The Use and Abuse of Pain Medications
One of life’s most conflicted relationships is the one between a pain patient and his or her medication. Issues of reliability, dependence, and the compromise of side effects dominate the decision to take medication. Most pain patients consider medication to be a necessary evil, with a trade off between excruciating pain on one hand and alertness, mental clarity, and smooth gastrointestinal functioning on the other.
In addition to the unpleasant side effects of most pain medication, there is the social stigma of taking addicting substances. Often family and friends are opposed to the patient’s use of narcotic medication for fear that the person will become a drug addict. Medications like OxyContin, morphine, and methadone have often been in the news, and their very names conjure up images of down-and-out street drug users. Therefore, it is very important to understand the distinction between physical dependence and psychological addiction if you are to make an informed decision about taking pain medication.
Physical dependence means that the body adapts to the substance and reacts when that substance is taken away. Abruptly stopping the medication can lead to withdrawal symptoms such as nausea, vomiting, chills, tremors, diarrhea, and feeling like you are crawling out of your skin. Narcotic pain medications are only one type of substance that can produce withdrawal symptoms. Blood pressure medication and antiseizure medication are two examples of non-narcotic substances that can cause serious withdrawal effects if discontinued suddenly. Even coffee produces withdrawal symptoms such as headache and muscle spasms if a four- or five-cup-a-day habit is stopped suddenly. Withdrawal is a purely physiological response and has nothing to do with the will power or moral fiber of the person taking the medication.
Psychological dependence, however, is something to be concerned about. True addiction is the emotional reliance on narcotics for their mood-altering properties. Addiction proceeds through stages. First comes the instrumental stage where the person occasionally takes and extra pill or two to alleviate stress. Feelings such as anger, anxiety, loneliness, boredom, and uselessness often underlie a person’s misuse of pain medication. Over time the occasional extra pill becomes a regular extra pill, and addiction proceeds to the habitual stage. At this point the person may feel irritable, restless, and distracted as the medication wears off. This leads to more use to maintain an even mood. Life begins to be organized around the next dose as craving sets in. In this stage, users often make rules about cutting back and then break them. The user’s life begins to be dominated by a struggle for control. The final stage of addiction is the compulsive stage where the user is preoccupied with use that he or she is unable to control. Personality changes are frequently present at this stage. The person may become desperate, arrogant, blaming, and demanding.
While physical dependence is present to some degree in everyone who takes narcotic pain medication, psychological addiction afflicts only about half of those who are prescribed narcotics. It is difficult to predict ahead of time who may be susceptible to psychological dependence. One personal trait that is the most frequently correlated with medication abuse is a high level of emotionality. People who are at risk for psychological addiction tend to have had problems with tolerating stress and may have had a history of depression, anxiety, and impatience or irritability before the pain condition developed. Unrealistic expectations can also set a person up for medication abuse. A person who expects that pain medication should block all the pain is at risk of taking more and more medication to chase the pain away. Over time the medication is not effective in reducing pain, but the person is hooked on the mood-altering effects. It is important to know that at best medication reduces the pain by only 50-60%.
It is easy to see the problems inherent in taking too much medication, but there are other ways to misuse pain medication as well. Taking extra medication to get through a physical task with the expectation that you will cut back on doses at a later time, or taking fewer doses and hoarding to be able to use the extra medication to get through a big event or project also constitutes misuse. This pattern ensures a “crash and burn” experience that can disrupt the central nervous system. Another common misuse of medication is abstaining or taking less than prescribed and then taking a dose when the pain becomes intolerable. This pattern is ineffective because no pain medication can catch up once there is this type of breakthrough pain. Medication is prescribed in doses and on time schedules to assure a steady state of relief. Seesawing up and down from severe pain to sedation ensures ongoing pain and emotional suffering.
If you are considering taking pain medication, or if you have been disappointed in the effectiveness of your medication, you should educate yourself about the medication. Knowing how it works and how it is prescribed is essential to responsible medication use. (See TYPES OF PAIN on this website.) If you are inclined to tinker with your doses or the times you take the medication, consult with your doctor first. Stay on top of the amount of medication you have on hand and schedule prescription refills on time so that you have no gaps in your supply. Remember that using your medication as it is prescribed does not constitute addiction even if you do have physical dependence. Have reasonable expectations for pain relief and explore other behavioral methods of pain management. Accept the fact that your life is not the same as it was before your pain condition, and be realistic about what you can and should accomplish. Stay tuned in to your body and your environment so you can make conscious and responsible decisions not only about your medication, but also about every aspect of your life.
Michele Gargan, PsyD
