which most likely include: lessening the pain and increased function.  Adverse side effects should be noted during the trial and if the effect is greater than the relief or causes decreased function then a different medication may be needed.  A pain assessment and functional impact should be done initially as well as a physical examination and discussion of all diagnoses.  Expectations, goals, side effects, and length of the trial need to be discussed prior to beginning the trial (21.)

 

If an opioid is to be used as an interim therapy an end may need to be defined.   Too much pain can cause more damage and even death.  Medications to treat a disease or disorder that is causing the pain tend to work more effectively when pain is adequately controlled.  Treatment with opioid medications is one of the most humane treatments given to those with cancer and patients with chronic, nonmalignant pain deserve the same relief.  No ideal analgesic exists for chronic pain but those that work on the µ-opioid receptors are as close to the ideal as possible (9). The most effective of analgesics are opioid medications that include “all drugs that interact with opioid receptors in the nervous system” (30).  Endorphins are the body’s own form of narcotics and opioids are chemically related to them (30). 

 

How they Work and Different Type of Opioid Medications

Opioids are classed as antagonists, agonist-antagonists and pure mu agonists.   Antagonists have no analgesic effect and reverse opioid toxicity from overdose.   One of the antagonists treats alcohol addiction (30.) Some of the agonist-antagonists works by both activating and blocking different receptors or by only activating the mu receptor until the level reaches a specific point and then levels off and eventually drops.  These medications are used for more acute pain (30).  They have a “ceiling effect” which means that once a certain dose is received, no higher dose produces more relief.  These medications also cannot be given to patients who take other opioids because they can block the effect of them and cause withdrawal.  Some in this class also cause more confusion than the pure mu agonist class.  They can be used to treat both acute and chronic pain but have no advantages over pure mu agonists and have some disadvantages that need to be taken into consideration (30). 

 

The pure mu agonist class has been used as both short-term, acute pain management and for long-term chronic, non-malignant or malignant pain that is moderate to severe.  Slowly there has been a greater acceptance of the benefits of use of these medications for chronic pain (30).  There are many forms of pure mu agonists: codeine, hydrocodone, oxycodone, morphine, meperidine, hydromorphone, fentanyl, and methadone.  There are many forms of these drugs that range from: short acting oral preparations that may be combined with nonopioid medications such as acetaminophen or Ibuprofen; intravenous, subcutaneous, or intramuscular injections; to extended release forms of these medications, and transdermal patches (30).  These pure mu agonist medications have no ceiling dose and in fact can have dosages increased until side effects become intolerable.  Patients who get to the level of intolerable side effects before receiving a therapeutic level of analgesic relief are said to be “poorly responsive” to that medication (30). 

 

Opioids can further be classed as having either lipophilic or hydrophilic properties.  Those that are lipophilic tend to bind to fats; the hydrophilic ones are made up of water loving properties.  Because the nervous system is made up of lipids, lipophilic drugs enter the system faster than those that are hydrophilic.  The drugs that are higher in lipophilic properties are also more potent.  A higher potency leads to needing less of a drug to achieve therapeutic levels (21). 

Opiates mimic the “initial amino acid sequence of the body’s naturally occurring enkephalins and endorphins.”  Opioids are synthetic compounds.   Morphine is a hydrophilic class opioid.  This class binds to the mu receptor around 60% of the time.  Also in this class are compounds that are prodrugs after being ingested.  Simply put, that means that the compound is not an analgesic but must first have something act upon it to cause a byproduct that is an analgesic.  One of the enzyme systems is usually responsible for this occurrence.  One example of this is codeine which is converted by the body into morphine and then can begin to relieve pain.  If a patient does not have enough of the enzyme responsible for this reaction to convert to a prodrug, then there will be no analgesic effect from the medicine (21). 

 

The lipophilic compounds are all derivatives of meperidine but do not have toxic byproducts unlike meperidine.  Fentanyl is the only one available by any method other than intravenously or by injection.  Fentanyl can be given through a transdermal patch or by an oral transmucosal device.  Sufentanyl and lofentanyl are only available through intravenous methods.  According to Daniel Bennett, “fentanyl binds approximately 82% to 85% of its life to the mu receptor.  Sufentanyl is 92% and lofentanyl is 100%” (21).  Due to this, lipophilic compounds have a higher therapeutic effect than the hydrophilic compounds.  Morphine is a hydrophilic compound that can be helpful for end of life care but also for chronic nonmalignant pain.  It is commonly used after surgery (25). 

The potential for side effects in all of the pure mu agonists is the same but tolerance for the side effects varies by patient.  This means that an individual’s response to one opioid may not be the same response to a different opioid (30).

 

Side Effects

All opioids have the potential for addiction and increased tolerance.  Other side effects can be: constipation, sedation, confusion, nausea, itch, urinary retention, dry mouth and decreased breathing. Many of the side effects are only present when initiating therapy and subside after regular use (8, 22, 30).  However, constipation at times does require the use of stool softeners while taking opioid medications.   The risk of respiratory depression is typically short-lived, and also occurs in patients who are not familiar with taking opioids or in people who have overdosed.  If properly used there should be no fear or withholding of opioids due to respirator concerns (8).

 

Opioids are reasonably non-toxic unlike acetaminophen, NSAIDS or steroids.  Opioids, unlike the others,  have no specific organ toxicity.  Addiction and respiratory depression are the biggest dangers of using opioids and with proper use these dangers can be reduced or even eliminated (13). Patients with chronic pain unfortunately have to travel long distances at times to find a physician who will manage their pain (13).  Patients can receive improvement of pain and function when given effective treatment such as opioid medications with little risk of addiction (13).  Daniel Brookoff states "Opioid medications allow us to treat chronic pain as aggressively as we would any pathogen, but we must first overcome ingrained misconceptions about patients' motivations for seeking treatment and about the addictive properties of the drugs. With controlled use, the newer sustained-release formulations give real hope for safe and sustained pain relief."(16).

 

Addiction, Dependence and Tolerance

Addiction and physical dependence are different from each other.  Arthur Rosenfeld states in his book on chronic pain that “While most patients on a regimen of opioid analgesics report overwhelming relief, some still regard these medications with suspicion, failing to understand the important distinction between tolerance, physical dependence and addiction(2).  He goes on to define tolerance as “the body’s need for an increasing quantity of a medication in order to achieve the same therapeutic effect (2).  “Physical dependence, by contrast, is a known effect of certain types of medication and is characterized by symptoms of withdrawal that differ among medicines, be they sleep aids, opioid analgesics, blood pressure medications or the caffeine in our daily cup of joe.  Medically speaking, physical dependence is not to be considered to be either positive or negative (2).  Rosenfeld also states that addiction is different entirely.  It is in fact a disease that has both psychosocial and environmental factors.  “Exposure to pain medications, or to alcohol, for that matter, does not create addicts.”(2). Addiction is biological and demands exposure and a predisposition.  Rosenfeld also states that there is a form of pseudo-addiction where chronic pain patients with under treated pain mimic the behavior of those seeking drugs for a high.  “People in genuine chronic pain suffer the more because these distinctions are not generally understood” (2). 

 

Kathleen Parker stated in a 2003 article that it is unlikely you will become addicted if you use legal medications as prescribed.  At that time the research showed that the occurrence of addiction in all chronic pain patients was 6-10% and that the percentage of the general population that becomes addicted to shopping, alcohol or gambling is the same percentage.  Presence of pain is the key to avoiding addiction.  Physical dependence is likely but that just means your body has adjusted to the medication and you may suffer withdrawal if you suddenly stop the medications.  Addiction is compulsive and uncontrollable despite knowledge of harm.  Parker goes on to quote the American Pain Foundation as saying that “when properly used, pain medications rarely give a ‘high’ – they give relief.  And, most importantly, they allow many to resume their normal lives” (3).

 

 

A 1980 survey by the Boston Collaborative Group found that 4 out of 11,882 (0.03%) patients became addicted to an opioid.  “Epidemiologic studies show a low risk of addiction to opioids taken by patients with no history of substance abuse” Included in the survey were patients who were given an opioid for at least 4 months (4).  Another study of 10,000 burn center patients who were treated with opioids showed no substance abuse in patients (4). Clarification of the risk of addiction would be made easier with more studies.  Portenoy recommends keeping careful patient records as progress notes as an alerting device during long-term treatment. Pain severity needs to be measured minimally on a scale of mild, moderate and severe. Does the patient experience side effects such as sedation, constipation, or cognitive impairment? What is the patient's physical and psychosocial status? Is there any drug-related aberrant behavior (4)?

 

There is a belief in the misinformation that all patients receiving opioid therapy are at high risk for developing addiction.  But, addiction rates in patients with chronic pain are no greater than the addiction rates in the general population.  The National Council on Alcoholism and Drug Dependence shows clinical evidence that patients with a history of substance abuse may be genetically inclined to have poor control of medication taking which may lead to addiction.  There is a difference between physical dependence and addiction.  Tolerance is also not an indicator of addiction (5). 

 

Addiction is defined by the Florida Board of Medicine as a “compulsive use, despite harm.”  Being able to function socially is a distinction between addicts and those who are physically dependent.  Addicts have a focus on their drug use, where the next dose is coming from; they cannot handle jobs, family obligations and social functions as well (5).

 

Chronic pain patients on the other hand, tend to gain greater function in their lives.  They return to work if possible, they become more socially active, and function better.  They have less depression and anxiety and see their treatment as a way to save their life as they know it (5). 

 

Due to these differences the Florida Board of Medicine has the position that “tolerance and physical dependence are normal consequences of sustained use of opioid analgesics and are not synonymous with addiction.” (5). Much of the medical community does not feel this way nor is there a public acceptance of these differences.  Patients even feel unneeded guilt over their use of pain medications because they are wrongly given the impression by their doctors that they are addicted (5).  

 

Some patients do not receive proper education of their use of opioid medications and due to this lack of education they believe the media hype that overemphasizes the dangers of these medications without properly pointing out that the problems occur with misuse.  There is a stigma put on people who legally take opioid medications.  When this stigma is put on patients with legitimate reason to take these medications it is wrong (5). 

 

Millions of patients who have legitimate pain are being punished for the careless misuse of medication by abusers.  Doctors have lost their perspective by withholding medications from people with chronic pain because of abusers (6). 

It seems that the main fear limiting the prescribing of opioid medications is fear of addiction.  Addiction is an irresistible craving, compulsive and continued use despite harm and a loss of control of the use of medications.  Addiction happens when medication interacts on the chemistry of the brain to produce a need for the medication like the need for basic life sustaining things such as food and water. Addiction experts know that there are many factors that lead to addiction such as “hereditary, psychological and situational factors” that are personal to the user.  Previously, tolerance and physical dependence were thought to be components of addiction as well as the symptoms of withdrawal that came if the medication was stopped. These factors may be symptoms of addiction to recreational drug use but not to use of drugs for a medical purpose (7). 

 

Patients who have taken opioid medications only a few times will exhibit tolerance and some symptoms of withdrawal if their use is abruptly stopped.  But this also occurs with medications such as corticosteroids, heart medications, and epilepsy medications to name a few.  Abrupt stoppage of anti-depressants can also cause withdrawal symptoms.  There are many symptoms that can be caused by withdrawal.  There should always be a distinction between addiction and physical dependence.  In their “Medications and Chronic Pain Supplement 2005” the American Chronic Pain Association states “Any person (or animal) that takes sufficient doses of certain types of drugs for a significant length of time can have withdrawal symptoms if the drug is suddenly stopped or reversed by another medicine.  This shows the presence of physical dependence but does not constitute addiction” (7).  They also state that there are four elements of true addiction that they call the 4 C’s:

 

·        “Compulsive use and preoccupation with the drug and its supply,

·        Inability to consistently Control the quantity used,

·        Craving the psychic effects of the drug, and

·        Continued use despite adverse effects from the drug (7).”  

 

Pseudo-addiction is a syndrome of poorly or under treated pain in which patients act out due to anger and isolation.  Being given ineffective or inadequate medication or having long intervals between allowed doses can lead to pseudo-addiction.  Pseudo-addiction can also occur because a physician is not fully educated in pain management or because they improperly fear true addiction (7).

 

There are some questions that can be useful in determining whether a person is positively or negatively using pain medication.  The following is an excerpt from “Medications and Chronic Pain Supplement 2005”. 

 

·        Is the person’s day centered on taking medication? If so, consultation with the health care professional may clarify long-term risks and benefits of the medication and identify other treatment options.

 

·        Does the person take pain medication only on occasion, perhaps three or four times per week? If this is the case, then the likelihood of addiction is low.

 

·        Have there been any other chemical (alcohol or drug) abuse problems in the person’s life? If so, then it is important to inform the health care professional, who will need to take that into consideration when prescribing.

 

·        Does the person in pain spend most of the day resting, avoiding activity, or feeling depressed? If so, that suggests the pain medication is failing to promote rehabilitation. Daily activity is necessary for the body to produce its own pain relievers, to maintain strength and flexibility, and to keep life full and meaningful. Encourage the person with pain to request recommendations from a physician for a graduated exercise program.

 

·        Is the person in pain able to function (work, household chores, and play) with pain medication in a way that is clearly better than without? Chances are that the pain medication is contributing to wellness. Most people who are addicted to pain medications or other substances (excluding Nicotine) do not function well. They are undependable and forgetful. “(7)

 

There are also signs that the risks outweigh the benefits of use.  Too much sleep, reversal of days and nights, lowered appetite, concentration problems, irritability, mood swings, isolation, side effects causing difficulties in functioning, and not paying attention to dress or hygiene (7).

 

Tolerance is the decreasing amount of pain relief at a consistent dosage over time.  Previously, the thought was that tolerance limited the efficacy of long-term use of opioid medications.  It is now been shown that tolerance initially appears to be disease progression in cancer patients.  There is also no upper dosage limit of opioid medications except the limit that side effects become intolerable to the analgesic effect (8). 

 

Diversion; acquisition of prescription medication controlled by the Controlled Substance Act (CSA) by theft, deception and or fraudulent means;  is a concern for health professionals but fear of diversion should not limit a physician from prescribing opioid medications to patients with legitimate pain relief needs.  Proper attention to the requests of the patient and the pattern of prescription can reduce the risk of diversion (8). 

 

Not fully understanding addiction, and thinking that patients with chronic pain are addicts are not reasons to withhold proper use of opioid medications.  Studies have shown that people who are known addicts can benefit from opioid medications as treatment for chronic pain given proper supervision (8). 

Dependency on a medication is characterized as a negative reaction to the reduction or absence of a medication.  Diabetics who stop taking insulin, patients with depression who stop their anti-depressants are all considered physically dependent on their medications but they are not addicted to those medications (10).  Addiction is neurobiological and has the previous mentioned behaviors as components of this disease (10).

 

In an article on Discovery Health titled “Addiction v. Dependence on Pain Medications”, Dr. Scott Fishman states “As any diabetic will testify about insulin, or any heart patient will testify about blood pressure medication, dependence is not necessarily indicative of addiction or drug abuse. In fact, regular use of these medications may be essential for good health” (11).  He goes on to state that patients with an addiction to opioid medications differ from patients who are dependent in that the patient who is dependent gains improved function due to medication use while the addict does not (11).  Physical dependence is manageable.  According to Dr. Hochman, in four years of following 204 patients, there were no instances of addiction (13).

 

There are ways to reduce the risks of problems associated with use of opioid medication.  Decide which medication is best appropriate for the patient by asking key questions such as: Is the severity of the pain enough to justify the use of this medication or is there a weaker medication that would be appropriate?  Are there other medications that may work as well as or better than this medication?  Is the use of this medication complicated by concurrent conditions that make this medication less safe?  Is the patient responsible about taking medications (30)?  Next, tailor the medication to the needs of the patient. Is a long acting drug needed or will a short acting drug be sufficient (30)?  After making sure the treatment is tailored to the needs of the patient, treat the side effects of the medication.  Give stool softeners or laxatives to patients who may become constipated with use of opioid medications, treat any nausea that arises from treatment.  Consider the possibility that a stimulant may be needed if fatigue or sleepiness occurs (30). Combine the use of opioid medications with complimentary therapies such as rehabilitation, physical therapy and other possible treatments (30).  There should be some outcomes that are expected and monitored in the use of opioid therapy as stated in an article titled “Treatment Options - Opioids and Other Medications.” 

 

• Pain relief,

• Side effects,

• Physical and psychosocial functioning, and

• The occurrence of any aberrant drug-related behaviors (30).

 

Patients need to be informed of the possible side effects and also need to speak to the physicians about any changes that take place due to the treatments (30).

 

One thing that also separates people who are addicted to opioid medications from those who are not addicted is that those with addiction deny problems and attempt to maintain their supply at all costs.  Some tolerance in opioid treatment is desirable as well.  Becoming tolerant to side effects such as sleepiness or nausea is one of the desirable tolerances.  But tolerance to the amount of pain relief is not desirable.  Thankfully a balance can usually be achieved. To combat the “zombie-like” feeling that can accompany opioid use, take them regularly. Once some tolerance is achieved patients can even work, drive and function normally.  Despite their many benefits, opioid medications are not cure-alls.  Most patients do benefit from therapy but some cannot tolerate the side effects of the medications, others are not able to responsibly use the medications and in few patients, true addiction occurs (31). Patients without a history of substance abuse do have a low risk of developing addiction.

 

 

Conclusion

In a joint statement from 21 health organizations and the DEA, is the statement that “Preventing drug abuse is an important societal goal, but there is consensus, by law enforcement agencies, health care practitioners, and patient advocates alike, that it should not hinder patients ability to receive the care they need and deserve” (27).  In her book on being an advocate, Devin Starlanyl writes that “under treated or inadequately treated pain can have profoundly negative physiological effects on the body, including the release of stress hormones, impaired immune response, altered respiratory patterns and couch suppression.”  But, appropriate treatment of pain can have “positive health benefits for patients.” (Starlanyl 1999 54)  McCaffrey et al (as quoted in Starlanyl 1996) states that “Research shows that, unfortunately, as pain continues through the years, the patient’s own internal narcotics, the endorphins, decrease and the patient perceives even greater pain from the same stimuli.”  They also state that “No evidence supports fear of addiction as a reason for withholding narcotics when they are indicated for pain relief.  All studies show that regardless of doses or length of time on narcotics, the incidence of addiction is less than 1%” (Starlanyl 1996 202).  Starlanyl, in the Survivors Manual, also quotes McCaffrey as saying “In programs for chronic pain management, an attitude of self-control is fostered.  If a patient with diabetes or chronic hypertension knows all about his medications and when he should take them, this is viewed as desirable.  When the patient with chronic pain has the same information and has learned to use it to manage his pain, ironically this tends to upset the health team…” (110).

 

Inadequate management of pain is common despite the fact that there are safe and effective treatments.  There are many ways to treat pain ranging from behavior changes, rehabilitation, lifestyle changes and medications (8).  Patients should neither fear addiction nor feel guilt that they need pain medications to live as normal and functional life as possible.  The incidence of addiction is not a valid concern in patients whose doctors properly prescribe medications, monitor usage responsibly, and properly assess and diagnose the causes of pain.  Even in patients who have prior addictive behaviors can successfully be treated with opioid medications with proper monitoring and education on the use of opioid medications. 

 

DISCLAIMER

All information is intended for your general knowledge only and is not a substitute for medical advice or treatment for specific medical conditions. You should seek prompt medical care for  any specific health issues and consult your physician The newsletter staff specifically disclaim  all responsibility for any liability, loss or risk, personal or otherwise, which is incurred as a consequence, directly or indirectly, of the use and application of any of the material in this newsletter.

 

Article © 2005 This email address is being protected from spam bots, you need Javascript enabled to view it    This article and the accompanying endnotes, sources and suggested reading may be reproduced for sharing provided that this notice is copied in full and accompanies all copies of this article. 

 

Endnotes

 

www.painfoundation.org

Rosenfeld

Parker

http://www.meds.com/conrad/pmcd/port3.html

http://headaches.about.com/od/advocacyissues/a/addict_depend.htm

http://www.aapainmanage.org/literature/PainPrac/V12N3_Cole_PrescribingOpioids.pdf

http://www.theacpa.org/documents/ACPA%20Meds%202005%20SDSF.pdf

http://www.ampainsoc.org/advocacy/opioids.htm

http://www.hosppract.com/issues/2000/09/brook.htm

http://www.nationalpainfoundation.org/MyTreatment/Consumer_Guide_FINAL.pdf

http://health.discovery.com/centers/pain/medicine/med_addict.html

http://www.doctorsforpain.com/patient/history.html

http://www.doctordeluca.com/Library/Pain/Hochman-HighDosageOpioids05.htm

http://www.doctordeluca.com/Library/WOD/ChallengePDA-Hurwitz05.htm

http://www.cpmission.com/main/addiction.html

http://www.hosppract.com/issues/2000/09/brook.htm

Elisabeth Kübler-Ross (b. 1926), Swiss–born U.S. psychiatrist. On Death and Dying, ch. 2 (1969).

Dr Joel J Nobel, cofounder, Emergency Care Research Institute, 1985

http://www.painreliefhumanright.com/pdf/05_why_pain_control.pdf

http://www.emergingsolutionsinpain.com/export/esp/reslib/Model_Policy_FSMB_Treatment_of_Pain.pdf

http://www.medscape.com/viewarticle/461612_1

http://www.intelihealth.com/IH/ihtIH/EMIHC271/29721/29724/336384.html?d=dmtContent

http://www.iasp-pain.org/terms-p.html

http://www.ninds.nih.gov/disorders/chronic_pain/chronic_pain.htm

http://www.mayoclinic.com/invoke.cfm?id=QZ00067&action=answer

http://www.fda.gov/fdac/features/2004/204_pain.html

http://www.ampainsoc.org/advocacy/promoting.htm

http://www.postgradmed.com/issues/2004/09_04/antoin.htm

http://www.stoppain.org/pcd/content/problem/treatment.asp

http://www.stoppain.org/pcd/content/problem/opioids.asp

http://www.stoppain.org/pain_medicine/content/medication/opioids.asp#physical

http://www.stoppain.org/pain_medicine/content/faqs/default.asp#abusers

http://www.medscape.com/viewarticle/503596

http://www.painnet.com/html/forpatients1.html

35. Starlanyl 1996 - Survivors

36. Starlanyl 1999 - Advocate

37. http://www.innerself.com/Health/pain_works.htm

38. http://www.jewishworldreview.com/0805/medicine.men081205.php3

 

 

Sources and Suggested Reading

 

Rosenfeld, Arthur.  The Truth About Chronic Pain: patients and professionals on how to face it, understand it, overcome it.  2003 Basic Books New York, NY.

 

Starlanyl, Devin, MD and Mary Ellen Copeland, MS, MA.  Fibromyalgia & Chronic Myofascial Pain Syndrome: A Survival Manual.  1996 New Harbinger Publications, Inc. Oakland CA.

 

Parker, Kathleen.  “Painkiller use doesn’t mean addiction” Article appearing in Oct 2003 Myrtle Beach Sun New. 

 

Lee, Matthew H. M. “Erasing Pain: New Treatments From the World-Famous Rusk Institute’s Medical Specialists.  2001. Thomas Dunne Books, New York, NY.

 

Starlanyl, Devin, MD. The Fibromyalgia Advocate.  1999 New Harbinger Publications, Inc. Oakland, CA