How Do You Handle Pain Relief If You're Concerned About Addiction?

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How Do You Handle Pain Relief If You're Concerned About Addiction?

By Laura Kiesel 07/18/16

I am a woman with a family history of addiction who is also in chronic pain. What if someday I need opioids to manage that pain?

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Treating Patients with Pain and Addiction
How do we treat pain patients without addictive drugs?

First, two discs in my lower spine degenerated. Then, they herniated, both bulging out and impinging nerves, inciting an excruciating, sciatica-like pain that affected me around the clock. More than a year since my discs were damaged, pain has become my daily reality. I wake up stiff and sore as though I’ve just been hit by a car (having been hit by a car as a kid, I actually know what that feels like). The only thing I struggle with as much as the pain itself is finding the best way to treat it so that I can have a better quality of life. 

For many people in my monthly chronic pain support group, opioids have offered them a lifeline by allowing them to engage in activities they couldn’t otherwise without assistance, including basic things like showering or grocery shopping. Some even credit opioids as the only medication that makes a dent in their pain after trying everything else. Yet, the opioid epidemic has also ushered in new rules that are restricting people from accessing their much-needed medication, as a Boston Globe article reported earlier this summer. Nevertheless, the epidemic is real and deadly, with opiate-related overdoses now claiming more lives each year than car accidents or guns—at a rate of approximately 20,0000 annually, according to the Centers for Disease Control and Prevention.

I am caught in the middle of the debate. I am a woman in chronic pain who fears she might someday need opioids for its management. I also come from a family in which drug addiction—particularly, to opioids—was not only present, but prevalent. My mother was a longtime heroin addict. Even after she managed to get off heroin with the help of methadone, she continued to do other non-opioid drugs like crack and cocaine. When she was diagnosed with terminal bone cancer in 2005, she was prescribed Dilaudid, an opiate that’s closely related to and considered as potent as heroin, despite her history of addiction. Being on this prescription medication not only caused her to spiral back into opioid addiction, but she passed many of her pills onto my brother, getting him hooked on them as well. When she finally died in 2010 and he no longer had access to her prescription, my brother suffered from debilitating withdrawal and took to the streets to procure hydromorphone pills or other substitutes, like OxyContin. It took him nearly a year to quit, with the help of drug counseling and a Suboxone regimen.

For someone like me, with a family history of—and therefore, presumably a strong genetic predisposition toward developing an—addiction, taking prescription opioids for pain seems like a Pandora’s box. Opening it could mean falling headfirst into addiction. However, it is also something that could potentially offer me much-needed relief from the constant pain that has begun to dictate my life. Considering that an estimated 23.5 million people are struggling with an addiction to one or more substances in the United States while 100 million suffer from chronic pain, there is bound to be an overlap of the two populations. And there is a reason why.

“People with addiction [often] have real physical pain and we can't ignore it,” says Dr. Daniel Alford, Associate Professor at Boston University School of Medicine and Director of the Clinical Addiction Research and Education Unit at Boston Medical Center.

According to Alford, who specializes in opioid addiction and chronic pain management, many people who are using illegal drugs or misusing prescription drugs may actually be doing so as a way to relieve pain. In fact, a study co-authored by Alford and published this past May in the Journal of General Internal Medicine found that the vast majority of patients they surveyed who were misusing drugs also reported suffering from severe physical pain.

Specifically, of the 589 individuals who screened positive for substance use among a sample of 25,000 patients, 87 percent reported having chronic pain, including 50% reporting “severe” pain. For those who were using illegal drugs (marijuana, cocaine or heroin), more than half (51%) reported using one or more drugs specifically to alleviate physical pain, while 81 percent of those misusing prescription opioids either without a proper prescription or not as directed also reported the use as a treatment for pain.

This means that chronic pain that is left untreated or inadequately treated could be a risk factor for drug use. That being said, Alford believes that there are methods that can be applied to those who are at high risk for developing an addiction to their medication that will help decrease those odds while still successfully managing their pain.

In particular, when prescribing opioids to patients with chronic pain who are in recovery, Alford ensures that they are also actively involved in ongoing addiction treatment such as a 12-step program or addiction counseling. Alford also has patients in recovery present for random pill counts and urine drug testing. However, he notes that it’s important to do this in a respectful manner and make clear it is not about judgment or stigma, but simply a preventative measure to lower one’s risk of relapse.

“It’s like if I were prescribing medication for blood pressure that carries certain risks, especially based on a patient’s medical history, we need to monitor for safety, like having periodic blood tests,” says Alford. “This is really not that different.”

Alford endorses the use of a written agreement between a patient and their provider outlining the responsibilities of each party and prefers to have an open communication with a patient’s chosen recovery program to coordinate care and keep track of their progress. However, if these methods fail and there are indications a patient is misusing their prescription or taking other illegal substances, Alford tapers them off their opioid regimen to avoid sending them into withdrawal and works to manage the patient's pain with non-opioids.

In addition to Alford’s recommendations, the World Health Organization also offers a “stepladder” approach for dealing with chronic pain according to its severity, with strong opioids such as oxycodone, morphine or hydromorphone (Dilaudid) only advised for serious levels of pain, and certain opioid drugs like meperidine (Demerol) and propoxyphene (Darvon) avoided altogether. The federal government has an online assessment tool called NIDA-Modified ASSIST that primary care doctors can use to inventory the substance use of their patients, especially those at high risk for addiction. And at the end of last year, Boston University Medical School partnered with Harvard Medical School, Tufts Medical School and University of Massachusetts Medical School to implement current medical school core competencies at their schools that will focus on prevention and management of prescription drug misuse, reaching an estimated 3,000 medical students a year. 

Overall, while some experts agree that opioids can be successfully used to treat pain, they assert it needs to be prescribed with caution.

“A responsible and thorough physician should assess each patient individually,” says Dr. Michael Lowenstein, medical director of the Waismann Method (an accelerated detox method) and pain management specialist. “If opioid addiction and or dependence was an issue in the past, it is very likely the patient is predisposed to relapsing if opioids are prescribed. In those cases, alternative non-opioid painkillers [like anti-convulsants for nerve pain] are preferred if possible.”

Others believe that opioids should never be prescribed to anyone with a personal history of addiction issues, no matter the diagnosis.

“I don’t believe it’s ever safe for a recovering addict to take opioids for pain,” says Cindy Perlin, a licensed clinical social worker, certified biofeedback practitioner and the author of The Truth About Chronic Pain Treatments: The Best and Worst Strategies for Becoming Pain Free. “Prescription opioids are basically chemically the same as heroin, and we’d never tell a heroin addict it was okay to take heroin again to manage pain.”

Instead Perlin believes that using a range of other treatments including physical therapy, chiropractic care, psychotherapy, biofeedback, massage, nutritional therapies, exercise, herbs, low-level laser therapy and medical marijuana (in states where it has been legalized) can lead to long-term relief from chronic pain. 

“The most effective treatment is a multi-disciplinary one that takes into account the specific condition and causes and includes both mind- and body-based strategies,” says Perlin, who herself suffered from severe back pain for three years before successfully treating it with biofeedback and exercise.

Unfortunately, many of these treatments are not covered by health insurance or only receive limited coverage and can be very expensive, keeping them out of reach for low-income patients, who tend to suffer disproportionately from chronic pain to begin with. 

Alford hopes that over time, there will be more centers that deal holistically with chronic pain and offer many of these modalities ranging from acupuncture to massage to cognitive behavioral therapy (CBT). 

In the meantime, patients often have to go through a trial and error of different treatments before finding one that works for them, especially if there is concern about the impact of opioids. 

Tara Glenn, a 30-year-old online business manager and freelance writer from Georgia who suffers from myofascial pain syndrome, decided to get off her prescription opioids when the impacts of those side effects outweighed the benefits. Instead, she successfully uses low-THC cannabis oil to manage her pain. 

“My family has a history of addiction, so I expressed that concern to my medical doctors when I started [opioids],” says Glenn. “I did not become addicted to painkillers thanks to my team of doctors using caution with their prescription choices, though I did drop a lot of weight and became unhealthy due to the side effects.”

For now, opioids are off the table as an option for me. How long that remains the case depends on how long I can withstand the pain until I find an alternative that keeps it at bay, or at least lessens it to the point that allows me to function better. 

Hopefully, I will discover that alternative soon.

Laura Kiesel is a Boston-based writer whose work has appeared in The Guardian, Salon, The Street, Alternet, Science and The Atlantic. She is currently completing a collection of connected personal essays, The Drug Addict's Daughter. Follow her on Twitter @SurvivalWriter or on Facebook or on her website.

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