In our previous article on pain medication and addicts we looked at how common opiate prescriptions are among people who are, or ever have been, identified as having substance abuse issues. We saw that although clinicians are often aware of the problem of possible prescription addiction developing, the issue of managing pain often results in the eventual prescription of opiate medications for chronic pain even in this population.
This time we're going to explore whether these prescriptions end up resulting in benefits to the patients. We are going to look both at opiate and non-opiate pain relief as it applies to addicts or past addicts with chronic pain.
Stimulant users (cocaine, amphetamines, and methamphetamine) are not expected to experience many physical or chemical (neurophysiological or neuropharmacological) changes in their brain and nervous system that would interfere with opioid medication therapy. Additionally, their use of meth, cocaine, and similar drugs is not expected to increase their experience of pain unless they've been injured while using those drugs. That by no way means that their drug abuse prevents them from experiencing pain, but it less of a direct influence on the future likelihood that they'll suffer with chronic pain.
But those who do, or have, abused alcohol, benzodiazepines, and obviously opiates (heroin, morphine, oxycontin, etc.) are much more likely to be differentially affected by these medications. Physicians know this well, and in preparation for serious medical procedures specifically ask about such drug use to properly manage patients during surgery (don't want someone waking up in the middle).
One of the most obvious factors has to do with the high tolerance opiate abusers and users build up to these drugs. For this reason, the doses often needed to help long-term opiate abusers with chronic paid using opiate pain medications can be so extreme that they would easily kill an inexperienced opiate user. We've talked about tolerance many times on A3, so I'll just summarize by saying that the body and brain of opiate addicts will have a much reduced response to opiate medications because their bodies have become less sensitive to the substances in response to the extended high dose use they have put it through. This can happen through reduction in available opiate receptors as well as increased responsiveness in other regulatory systems meant to counteract the opiates (the opponent process theory).
In short, since pain perception and experience is so dependent on the body's natural opiate response, people addicted to opiate drugs (heroin, morphine, oxycontin, vicodin) have essentially neutralized their natural pain machinery and are more likely to feel pain for an extended period after they quit. By super-activating their pain-blocking response using drugs they have weakened the body's natural pain-response and are more likely to experience pain when they stop.
These factors are also important when considering pain medication for people in addiction treatment. Indeed, research (1) has found that patients in Methadone Maintenance programs, who are maintained on long-term opiate therapy, are more likely to experience severe pain and more likely to get opiate pain medication prescriptions for it when compared with people in drug-free residential treatment. However, the patients in the drug-free environments were more likely to have used alcohol or benzodiazepines to deal with their chronic pain, so it seems like a bit of a case of choosing between the better of two evils.
The specific medications for opiate-experience patients can also be different, and using more long-release or extended release formulations of these drugs can reduce the abuse liability of the medication itself while also offering better outcomes. I have to say though that the results differ when looking at different populations, and it's always important to consult, and be very honest and clear, with your doctor.
Overall, research suggests that opiate pain medications are as effective for patients who have a history of substance abuse as they are in the general population (but our Part I article suggests that effectiveness is itself limited). One issue, especially for heroin addicts (or people addicted to other opiates) who are in recovery or active use, is balancing pain management with potential abuse problems. Unfortunately, it is true that the medications most effective in treating the pain are also the ones most likely to be abused (2). Our next article is going to cover the issues of prescription abuse in this population, but I think it's important to point out that chronic pain can be debilitating in itself, and that it is likely not useful to withhold medication from someone because of the possibility that they will abuse it if the medication itself will help them.
There are certainly approaches to pain-management that do not use medication (exercises, meditation, cognitive behavioral approaches, and more) and an initial recommendation can be that those be tried first, followed by non-opiate pain-relief and then the opiates. However, when other options do not manage to deliver results, opiate pain medication can be effective in managing pain symptoms, especially if physicians are aware of methods to spot abuse and control it.
Next up - how to identify prescription abuse in patients, what does it mean, and what should we do about it?
1. Rosenblum, Joseph, Fong, Kipnis, Cleland, and Portenoy (2003). Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities. The Journal of the American Medical Association, 289, 2370-2378.
© 2012 Adi Jaffe, All Rights Reserved
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