Posted: Aug 10, 2011 2:47 PM
Prescription pain medicine addiction grabs headlines when it sends celebrities spinning out of control. It also plagues many people out of the spotlight who grapple with painkiller addiction behind closed doors.
But although widespread, addiction to prescription painkillers is also widely misunderstood -- and those misunderstandings can be dangerous and frightening for patients dealing with pain.
Where is the line between appropriate use and addiction to prescription pain medicines? And how can patients stay on the right side of that line, without suffering needlessly?
For answers, WebMD spoke with two pain medicine doctors, an expert from the National Institute on Drug Abuse, and a psychiatrist who treats addictions.
Here are seven myths they identified about addiction to prescription pain medication.
Reality: That might sound like addiction to you, but it's not how doctors and addiction specialists define addiction.
"Everybody can become tolerant and dependent to a medication, and that does not mean that they are addicted," says Christopher Gharibo, MD, director of pain medicine at the NYU Langone Medical School and NYU Hospital for Joint Diseases.
Tolerance and dependence don't just happen with prescription pain drugs, notes Scott Fishman, MD, professor of anesthesiology and chief of the division of pain medicine at the University of California, Davis School of Medicine.
"They occur in drugs that aren't addictive at all, and they occur in drugs that are addictive. So it's independent of addiction," says Fishman, who is the president and chairman of the American Pain Foundation and a past president of the American Academy of Pain Medication.
Many people mistakenly use the term "addiction" to refer to physical dependence. That includes doctors. "Probably not a week goes by that I don't hear from a doctor who wants me to see their patient because they think they're addicted, but really they're just physically dependent," Fishman says.
Fishman defines addiction as a "chronic disease ... that's typically defined by causing the compulsive use of a drug that produces harm or dysfunction, and the continued use despite that dysfunction."
For instance, someone who's addicted might have symptoms such as "having drugs interfere with your ability to function in your role [or] spending most of your time trying to procure a drug and take the drug," says Susan Weiss, PhD, chief of the science policy branch at the National Institute on Drug Abuse.
"Physical dependence, which can include tolerance and withdrawal, is different," says Weiss. "It's a part of addiction but it can happen without someone being addicted."
She adds that if people have withdrawal symptoms when they stop taking their painkiller, "it means that they need to be under a doctor's care to stop taking the drugs, but not necessarily that they're addicted."
Reality: "The vast majority of people, when prescribed these medications, use them correctly without developing addiction," says Marvin Seppala, MD, chief medical officer at the Hazelden Foundation, an addiction treatment center in Center City, Minn.
Fishman agrees. "In a program where these prescription drugs are used with responsible management, the signs of addiction or abuse would become evident over time and therefore would be acted on," says Fishman.
Some warning signs, according to Seppala, could include raising your dose without consulting your doctor, or going to several doctors to get prescriptions without telling them about the prescriptions you already have. And as Weiss points out, being addicted means that your drug use is causing problems in your life but you keep doing it anyway.
But trying to diagnose early signs of addiction in yourself or a loved one can be tricky.
"Unless you really find out what's going on, you'd be surprised by the individual facts behind any patient's behavior. And again, at the end of the day, we're here to treat suffering," says Fishman.
Likewise, Weiss says it can be "very, very hard" to identify patients who are becoming addicted.
"When it comes to people who don't have chronic pain and they're addicted, it's more straightforward because they're using some of these drugs as party drugs, things like that and the criteria for addiction are pretty clear," says Weiss.
"I think where it gets really complicated is when you've got somebody that's in chronic pain and they wind up needing higher and higher doses, and you don't know if this is a sign that they're developing problems of addiction because something is really happening in their brain that's ... getting them more compulsively involved in taking the drug, or if their pain is getting worse because their disease is getting worse, or because they're developing tolerance to the painkiller," Weiss says.
"We know that drugs have risk, and what we're good at in medicine is recognizing risk and managing it, as long as we're willing to rise to that occasion," says Fishman. "The key is that one has to manage the risks."
Reality: You need to use prescription painkillers (and any other drug) properly. It's not something patients should tinker with themselves.
"They definitely have an addiction potential," says Gharibo. His advice: Use prescription pain medicines as prescribed by your doctor and report your responses -- positive and negative -- to your doctor.
Gharibo also says that he doesn't encourage using opioids alone, but as part of a plan that also includes other treatment -- including other types of drugs, as well as physical therapy and psychotherapy, when needed.
Gharibo says he tells patients about drugs' risks and benefits, and if he thinks an opioid is appropriate for the patient, he prescribes it on a trial basis to see how the patient responds.
And although you may find that you need a higher dose, you shouldn't take matters into your own hands. Overdosing is a risk, so setting your dose isn't a do-it-yourself task.
"I think the escalation of the dosage is key," says Seppala. "If people find that they just keep adding to the dose, whether it's legitimate for pain or not, it's worth taking a look at what's going on, especially if they're not talking with the caregiver as they do that."
Reality: Undertreating pain can cause needless suffering. If you have pain, talk to your doctor about it, and if you're afraid about addiction, talk with them about that, too.
"People have a right to have their pain addressed," says Fishman. "When someone's in pain, there's no risk-free option, including doing nothing."
Fishman remembers a man who came to his emergency room with pain from prostate cancer that had spread throughout his body. "He was on no pain medicine at all," Fishman recalls.
Fishman wrote the man a prescription for morphine, and the next day, the man was out golfing. "But a week later, he was back in the emergency room with pain out of control," says Fishman. "He stopped taking his morphine because he thought anyone who took morphine for more than a week was an addict. And he was afraid that he was going to start robbing liquor stores and stealing lottery tickets. So these are very pervasive beliefs."
Weiss, who has seen her mother-in-law resist taking opioids to treat chronic pain, notes that some people suffer pain because they fear addiction, while others are too casual about using painkillers.
"We don't want to make people afraid of taking a medication that they need," says Weiss. "At the same time, we want people to take these drugs seriously."
Reality: Pain relief is key, but it's not the only goal.
"We're focusing on functional restoration when we prescribe analgesics or any intervention to control the patient's pain," says Gharibo.
He explains that functional restoration means "being autonomous, being able to attend to their activities of daily living, as well as forming friendships and an appropriate social environment."
In other words, pain relief isn't enough.
"If there is pain reduction without improved function, that may not be sufficient to continue opioid pharmacotherapy," says Gharibo. "If we're faced with a situation where we continue to increase the doses and we're not getting any functional improvement, we're not just going to go up and up on the dose. We're going to change the plan."
Reality: Addiction isn't about willpower, and it's not a moral failure. It's a chronic disease, and some people are genetically more vulnerable than others, notes Fishman.
"The main risk factor for addiction is genetic predisposition," Seppala agrees. "Do you have a family history of alcohol or addiction? Or do you have a history yourself and now you're in recovery from that? That genetic history would potentially place you at higher risk of addiction for any substance, and in particular, you should be careful using the opioids for any length of time."
Seppala says prescription painkiller abuse was "rare" when his career began, but is now second only to marijuana in terms of illicit use.
Exactly how many people are addicted to prescription painkillers isn't clear. But 1.7 million people age 12 and older in the U.S. abused or were addicted to pain relievers in 2007, according to government data.
And in a 2007 government survey, about 57% of people who reported taking pain relievers for "nonmedical" uses in the previous month said they'd gotten pain pills for free from someone they knew; only 18% said they'd gotten it from a doctor.
Don't share prescription pain pills and don't leave them somewhere that people could help themselves. "These are not something that you should hand out to your friends or relatives or leave around so that people can take a few from you without your even noticing it," says Weiss.
Reality: Doctors certainly don't want their patients to get addicted. But they may not have much training in addiction, or in pain management.
Most doctors don't get much training in either topic, says Seppala. "We've got a naive physician population providing pain care and not knowing much about addiction. That's a bad combination."
Fishman agrees and urges patients to educate themselves about their prescriptions and to work with their doctors. "The best relationships are the ones where you're partnering with your clinicians and exchanging ideas."