Painkiller Addiction

WebMD Live Events Transcript

Abuse of prescription pain medication is a headline-making problem, but what are your chances of becoming dependent? What are the signs of addiction, and where can you turn for help? We asked these questions and more when pain management expert Allen Lebovits, PhD, was our guest on Aug. 10, 2004.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

MODERATOR:
Welcome to WebMD Live, Dr. Lebovits. Addiction is a word thrown around pretty casually these days. What exactly is an addiction to pain medication, and how can we recognize there's a problem, either in ourselves or in a friend or family member?

LEBOVITS:
That is a great first question. Addiction is a behavioral phenomenon that actually is very uncommon with people who have pain. It is very different than some normal physiological phenomenon, such as dependence, tolerance, and withdrawal. I will try to define all four of these terms: addiction, tolerance, dependence, and withdrawal.
  • Addiction is the behavioral phenomenon and addiction can be defined as compulsive use of a substance. It's also characterized by lack of control, so you lose control over yourself; you tend to focus very much on the drug. In fact, your whole life becomes the drug, obtaining the drug, and when are you going to get it next. You become preoccupied with obtaining the drug. This happens even when you are harming yourself.
  • Physical dependence refers to developing withdrawal symptoms during abstinence. In other words, if you're taking a certain drug, and we're talking here about opioid drugs, and you suddenly stop it, it is normal for you to go through withdrawal. That simply means you have developed a physical dependence.
  • Tolerance , once again, is a normal physiological process and it refers to the need for an increased dosage in order to produce the desired effect. So what this would refer to in pain is when a patient needs more of an opioid in order to obtain the same degree of pain relief they've had on a lower dosage.
Now I'm referring to opioid and narcotics as interchangeable terms. In the medical setting we prefer to refer to it as opioids, rather than narcotics. I'd like to explain one more term, and that is something called pseudo addiction . That refers to when a patient is not getting enough of an opioid, in other words they are undertreated for their pain. They will develop symptoms similar to addiction, so they will require more of the drug and may even engage in some addictive behaviors, but the reason for that is that their pain has been undertreated.

This whole area is a major problem for pain management specialists, because we want to treat patients who have pain and we want their pain obviously to get better, but there is a lot of misunderstanding, a lot of lack of knowledge, about these concepts.

MEMBER QUESTION:
Painkiller is a broad term. I assume all prescription pain meds are not the same. Can you explain which kinds are more likely to be abused and why?

LEBOVITS:
Good question. Painkillers come in many sizes and shapes. There are the nonsteroidal anti-inflammatory agents. These do not contain codeine or morphine, so these drugs are not addictive. These drugs are usually the first line of drugs that are used for people who have pain. There has been a lot of research on these drugs, and newer nonsteroidals, such as Cox-2 agents, have now emerged on the market and are widely used.

The problem with the older nonsteroidal agents is their significant side effects, such as the gastric effects that sometimes limit their use particularly in the elderly. The newer Cox-2 agents are designed to minimize these gastric side effects.

When the first line of agents do not help control a patient's pain, then typically the pain-management specialist will then begin to go to the opioid drugs, and these drugs contain either codeine or morphine. These opioid agents are more likely to be abused, because codeine and morphine can be highly addictive.

"The negative publicity about OxyContin...did much harm to people who have pain. Patients we encountered were reluctant to take the drug because of all the publicity."

MEMBER QUESTION:
Are some pain meds safer to use than others?

LEBOVITS:
Yes, some opioid agents are safer to use. They have now designed opioid drugs that are long-lasting, rather then short-acting. Drugs such as Percocet or Darvocet are short acting; in other words, they build up in your bloodstream, but then quickly are depleted out of your body. Newer, long-lasting agents, such as MS Contin, are long lasting; in other words, they are released slowly into the bloodstream and remain in your body in a stable, steady state. So these drugs are less likely to have an addictive component to it.

MEMBER QUESTION:
As I remember, OxyContin was a problem as a "street" drug because people were crushing it in order to bypass the time-release properties of the capsules. Has the way the pills are manufactured changed so that is no longer an issue?

LEBOVITS:
It's my understanding they are currently trying to reformulate OxyContin so it cannot be broken, so the time-release mechanism cannot be tampered with. However, OxyContin still remains vulnerable to that.

I would like to add that the negative publicity about OxyContin, which exploded in the media, did much harm to people who have pain, because OxyContin happens to be a very good analgesic. Patients we encountered were reluctant to take the drug because of all the publicity. The abuse seemed to occur in lower-socioeconomic neighborhoods and isolated parts of the country.

MEMBER QUESTION:
What do you think of celebrities like Rush Limbaugh getting a slap on the wrist (if that) for abusing pain killers when a low-income person using crack gets a harsh jail sentence?

LEBOVITS:
I believe that everyone should be treated equally. I think the notoriety in the Rush Limbaugh case harms pain patients, because once again the media focuses on the use of pain medication and addiction, so the public associates pain medication with addiction, which leads to attitudes about taking pain medications that are harmful to people who really need pain medication.

MEMBER QUESTION:
Why is OxyContin so addictive? If it is such a problem, why do doctors prescribe it?

LEBOVITS:
Doctors prescribe it because it is a good drug for pain. It is a better drug than the shorter-acting agents, such as Percocet, because it stays in your bloodstream longer, so you don't have to take it every four hours and it produces more of a stable, steady state.

My experience has been that a very small minority of patients who have pain become addicted to OxyContin. Even when that happens we can deal with the addiction, we can treat the addiction successfully, still allowing the patient to have the proper amount of medication they need.

"I do believe, and this may be my own personal bias, the 'Just Say No to Drugs' movement has hurt pain management efforts in the United States."

MEMBER QUESTION:
My grandmother has back pain and pain related to a bladder problem. She won't take her prescription pain meds twice a day as instructed, because she's afraid of getting addicted to them. I don't remember which kind she's prescribed, but if the doctor says twice a day, he wouldn't say that if she could get addicted, right?

LEBOVITS:
This is an important point. The fear of addiction today in the United States leads to the undertreatment of pain. There really is a lack of knowledge, not only on the part of the public, but also on the part of health care providers. We are faced with this all the time with patients who have to suffer in pain because they refuse or their family refuses to take pain medications. I have faced this particularly in the palliative care setting, where there is a terminally ill patient refusing to take pain medication or having the family refuse because they don't want to become an addict.

I do believe, and this may be my own personal bias, the "Just Say No to Drugs" movement has hurt pain management efforts in the United States.

So if your doctor tells your mother to take a drug twice a day to help her, there's no reason she should have to suffer or have a poor quality of life because of the fear of addiction.

MEMBER QUESTION:
I have been taking MS Contin (for my rheumatoid/osteoarthritis and disectomy on my L4 and L5 discs) for about four years. Is there anyway I can get off this drug other than spending thousands of dollars at a clinic?

LEBOVITS:
Yes. I assume you want to get off the MS Contin because it's not helping your pain anymore. Many times when your pain drug is not working, we substitute a similar but different analgesic. So for example, you might try or ask your doctor about Avinza, which is similar to MS Contin in that it is long acting, but is different enough that perhaps that drug would help your pain.

So the way to switch drugs, and of course your doctor is the one to advise you, would be to slowly taper off the MS Contin and gradually start on the new drug. You might also want to put in some short acting drugs for what's called breakthrough pain.

The good news today is that because the analgesic market is so lucrative to pharmaceutical companies, I believe it's either the No. 1 class of agents or No. 2 in terms of profit share in the market today, they are spending more money on newer and more effective agents so that patients and doctors have a broader choice today of what to use.

MEMBER QUESTION:
If a pain med works really great for you, are you more likely to abuse it, or is it the other way around; if it doesn't work too well you end up taking too much to deal with the pain? Or is the degree of relief one gets from a drug not related to eventual abuse?

LEBOVITS:
Good question. If the drug does not work well you are more likely to develop pseudo addiction, which I referred to before. This is your body's need for more of the drug. However, I want to emphasize that the vast majority of people who have pain do not develop an addiction.

Risk factors for addiction are if you have a previous history of substance abuse, and this can include alcohol, or if there is a family member, such as a parent, who had an addiction problem. There seems to be a strong genetic component to addiction.

MEMBER QUESTION:
What should someone do who thinks a family member (brother) is abusing painkillers?

LEBOVITS:
Well, it's important to know what the evidence is for this abuse. I hear it a lot from family members who are concerned about their loved one abusing their pain drug. Many times when I investigate or inquire they're in fact not abusing the drug; they're using it the way it's been prescribed.

However, in the case when abuse might be happening, certainly the patient's doctor should be informed, and there are doctors, specifically psychiatrists, who specialize in addiction medicine. There are outpatient- as well as inpatient-treatment facilities.

MEMBER QUESTION:
How can I tell if my boyfriend is really still in pain or just trying to get more pain pills? He was in a car accident more than a year ago.

LEBOVITS:
That's one of the difficult things about pain. Pain is a very subjective sensation. You cannot see anybody else's pain. In fact, you can't measure someone else's pain, and that's what makes the assessment of pain difficult. Everyone has different sensitivities or thresholds for pain. A patient may appear to be very comfortable, relaxed, even enjoying themselves, yet they tell you their pain is what's called a 10 of 10, meaning you ask the patient to rate their pain on a pain scale where zero is no pain at all and 10 is the worst imaginable pain.

In terms of your boyfriend, it's important to see if there are different behaviors, if it has changed since the onset of his pain. It is not easy, and probably the best thing to do is discuss your concerns with his doctor. We see many people after car accidents where pain can last for years.

MEMBER QUESTION:
I am concerned about my son drinking alcohol while he is taking prescription pain pills. He really did hurt his back on the job, and really has pain, but I think he is combining the alcohol and the drugs to get high. How can I tell if that is the case? And what should we do?

LEBOVITS:
This is a problem. He should not be drinking alcohol. Many people who have pain drink alcohol to help relieve the pain. However, there can be very serious consequences to the combination of alcohol and prescription drugs. The two can interact very negatively, and depending on the amount of the alcohol and prescription drugs, it could be fatal. So I would strongly suggest that your son gets help for himself and address this problem.

MEMBER QUESTION:
How easy is it to OD on prescription painkillers?

LEBOVITS:
It is easier to overdose on the shorter-acting drugs such as Percocet or Vicodin, but you do have to take quite a bit to overdose. Once again, everyone's body is different, but certainly it is something that needs to be looked out after.

There are some pain patients who do try to commit suicide by overdosing, but usually there's a strong history of depression. That's why people who have chronic pain should get treated in a multidisciplinary treatment center and should get a psychological evaluation. Chronic pain leads to depression, and sometimes the depression can be very severe and sometimes leads to more impairment than the pain itself.

"Pain is a very subjective sensation. You can't measure someone else's pain, and that's what makes the assessment of pain difficult."

MEMBER QUESTION:
I feel that as long as I take my medication as directed, and the BT only as needed, I will not become addicted. Am I right?

LEBOVITS:
Yes, you are right. As I have said before, almost all pain patients do not get addicted to pain medications if they're taken in the proper fashion. You may develop dependence or tolerance, but as I've said before those are normal physiological reactions.

MEMBER QUESTION:
Are people who manage their pain through a pain management clinic or through a provider who specializes in pain management less likely to abuse or become addicted to painkillers than someone who is treated by their primary care provider?

LEBOVITS:
That's an interesting question. I think that the main difference between being treated in a multidisciplinary pain environment, as opposed to your primary care provider, is that if an addiction does develop it can be detected earlier and treated effectively.

MODERATOR:
Dr. Lebovitz, before we wrap things up, do you have any final words for us?

LEBOVITS:
I want to thank everyone for your very insightful questions, and I hope that everyone will come away with the knowledge that quality of life is important, and that when someone has pain it is important that we believe them when they say that they have pain. It may seem to you like they don't, or it may seem like they're exaggerating their pain, but unless you walk in their shoes, unless you actually experience what they're going through, it can be harmful to judge them. So we need to err on the side of believing a patient about their pain, rather than dismissing them or not believing them. The harmful consequence of that would be that their pain gets undertreated, and that's when you can create an addiction.

MODERATOR:
Can you give us some resources to visit or follow-up on after today's discussion?

LEBOVITS:
For more information, there's American Pain Society. Their web site is ampainsoc.org. There's also the Eastern Pain Association, for those people who are in the Eastern part of the United States. I happen to be president of the Eastern Pain Association. Their web site is easternpain.org. We're having a one-day meeting on pain management on Sept. 10, 2004, in New York City, and if people want more information they can go to the web site. One final resource: the NYU Pain Management Center, and their phone number is (212) 201-1004.

MODERATOR:
Our thanks to Allen Lebovits, PhD, co-director of the NYU Pain Management Center, for sharing his expertise with us.

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