Back Pain: Medication and Addiction
Narcotic addiction is a risk, especially for chronic pain treatment, but the larger problem may be untreated pain. Part 3 of a four-part series.
By R. Morgan Griffin
Reviewed By Brunilda Nazario
In the last few years, everyone's heard about the apparent epidemic of prescription drug addiction, especially to narcotic painkillers. We see human-interest stories on the news about regular folks getting hooked on OxyContin or Vicodin. Every few months, it seems, we get another news release from a new celebrity confessing to an addiction. The reports may give you the impression that the lure of these drugs is irresistible, that we're all just a few pills away from addiction.
This leaves many people with chronic back pain -- and often their doctors -- stuck in the middle. On the one hand, they're afraid of the risks of addiction that come with powerful painkillers. On the other, they're suffering from severe and debilitating pain and need some kind of help.
But are the risks of prescription drug addiction really as great as we think?
"There's this buzz that these painkillers are demon drugs being marketed to unsuspecting grandmas," says Karen Miotto, MD, an addiction psychiatrist at the UCLA Neuropsychiatric Institute. "But that's not the case."
There's no doubt that prescription drug addiction can be devastating and destroy lives. But for many experts, the more widespread public health issue is that people in desperate and debilitating pain aren't getting the painkillers they need because of inflated fears of addiction. While opioid painkillers -- like OxyContin, Percocet, and Vicodin -- have risks, they're often outweighed by the benefits, experts say.
How Big Is the Addiction Problem?
Prescription drug addiction is a growing problem. According to the Office of National Drug Policy, emergency room visits resulting from the abuse of painkillers alone has gone up 163% since 1995. There are three main classes of prescriptions drugs that are abused: opioid narcotics used to treat pain, depressants used to treat anxiety, and stimulants used to treat conditions like ADHD and obesity.
But those numbers may not be as meaningful they appear, says Jim Zacny, PhD, a professor in the department of anesthesia and critical care at the University of Chicago. More people are abusing the drugs because more people are receiving prescriptions for them. So while there has been a growth in the number of abusers, there has been a much greater rise in the number of people who are using these medications safely and benefiting from them.
Zacny also cites recent data showing that of all the people in the U.S. who checked into substance abuse centers in 2002, only 2.4% were there because of an addiction to opioid narcotics. "In other words," he tells WebMD, "the majority of people who use prescription opioids are using them responsibly."
Miotto stresses that addiction is a more complex process than people tend to think. "It's not the pills alone that make an addiction," she says. She points out that addiction develops from a number of physiological, psychological, and social factors.
Zacny agrees. "There's this myth out there that if you take an opiate, you automatically become enslaved to it," he says. "That's not the truth at all."
Who Is at Risk?
Most people who have back pain are not at risk of prescription drug addiction for a number of reasons. First off, the majority of people with back pain never get prescribed potentially addictive painkillers in the first place.
"Most of the people with back pain will take drugs that don't pose a risk of addiction," says Larry Khoo, MD, co-director of the UCLA Comprehensive Spine Center. People with back pain often use non-addictive medications like Tylenol or nonsteroidal anti-inflammatory drugs (NSAIDs). Some NSAIDs are over-the-counter, like Motrin or Advil, and others are by prescription. In April 2004 the FDA asked that over-the-counter NSAIDs revise their labels to include information about potential heart and stomach ulcer bleeding risks.
Steroids can also be prescribed for pain due to swelling and inflammation. Steroids are not narcotics either, but these powerful drugs must be used carefully.
While opioid narcotics like OxyContin, Percocet, and Vicodin are options for patients with acute pain that's more severe, the risks of developing prescription drug addiction still aren't very high.
"Most of the people who need opioid drugs will only use them for a very short time, often a few weeks or a month," says Khoo. "Even the most powerful drugs are not very addictive when they're used that way."
Khoo says these drugs relieve pain immediately and allow people to get out of bed, start physical therapy, and change some of the behaviors that caused their back problem in the first place. "But it all hinges on being able to get out of bed," says Khoo, and without these drugs, that first step is sometimes just too painful.
While some treatments and physical therapy work for most people, Khoo says there are some problems that don't respond to this approach. Despite a good treatment plan, the pain remains. Khoo says patients who develop chronic back pain often have multiple problems with the spine, due perhaps to arthritis or a history of heavy labor, that can't be corrected surgically. He also says people who don't respond to one or two surgeries are more likely to develop difficult-to-treat chronic pain.
It's this small population of people who have chronic pain and hard-to-treat problems that usually need long-term medication, Khoo says.
What Increases the Risk of Abuse?
According to rough estimates, between 3%-16% of people who suffer from chronic pain and are treated with long-term opioid narcotics have a prescription drug addiction, says Miotto. But what increases the risk?
According to Zacny, we still don't have a perfect way of knowing. "The studies just haven't been done," he says. However, most people agree that a recent history of any substance abuse may increase the danger.
Other possible risk factors for prescription drug addiction include any personal or family history of substance abuse, as well as recent emotional or psychiatric problems. "If you're in a high-risk group, if you or a family member has had a past history of addiction, or you're coping with a great deal of stress, you and your doctor may need to be especially vigilant," says Miotto.
Although certain opioid drugs are often viewed as more addictive than others, there's very little evidence one way or another, Zacny says. Still, many think that the narcotics that don't last very long -- such as quick-release OxyContin or Vicodin -- may pose a somewhat higher risk of causing addiction. For opiods that last only a few hours, the pain will return. Over time, repeated medication can lead to a tolerance to these drugs. When tolerance develops, higher doses will be needed to get the same effective pain relief.
The risks of prescription drug addiction also depend on how you react to the drug. People who become addicted to prescription painkillers clearly experience a high, but most people find that the drug makes them feel unwell or nauseated. Other frequent side effects include mild dizziness, sedation, and confusion. According to some of Zacny's research, the majority of people who try the drug don't like the effects and would rather not take it again. So the risks of addiction may be higher in those who, for physiological reasons not understood, have a more positive reaction to the drug's effects.
Miotto says she worries less about people who are simply taking too much of the painkiller than those who use the painkiller along with other drugs, such as sleeping pills or muscle relaxants. "It's the people who are mixing drugs that I find are often at highest risk of problematic use and side effects," she tells WebMD.
There's also a widely held belief that people who are in pain are less likely to experience euphoric effects from a drug. The idea is that the medication is targeted -- it "goes to the pain" only and doesn't cause other euphoric effects, meaning that people with real pain are less likely to become addicted than people who don't.
"That's lore, sad to say," Zacny says. "It may very well be true, but it hasn't been really established. There's just a lot we don't know."
The Effects of Addiction
For the relatively small number of people who do develop a prescription drug addiction, the effects can be devastating. Miotto says addiction often sneaks up on people.
"Often, you just start to call in prescriptions early, or take your spouse's medication, or take the medication when you're not really in pain, but when you're tired or depressed," says Miotto. "These behaviors can creep up on people slowly and then, all of a sudden, they have a physical dependency."
The problem is that the people who have a prescription drug addiction don't realize it. "Addiction is a disease of denial," Miotto says. It also pushes people to horrible extremes. Miotto knows one patient who eventually admitted that she pushed for surgery solely because she wanted the narcotic painkillers she knew she'd get afterward.
For many people, prescription drug addiction can cause a deep sense of shame that prevents them from getting help.
"Addiction is hard to talk about in normal terms," says Miotto. "People think of it as evil, as something that leads to lying and cheating and stealing. But we need to find a way of talking about addiction that isn't so shameful. We should treat it more like other chronic illnesses, like cancer or hypertension."
Doctor vs. Patient
In part because of the stigma of prescription drug addiction, chronic back pain can sour even the best doctor-patient relationships. Over time, the patient becomes increasingly frustrated by the doctor's inability to cure his or her pain. Meanwhile, the doctor may become suspicious of someone who always refills of powerful narcotics.
"Doctors can get afraid when dealing with patients with chronic pain, because they don't want to be the ones handing out hardcore painkillers all the time," says Khoo. "But that leads to a lot of undertreated patients with real back problems. These are people who are in so much pain that they're just not functional human beings."
Khoo also says doctors may be too focused on trying to figure out the underlying source of pain while in the meantime ignoring the debilitating symptom.
"The patient came to see the doctor because of pain," says Khoo, "and he doesn't really care about the underlying cause. He doesn't care whether it's a disc problem or a deformity. He just wants the pain to go away. So doctors need to concentrate on treating the symptom, too."
While this situation can be difficult for anyone with chronic back pain, people with a past history of addiction face the most skepticism from their doctors.
"I hate to say it, but when people walk in to the doctor and mention an addiction history, they may not be able to get these painkillers," says Miotto. "The doctor may just not trust them."
Working With Your Doctor
In order to get the treatment you need, you need to keep a good relationship with your doctor. This may require that you seek out a doctor with expertise in pain management. For a lot of understandable reasons, your regular doctor may not be comfortable handing out long-term prescriptions for narcotics.
For people who have a past history of substance abuse or are at higher risk of developing a prescription drug addiction for any reason, seeking out an expert -- or specialty center -- is especially important.
"Too often, addiction programs are completely divorced from pain management programs and vice versa," says Miotto. Khoo agrees and recommends programs that combine not only pain management and prescription drug addiction treatment, but also exercise, physical therapy, weight loss, and if necessary, therapy for depression.
One common way of using opioid narcotics safely is to use a pain agreement, a formal understanding between a doctor and patient about how the drugs will be used. The patient may promise to use the medication as instructed and, in some cases, agree to regular drug testing by urine analysis. In return, the doctor agrees to prescribe narcotic pain relievers as part of the treatment plan.
"Pain agreements or contracts are a way for a doctor to say to the patient, 'We're taking you seriously, so you need to take us seriously,'" says Khoo.
But these agreements may not be enough for people at high risk of addiction. "Some people decide that they just can't take pain medications responsibly," says Miotto. If that's the case, you may be able to get someone else to hold and dispense your medication for you. Another possibility is to use a transdermal patch -- these contain the medicine but deliver it slowly through the skin, preventing the high and reducing the risk of addiction.
For anyone with chronic pain, having a knowledgeable doctor and a trusting relationship is key. An expert won't have unfounded worries about the relatively small risk of prescription drug addiction. But he or she will also know how to help people at high risk of developing a problem.
"Doctors should not be afraid of treating pain," Miotto tells WebMD. "There are addicts out there who don't have pain but shop around and hustle for medication. But I think that there are very few compared to the number of people who have terrible pain and need help."
Originally published August 2004.
Medically updated April 2005.
SOURCES: Larry Khoo, MD, assistant professor, department of neurosurgery; co-director, UCLA Comprehensive Spine Center. Karen Miotto, MD, associate professor, UCLA Neuropsychiatric Institute. Jim Zacny, PhD, professor, department of anesthesia and critical care, University of Chicago. Mitka, M. JAMA, March 1, 2000; vol 283: pp 1126-1129. National Institute on Drug Abuse. Rosenblum, A. JAMA, May 14, 2003; vol 289: pp 2370-2378. WebMD Medical News: "Over One Million Americans Abuse Prescriptions." WebMD Medical News: "Getting Past Painkiller Abuse."
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