Walking the Tightrope of Pain Management and Addiction Part 1

Beware of the Quick Fix Trap

It is very frustrating when you live with chronic pain
and are not getting the pain relief you want and need.
I know because I have lived with chronic pain for many
years. Like others I work with, when we experience
a pain flare up our first reaction is that we want it to
stop—now!

Unfortunately, problems can arise when medications
that have been developed for acute pain conditions are
prescribed for chronic conditions. When people are in
pain, they often have a need for instant gratification (I
want it and I want it now). While acute pain medication
can give them the relief they are looking for, it can also
lead them to expect the quick fix.

Being able to tell the difference between the appropriate
and effective use of pain medication and the beginning
of abuse on through to addiction is sometimes difficult
to determine. What is important to keep in mind is
that there is a progression individuals go through that
includes medication dependency, medication abuse,
pseudo-addiction, and finally addiction. The confusion
and uncertainty of this progression can be a challenge
for both patients and treatment providers.

Some people living with chronic pain are afraid to take
their narcotic (opiates etc.) medication because they
have heard horror stories of people getting hooked on
pain pills. This leads to a decision to under-medicate, to
live in pain, and suffer. If you happen to be in recovery
for alcoholism or any other drug addiction, the problem
is even worse. If you under-medicate it could trigger a
relapse when you don’t adequately manage your pain.
Or you could overmedicate which can lead to a rapid
tolerance buildup and finally a reactivation of your addiction.

Understanding Addiction

In this section I will use the terms addictive disorders
and addiction to discuss what the DSM-IV-TR™ (Diagnostic
and Statistical Manual of Mental Disorders;
Fourth Edition, Text Revision) classifies as substance
use disorders and is also referred to as chemical dependency
or psychological dependence.

I define an addictive disorder as: A collection of symptoms
(i.e., a syndrome) that is caused by a pathological
response to the ingestion of mood-altering substances
and has ten major characteristics which are listed below.

 

Differentiating Between Addiction and Pseudoaddiction

No one who is in treatment for chronic pain starts out
with the goal of becoming addicted to their pain medication;
nevertheless it happens at least 10 percent of
the time. If someone has a family member with addiction
or mental health conditions, or if they have a personal
history of addiction or mental health problems,
they are at high risk for racing through the progression
of addiction.

People at risk for addiction react differently from the
very first experience of taking pain medication. With
ongoing exposure they experience the “seeking-reaching”
stage, at which time doctor shopping can begin.

There are many questions to be addressed when treating
someone who has chronic pain and coexisting substance
use disorders. The three most important ones
I talk about at my Addiction-Free Pain Management®
trainings are these:

1. Are we managing pain but fueling
the addiction?

2. Are we treating the addiction but
sabotaging the pain management?

3. Is it addiction or pseudoaddiction?

The term pseudoaddiction is fairly new to the addiction
treatment field, but has been used in the pain management
field for quite some time. The point to remember
is that even though pseudoaddiction looks like addiction,
it is actually caused by an undertreated or mistreated
chronic pain condition. However, the treatment
plan for pseudoaddiction and addiction is identical.
The major danger of pseudoaddiction is that if it is not
adequately addressed, it can turn into full blown addiction—
sometimes quickly, sometimes slowly.

I have worked with many patients over the years that
were labeled prescription drug addicts, but were actually
suffering with pseudoaddiction. A client, Sharon
was an example of how damaging this misdiagnosis
can be. Sharon was in her early forties and came from
a fairly normal and religious upbringing. She had never
used alcohol or any other drugs, including nicotine,
and up until her chronic pain condition had never used
psychoactive prescription medications either.

Sharon began having infrequent migraine headaches
and went to her general practitioner who gave her Vicodin
which worked for a time. As the Vicodin began
losing its effectiveness, her doctor prescribed OxyContin,
but Sharon also used Vicodin for breakthrough pain.
Sharon later found out that she would have been better
off using migraine specific medication from the start.

Although barbiturates and opioids are sometimes considered
effective for short-term migraine relief, many
doctors are now recommending against prescribing
this type of medication for long-term use. The risks
for potential dependence and abuse are too high and
there is a real danger of developing medication overuse
headaches (sometimes called pain rebound or
transformed migraines).

Because transformed migraines are difficult to diagnose,
many people are not being treated appropriately.
Treatment is further complicated by the chronic nature
of migraine headaches. People with transformed migraines
may overuse pain relievers, both prescription
and over-the-counter, on a daily basis with or without
having a headache. This puts them at risk for building
a tolerance to the drugs. Additionally, taking too many
pain relievers containing caffeine can also lead to rebound
headaches.

As Sharon’s migraines became more frequent, she began
taking more and more medication to get any relief.
As the dose increased, her family and then her doctor
became concerned that she had become “addicted” to
the OxyContin and Vicodin. Sharon’s doctor told her he
couldn’t help her anymore unless she went into an addiction
treatment program.

Sharon’s family found a program that reportedly treated
pain and prescription drug addiction which is when
her nightmare began. While undergoing detoxification
from the OxyContin and Vicodin, Sharon was forced
to stand up in front of groups and identify herself as a
drug addict. She was not even allowed to say she was a
prescription drug addict, which was humiliating for this
very conservative woman.

After Sharon stopped all of her medications, the migraines
kept coming back. To add insult to injury, when
she asked for help with the migraines, the program staff
said she was “drug seeking” and all she needed to do
was “turn it over” and work the steps. Even though I’m a
big advocate of a 12-Step approach for people with addictive
disorders, it can be dangerous to label or advise
chronic pain patients in this manner.

Sharon was discharged from this program with a letter
to her doctor stating she was an addict and should not
be given opiates anymore. She became depressed and
attempted suicide. Sharon’s family finally sent Sharon
to a pain clinic I consulted with. I met with her several
times, assessed her case and discovered that her diagnosis
was not addiction; but pseudoaddiction.

Addressing Pseudoaddiction

As mentioned above, Pseudoaddiction describes behaviors
that may occur when pain is under-treated.
People with unrelieved pain may become focused on
obtaining medications, clock watching, or otherwise
seem to be inappropriately drug seeking. Even such behaviors
as illicit drug use and deception can occur in a
person’s efforts to obtain relief. Pseudoaddiction can be
distinguished from true addiction in that the behaviors
will resolve once the pain is effectively treated.

• Pseudoaddiction looks a lot like addiction

• Patients may appear to be “Drug-Seeking”

• Patients may need frequent early refills

• Behaviors are caused by under-treatment

• Problematic behaviors resolve when the
patient’s pain is adequately treated

Since this was the case for Sharon, the pain clinic prescribed
migraine specific medications as opiates are
contraindicated for ongoing migraine treatment. There
are seven triptans (Imitrex, Maxalt, Zomig, Amerge,
Axert, Frova, and Relpax) that were developed and FDA
approved as migraine abortive (management) medications.

These medications work to stop the migrainous
process in the brain and stop an attack with its associated
symptoms.

Sharon responded well to Maxalt, but she also was put
on a preventative medication called Migranal. Ergotamine
medications such as DHE and Migranal are used
as vasoconstrictors for migraine prevention and sometimes
mixed with caffeine. They are also FDA approved
for migraine treatment as is Midrin (a combination of
acetaminophen, dichloralphenazone, and isometheptene).
Because of these two medications, her migraines
were being effectively managed.

Sharon was also prescribed an SSRI antidepressant as
we began to implement a cognitive behavioral therapy
treatment plan for the depression and pain-focused
psychotherapy for pain management. Today Sharon is
experiencing a great quality of life, but still has nightmares
about her time at the treatment program. Referring
back to my original three questions, Sharon’s
general practitioner risked fueling an addiction and the
addiction treatment program definitely sabotaged her
pain management.

It’s important to work with a multidisciplinary team
and perform assessments to determine if you are experiencing
addiction or pseudoaddiction when you have
chronic pain and coexisting addictive disorders. Sharon
experienced pseudoaddiction—not addiction as everyone
thought. Once she was placed on an appropriate
migraine medication management plan, along with
cognitive behavioral therapy to address the psychological
pain symptoms, Sharon’s quality of life improved
dramatically and her migraine episodes lessened both
in frequency and intensity.