According to Peter Hart Research Associates over 57% of all U.S. adults experience chronic pain—which translates to about 117 million people. Many of these people turned to pain medication to cope, and most people on appropriately prescribed pain medication didn’t experience any problems. However, many did experience problems and using a conservative 10% estimate would mean that about 11.7 million people with chronic pain were experiencing prescription drug abuse or addiction. Unfortunately, this problem only comes to the public’s awareness when a nationally recognized personality is “caught” in the pain/addiction trap. So how do intelligent, high functioning people fall into this prescription drug trap and how can it be avoided?
First of all, there is quite a bit of confusion and mislabeling of people on long-term use of pain medication. Many patients are identified as “ pill addicts” when they really aren’t. To help clarify this issue we can refer to a consensus document that was developed by the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine. They have agreed upon the following definitions for addiction, physical dependence, tolerance, and pseudo addiction:
Addiction: Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.
Physical Dependence: Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.
Tolerance: Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution (lessening) of one or more of the drug’s effects over time.
Pseudoaddiction: The term pseudoaddiction has developed over the past several years in an attempt to explain and understand how some chronic pain patients exhibit many red flags that look like addition. Pseudoaddiction is a term which has been used to describe patient behaviors that may occur when pain is under treated. Patients with unrelieved pain may become focused on obtaining medications, may “clock watch,” and may otherwise seem inappropriately “drug seeking.” Even such behaviors as illicit drug use and deception can occur in the patient’s efforts to obtain relief. Pseudoaddiction can be distinguished from true addiction in that the behaviors resolve when pain is effectively treated.
The leading cause for people falling into the prescription drug trap is an under-treated or a mismanaged chronic pain condition. How does this happen? In many cases the chronic pain patient has become a passive recipient of treatment and is unable to articulate his or her concerns about the course of treatment. In other situations the patient has a past history, or family history, of an addictive disorder, which makes them significantly more vulnerable to abuse or addiction to the prescription medications. In other cases the patient may have a pre-existing trauma history that could make them much more susceptible for addiction and/or have a greater sensitivity to pain than the “normal” population. With the advent of Managed Care and HMOs many medical professionals are rushed and cannot or do not perform adequate history and physicals that delve into their patients’ addiction, trauma, and psychological history.
Another major factor of people getting into trouble is lack of knowledge about effective pain management and the addiction potential of the medication they are using. Patients are at a much higher risk for experiencing problems when they do not receive sufficient information and education about potentially addictive medications. People also need to be taught non-pharmacological pain management tools they often reduce the amount of pain medication they need to effectively manage their pain. They also need to learn about the importance of identifying and managing the psychological and emotional components of their pain. In addition, people need to know how to foresee problems that may arise when taking potentially addictive medications.
There are several warning signs or red flags that someone may be at risk of experiencing that can lead to abuse or addiction to their medication. Some of these indicators include the following:
- Frequently taking more medication than prescribed
- Using medications in physically dangerous situations, i.e., driving, childcare, etc.
- Experiencing problems with thinking, feelings and/or behavior due to medication
- Quality of life and/or relationships are being impacted by use of medication
- History—or family history—of alcoholism or other drug addiction
- Using medication to manage psychological/emotional type pain or to cope with stress
- Family members or friends report concerns about medication use/abuse
- Having considerable urges or cravings for the medication
Some of the items above may be difficult to determine, which is why obtaining information from significant others as well as the patient becomes so essential. This collaboration should include the patient, their support network, other healthcare providers, and any other sources that could help in more accurately determining the above. If two or more of the red flag areas are present, it is time to seek a referral to an appropriate addiction specialist to make a more accurate assessment to determine the presence of a potential medication abuse/addiction problem.
Another major risk factor for medication abuse/addiction is when patients don’t identifying and manage the psychological or emotional components of their pain. This often leads to patients using their pain medication to cover up those symptoms. The negative thinking patterns often lead to uncomfortable emotions and the person moves from experiencing pain—“ouch this hurts”—to suffering—“this is horrible, awful, terrible.” Or, “I can’t take this anymore.” The thinking and emotional components of pain often act like an amplifier circuit that boosts the intensity of the original pain signal.
Pain is a total biopsychosocial experience. People hurt physically. They psychologically respond to the pain by thinking, feeling, and acting. They think about the pain and try to figure out what it is causing it and why they’re hurting. They also experience emotional reactions to their pain. They may get angry, frightened, or frustrated by their pain. They talk about their pain with family, friends, and coworkers who help them to develop a social and cultural context for assigning meaning to their personal pain experience and taking appropriate action.
Effective pain management includes three core components that work together to systematically approach the treatment of pain at all three levels—biological-psychological-social—simultaneously. This means using physical treatments to reduce the intensity of the physical pain, which includes in part developing an effective medication management plan. The second component involves using psychological treatments to identify the thoughts, feelings, and behaviors that are making the pain more intense and replacing the old ways with positive thinking, as well as feeling and behavior management skills that work together to reduce the intensity of the pain. The third component of a truly effective chronic pain management plan is to help patients develop non-pharmacological pain management interventions such as biofeedback, massage therapy, physical therapy, hydrotherapy, etc.
Effective pain management and avoiding the prescription drug trap is possible if someone is willing to do the footwork and follow a strategic treatment plan using a collaborative multi-disciplinary treatment team. With the proper treatment plan and support, patients with chronic pain can have successful treatment outcomes. They can move from being a passive recipient (i.e., victim) to being an active participant in their healing process, leading them to once again feeling empowered and experiencing a higher quality of life.