Treating Pain and Avoiding Addiction

One of the greater concerns in pain management is the use of narcotics and their potential side effects.  Narcotics are morphine-like medicines and are extremely helpful in treating pain.  Over time, physicians have learned to be more judicious in our reliance upon them as the primary pain relieving therapy.   We have come to realize that their powerful effects, unrelated to the original intention, can lead to negative behaviors and tragic outcomes for patients and their families.

Addiction is a risk of using narcotic pain medicines regularly.  The quantitative risk may be significant or minimal depending on the person or problem for which it is used.   Addiction occurs as a result of the properties of narcotics outside of their pain relieving effects.  Specifically, narcotics can cause euphoria and a state of well-being and tranquility as a side effect.  Most of us would agree that these are desirable or positive side effects, however, when a person uses narcotic medications to obtain these mental states, as opposed to using them  to reduce pain, the chance of addiction is high.   Addiction is a psychological and behavioral syndrome characterized by: 1.  Loss of control of use 2.  Use despite harm to user or family 3. Preoccupation with obtaining the drug.   These behaviors will spiral out of control, if no intervention takes place, until the person becomes completely dysfunctional and/ or dies due to drug overdose in trying to prolong the psychological state they are seeking .

 Oftentimes people confuse addiction with physical dependence.  Physical dependence is a natural physical syndrome that occurs when the body is exposed to certain medications regularly.  The medication molecules attach to “receptors” in tissues in order for the active substances to take effect.  When the medicine is taken regularly,the body builds more receptors to make sure the extra medicine has a place to go.  This is analogous to a parking lot at a mall.  When the mall becomes more popular, more parking spaces “receptors” are needed to accommodate the extra people.  The problems start when the  medication is abruptly discontinued.  Now there are too many empty receptors or parking spaces that the body is used to having full.  This discrepancy causes withdrawal symptoms, which are specific symptoms from different organs as a result of having an empty parking lot.  Withdrawal symptoms aren’t synonymous with addiction and can also occur when many non-addictive medications have been quickly stopped.  These symptoms can be prevented by slowly weaning off of the particular medicine so the body has time to adjust to the change and remove the excess parking spaces.

As physicians, it’s our job to weigh and balance both the positive and negative effects of narcotic medications when deciding to use them or not.  We tailor the medication to the specific patient and problem that we are treating.  Much of the balancing act is first determined by considering factors related to the individual’s medical and social history.  For example, a patient with a strong personal or  family history of substance abuse, physical abuse, emotional trauma, depression and psychological disorders may be at a much higher risk.  Also, studies have shown that an active smoking history has a strong correlation to potential narcotic addiction.  This information doesn’t mean that people who have more addiction risk factors should not be treated with narcotic pain medications, but that the utmost care should be taken in deciding the best pain treatment plan and proper surveillance should be done to identify any issues should they begin to occur.

Interestingly, for some types of pain, narcotic medications may not be very helpful at all.  For example, muscle and nerve pains tend to be less responsive to morphine-like medicine.  I find it more useful to use muscle relaxants and anti-epileptic medications that target those specific tissues before using higher potency and addictive types.

I also use treatments outside of prescribing medicine to reduce the risk of addiction.  Rather than using any oral medication by itself, I incorporate steroid injections, nerve blocks, physical therapy and psychotherapy  into the patients’ treatment plans.  These modalities block the pain cycle and allow the patient to be more active in their recovery without the risk of taking pills.

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