A big thank you to Dr. Laurie Romig, medical expert at Addictions.com for sharing her knowledge on chronic pain and addiction.

Everywhere we look these days, the opiate use epidemic and its consequences are making headlines. If you’re reading this, you may either have non cancer-related chronic pain or know or care for someone who bears this burden. Doctors were encouraged to provide more aggressive opiate pain management 15 to 20 years ago, but we’re now receiving recommendations that we need to limit prescribing opiate pain meds, largely because of increasing impacts to society in terms of drug-related deaths and improper use of opiates.

These new and onerous recommendations have left doctors and chronic pain patients confused and frustrated. We don’t know a great deal about long term narcotic use and dangers related to people who have pain all the time. We do know that your pain doesn’t go away just because we’re told that we need to do something to alter behavior on a societal level!

One of the major concerns about chronic opiate use is the possibility of creating addicts. So let’s talk about addiction and some of the other buzzwords related to it, what factors may put you at higher risk for addiction, signals that may mean that you are addicted, and how to walk the tightrope between improving your quality of life on one hand and suffering what could be catastrophic effects of opiate addiction on the other.

What is addiction anyway and how does it happen?

Addiction is at the far end of a process that starts when a person begins to take an addictive, illegal drug or prescription medicine like opiates. The beginning of this process is automatic; you have no choice.

The brain works by making and using certain chemicals that control functions like emotions, perception, judgment, memory, and mood. Opiates and other drugs affect brain function in these and other areas, with the effect being some version of “feeling better”. Soon, the brain adjusts to expect these new chemical balances, but higher and higher doses are required to get the “feel better” results such as pain control or euphoria. This is called “tolerance”. This is a normal process that happens to everyone who takes addictive drugs regularly. This is why your doctor may have you take higher med doses over time. It’s not a bad thing, a weakness, or a choice; it just is!

As the brain gets used to getting these chemicals from outside the body, it may decrease or shut down its own chemical-making. When this happens, “dependence” occurs. You depend on the meds to even stay somewhat functional because the brain isn’t making its own chemical.

When you stop or quickly decrease the amount of medication that you’re taking, you experience “withdrawal symptoms”. These symptoms vary depending on the specific drug and other factors. The best way to stop the drug is through a detoxification process (“detox”) during which the body is slowly weaned off of the medication and the brain starts making its own chemicals again. The only voluntary control over this is your decision to either continue through the detox process or start taking the medication again to feel better.

“Prescription Drug Addiction” is more subjective and variable, and only happens in 8% to 25% of chronic pain patients taking opiates regularly. At this stage, the person’s judgment is altered, and obtaining the medication is their highest priority. This can involve criminal activity, doctor shopping, buying meds from illegal sources, and in some cases, switching to a different drug such as heroin or fentanyl.

Are some people more likely to develop an addiction to chronic pain meds?

Yes! These are some of the risk factors for addiction:

• Personal or family history of addiction (including alcohol)
• Taking high doses of pain meds
• Regularly taking an opiate for more than 3 months
• Depression
• Certain inherited genes
• Adolescence

How can I tell if I might be developing an addiction to my meds?

Monitor yourself and have your friends, family, and health care team help to spot:

• Development of poor judgment and decision-making
• Changes in behavior and memory
• Taking or thinking about taking more meds than prescribed or adding other substances not prescribed for you
• Thinking more and more frequently about how to get more drugs
• Doctor shopping (getting multiple prescriptions from different doctors without disclosing that you have seen other doctors)

This is complicated stuff. How do I keep my balance on this tightrope?

You need pain management just to maintain your ability to function, much less be pain-free, but you can’t get the meds you think you need or have needed in the past. What can you do? The key is to understand that chronic pain management requires a team effort. It’s not just you out on that tightrope!

• Be honest, proactive, inquisitive, and open with your physician and medical team about:
  • Questions and concerns, risks and benefits
  • Your options for non-medication treatments, including sources of emotional and stress-related support
  • Signs to be alert for or to report
  • What the game plan would be if you do develop signs of addiction
• If your doctor won’t talk about these things or doesn’t seem to be educated about chronic pain management, ask for a referral to a pain clinic or specialist or get a new doctor.
• Many primary care doctors aren’t well-versed in or comfortable with currently recommended medication-assisted therapy for opiate addiction. Doctors at community health clinics or in multiple physician practices are more likely to be comfortable with chronic pain management and substance use disorder diagnosis and treatment.
• If you have multiple doctors, make sure that they know about each other and preferably have only one doctor as your medication prescriber and coordinator.
• Take advantage of the Branch app! It helps you track your pain, sleep habits, stressors, medication use and results, response to other treatments, questions to bring to your doctor, and other information that may be valuable to your team in customizing your treatment program.

We may not have proven, reliable, and always safe options for managing chronic pain, but the current concern about opiates is going to drive the development of treatments that are specific to different types and sources of pain, new non-opiate pain medications, and development of opiates or drug combinations that treat pain but block or don’t have addictive properties. More work still needs to be done on the specific needs of chronic pain patients and allowing physicians and their patients to responsibly use their best judgment on tailoring opiate treatments for individual care plans. By learning more about what addiction is (and is not), providing feedback to your medical team, and being a tireless advocate for yourself, you can help to make the future less painful for yourself and others.