Analgesics?

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Back Pain: Medication and Addiction

How can we balance the risk of drug abuse with the suffering caused by untreated back pain?
By      R.  Morgan Griffin
WebMD Feature
Reviewed by      Brunilda  Nazario, MD

People living with serious back pain have to sort through a lot of mixedmessages about opioid — or narcotic — painkillers.

On the one hand, you’ve heard stories about the seeming epidemic ofaddiction to these drugs, like OxyContin, Percocet, and Vicodin. All thosecelebrities checking into rehab for painkiller addiction may give you theimpression that the lure of these drugs is irresistible, that we’re all just afew pills away from addiction.

But on the other hand, you might have heard that pain is chronicallyundertreated and many people are suffering needlessly. Which is true?

“They’re both true,” says Lynn Webster MD, medical director at the LifetreeClinical Research and Pain Clinic in Salt Lake City. “In this country, weundertreat pain and we underutilize opioid painkillers. But we’ve also had aserious increase in the misuse and abuse of these drugs.”

This leaves many people with chronic back pain — and often their doctors –stuck in the middle. On the one hand, people are afraid of the risks of drugabuse and addiction that come with powerful painkillers. On the other, they’resuffering from severe and debilitating pain and need some kind of help.

Opioid medicines can save lives. But they can destroy them too. What’s anaverage person with severe back pain supposed to do?

Who Needs Opioid Painkillers?

Here’s one piece of good news: most people with back pain don’t need thesepowerful painkillers to begin with.

Many with back pain often just use non-addictive medications like Tylenol ornonsteroidal anti-inflammatory drugs (NSAIDs). Some NSAIDs are sold over thecounter, like Motrin or Advil, and others are sold by prescription. Steroidscan also be prescribed for back pain due to swelling and inflammation. Thesedrugs do have some risks of their own, but the potential for addiction is notamong them.

Even when powerful opioids like Percocet and Vicodin are necessary, manypeople only need them in the short term. After an acute back injury or surgery,many just use these drugs to ease the pain enough that they can start movingaround and begin physical therapy.

But sometimes, the back pain lingers. Chronic back pain can sometimesdevelop as a result of arthritis or injuries that can’t be correctedsurgically. In the small percentage of people with chronic and hard-to-treatback pain, a doctor may recommend long-term opioid therapy. Others may getopioid therapy if the side effects of other painkillers — like NSAIDs — aretoo risky.

While some patients and doctors swear by opioids as a treatment for severechronic back pain, the evidence is not all that strong. One 2007 review in theAnnals of Internal Medicine found that while opioids do help withshort-term back pain, it’s not clear that they help with chronic back pain. A2007 Cochrane Review found that opioids may not work any better than anNSAID for chronic lower back pain.

How Big Is the Opioid Abuse Problem?

Prescription narcotic abuse is a serious issue, says Jim Zacny, PhD, aprofessor in the department of anesthesia and critical care at the Universityof Chicago. He points to the 2007 National Survey on Drug Use and Health. Itfound that as many as 5.2 million people reported using prescription opioids inthe last month for non-medical reasons. That’s more than double the number ofpeople who used cocaine.

But many of the people illicitly using these drugs are not in pain. So theimportant question is this: how high is the risk of abuse for someone livingwith serious back pain?

There’s some good news: the risks of actual addiction may be lower thanassumed. “Among people with legitimate pain issues, it’s a very small group whoactually develop the disease of addiction,” says Webster.

Zacny agrees. “There’s this myth out there that if you take an opiate, youautomatically become enslaved to it,” he says. “That’s not the truth atall.”

However, addiction isn’t the only issue. Webster observes that a much largernumber of these people — perhaps 20%-30% — do wind up misusing or abusing thedrug.

Opioid Addiction vs. Abuse

What’s the distinction between drug addiction and drug abuse? Many peoplewith real back pain aren’t addicted, but they begin to use their medicationincorrectly. They might take too much, simply because the prescribed dosedoesn’t seem to be helping enough. Or they might use their medication to copein other ways.

“People with pain sometimes take pain medicine inappropriately to feel alittle high or improve their mood,” says Karen Miotto, MD, an addictionpsychiatrist at the UCLA Neuropsychiatric Institute. “They might take one aftera fight with a spouse or a hard day at work.” Some people with chronic painalso have issues like anxiety and depression. They might start leaning on theirpain medication to help them with these conditions too.

While we tend to focus on addiction, misuse and abuse can also be dangerous.Opioids are powerful drugs with real risks.

“In the last three to five years, we’ve seen a significant increase in thenumber of unintentional overdose deaths caused by prescription painkillers,”Webster tells WebMD. “At least half of them are in people who have legitimatepain problems with legitimate prescriptions.” Taking these drugs in ways yourdoctor didn’t intend simply isn’t safe.

“Our culture encourages the attitude that if one pill is good, two isbetter,” Webster says. “With opioids, that can be lethal.”

What Increases the Risk of Drug Addiction and Abuse?

The risks of drug addiction and abuse don’t seem to be the same foreveryone.

“It’s not the pills alone that make an addiction,” Miotto says. She pointsout that addiction develops from a number of physiological, psychological,genetic, and social factors. A personal history of substance abuse also seemsto increase the risk.

Mixing drugs also increases the risk of problems. “If you’re taking yourpain medicine along with other prescription drugs, you ratchet up the risk ofaddiction enormously,” says Miotto.

Webster says that pain itself is a risk factor: the greater the severity ofthe pain, the higher the risk of drug abuse and addiction. “After years ofliving with severe chronic pain, people will do anything to get rid of it,” hetells WebMD.

The Effects of Addiction and Abuse

Miotto says that drug addiction may seem to start innocently. A person mightjust occasionally call in a prescription early, or take a spouse’s medicationas well as their own. “These behaviors can creep up on people slowly and then,all of a sudden, they have a physical dependency,” says Miotto.

The problem is that people who have a prescription drug addiction don’trealize it. “Addiction is a disease of denial,” Miotto says. “It can take yearsbefore people realize what’s happening to them.” It pushes people to horribleextremes. Miotto knows one patient who eventually admitted that she pushed forsurgery solely because she wanted the opioid painkillers she knew she’d getafterward.

There’s also another dimension to prescription drug abuse you shouldconsider. Even if you don’t abuse the opioid pills you’ve been prescribed,someone else could.

“A lot of the opioids that get used illicitly — especially by adolescents– come from the medicine cabinets of people who were prescribed the drug forlegitimate pain,” says Webster. “People need to understand the potential harmthat they can do to communities if these medications aren’t properlysecured.”

Doctor vs. Patient

In part because of the stigma of prescription drug addiction, chronic backpain can sour even the best doctor-patient relationships. The patient canbecome frustrated by the doctor’s inability to cure his or her pain. Meanwhile,the doctor may become suspicious of someone who’s always demanding refills ofpowerful opioids.

“Doctors are getting sued from both ends,” says Miotto. Some have been suedfor providing opioid painkillers that lead to addiction; others get sued fornot prescribing them to relieve debilitating pain.

People with a past history of addiction face the most skepticism from theirdoctors.

“I hate to say it, but when people walk in to the doctor and mention anaddiction history, they may not be able to get these painkillers,” says Miotto.”The doctor may just not trust them.”

Alternatives to Opioids for Back Pain

Miotto says that some people with serious pain become too focused onopioids. They come to believe that opioids are the only thing that will help.But sometimes, you need to take a step back.

“If you keep increasing your dose of opioid pain medication but pain isstill an 8 or 9 out of 10, it’s time to shift gears and try something else,”says Miotto. She points out that at high doses, opioid painkillers can actuallymake your pain worse — a condition called opiate-induced hyperalgesia.

In addition to NSAIDs and other drug treatments, there are non-drug optionsfor coping with chronic pain. Physical therapy can be invaluable. Miotto notesthat treatments like massage, water therapy, and biofeedback can make a bigdifference with chronic pain. Unfortunately, it can be hard to get insurance tocover these sorts of treatments, Miotto says.

It’s also important to treat any other conditions that might be exacerbatingyour pain. For instance, experts say that many people with chronic pain alsostruggle with depression and anxiety. “People who feel an increased amount ofanxiety also feel an increased amount of pain,” says Webster. Even those whodon’t have diagnosed psychological condition can benefit from support groups ortherapy.

Of course, some with chronic pain will bristle at that suggestion. Theybelieve that it implies that the horrible pain they feel is “all in theirheads.”

But Miotto says that’s not the case at all.

“Severe, chronic pain makes life terribly difficult,” Miotto tells WebMD.”Therapy is just another helpful tool in getting people to cope better.”

Using Opioids Safely

Clearly, there’s no simple advice when it comes to balancing the benefitsand risks of opioids for back pain. But if you and your doctor decide to usethese medicines, here are some tips for taking them safely.

  • Follow your doctor’s prescription precisely. Never double up a dose.Never take your medicine for any symptom besides pain.
  • Find a specialist. Dealing with chronic pain is complicated. Yourregular doctor may not be comfortable handing out long-term prescriptions foropioids. So seek out a specialist in pain management or, better yet, a painmanagement center. This is essential for people who have a past history ofsubstance abuse.
  • Don’t mix opioids with other drugs. If you already use prescriptionor over-the counter drugs, supplements, or alternative medicines, make sureyour doctor knows about every single one. Ask about the safety of using youropioid painkillers with alcohol.
  • Sign a pain agreement. These documents help build trust between adoctor and patient. A patient might promise to use the medication as instructedand, in some cases, agree to regular drug testing. In return, the doctor agreesto prescribe opioid pain relievers as part of the treatment plan.
  • Take a screener. Experts now recommend that doctors use screeners –a short series of questions — that help them identify people who might be athigher risk of opioid abuse. Like pain agreements, they help build trustbetween patients and doctors.
  • Ask about alternatives. Talk to your doctor about other ways youcould reduce your back pain. Might non-opioid medicines help? What aboutsurgery? Or non-traditional treatments like massage or relaxation?
  • Get support. Consider seeing a therapist or joining a support groupfor people with back pain.
  • Keep your medication in a safe place. Remember that it’s not onlythe person in pain who’s at risk of abusing opioids. So be careful. Don’t keepyour medicine where other people — your children, grandchildren, friends, orneighbors — can get to it.

Using Opioids Safely continued…

Finally, the most important way to assure that you’re using your medicinesafely is to have a trusting and open relationship with your doctor.

“Anyone with chronic pain needs to find a physician who is compassionate andunderstanding,” says Webster. Trust between a doctor and patient is the basisof any good pain management.

SOURCES:

Deshpande A et al, Cochrane Database of Systematic Review, 2007; pp1-26.

Martell BA et al, Annals of Internal Medicine, 2007; vol 146: pp116-127.

Karen Miotto MD, addiction psychiatrist; associate professor, UCLANeuropsychiatric Institute.

SAMHSA web site: “Results from the 2007 National Survey on Drug Use andHealth: National Findings.”

Lynn Webster MD, medical director, Lifetree Clinical Research and PainClinic, Salt Lake City.

Jim Zacny, PhD, professor, department of anesthesia and critical care,University of Chicago.

Reviewed on             March 01, 2010
© 2008 WebMD, LLC. All rights reserved.
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