R. Morgan Griffin
Brunilda Nazario, MD
People living with serious back pain have to sort through a lot of mixed messages about opioid -- or narcotic -- painkillers.
On the one hand, you've heard stories about the seeming epidemic of addiction to these drugs, like OxyContin, Percocet, and Vicodin. All those celebrities checking into rehab for painkiller addiction may give you the impression that the lure of these drugs is irresistible, that we're all just a few pills away from addiction.
But on the other hand, you might have heard that pain is chronically undertreated and many people are suffering needlessly. Which is true?
"They're both true," says Lynn Webster MD, medical director at the Lifetree Clinical Research and Pain Clinic in Salt Lake City. "In this country, we undertreat pain and we underutilize opioid painkillers. But we've also had a serious 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 drug abuse and addiction that come with powerful painkillers. On the other, they're suffering from severe and debilitating pain and need some kind of help.
Opioid medicines can save lives. But they can destroy them too. What's an average person with severe back pain supposed to do?
Here's one piece of good news: most people with back pain don't need these powerful painkillers to begin with.
Many with back pain often just use non-addictive medications like acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs). Some NSAIDs are sold over the counter, like ibuprofen or naproxen, and others are sold by prescription. Steroids can also be prescribed for back pain due to swelling and inflammation. These drugs do have some risks of their own, but the potential for addiction is not among them.
Even when powerful opioids like Percocet and Vicodin are necessary, many people 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 moving around and begin physical therapy.
But sometimes, the back pain lingers. Chronic back pain can sometimes develop as a result of arthritis or injuries that can't be corrected surgically. In the small percentage of people with chronic and hard-to-treat back pain, a doctor may recommend long-term opioid therapy. Others may get opioid therapy if the side effects of other painkillers -- like NSAIDs -- are too risky.
While some patients and doctors swear by opioids as a treatment for severe chronic back pain, the evidence is not all that strong. One 2007 review in the Annals of Internal Medicine found that while opioids do help with short-term back pain, it's not clear that they help with chronic back pain. A 2007 Cochrane Review found that opioids may not work any better than an NSAID for chronic lower back pain.
Prescription narcotic abuse is a serious issue, says Jim Zacny, PhD, a professor in the department of anesthesia and critical care at the University of Chicago. He points to the 2007 National Survey on Drug Use and Health. It found that as many as 5.2 million people reported using prescription opioids in the last month for non-medical reasons. That's more than double the number of people who used cocaine.
But many of the people illicitly using these drugs are not in pain. So the important question is this: how high is the risk of abuse for someone living with serious back pain?
There's some good news: the risks of actual addiction may be lower than assumed. "Among people with legitimate pain issues, it's a very small group who actually develop the disease of addiction," says Webster.
Zacny agrees. "There's this myth out there that if you take an opiate, you automatically become enslaved to it," he says. "That's not the truth at all."
However, addiction isn't the only issue. Webster observes that a much larger number of these people -- perhaps 20%-30% -- do wind up misusing or abusing the drug.
What's the distinction between drug addiction and drug abuse? Many people with real back pain aren't addicted, but they may begin to use their medication incorrectly. They might take too much, simply because the prescribed dose doesn't seem to be helping enough. Or they might use their medication to cope in other ways.
"People with pain sometimes take pain medicine inappropriately to feel a little high or improve their mood," says Karen Miotto, MD, an addiction psychiatrist at the UCLA Neuropsychiatric Institute. "They might take one after a fight with a spouse or a hard day at work." Some people with chronic pain also have issues like anxiety and depression. They might start leaning on their pain 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 the number of unintentional overdose deaths caused by prescription painkillers," Webster tells WebMD. "At least half of them are in people who have legitimate pain problems with legitimate prescriptions." Taking these drugs in ways your doctor didn't intend simply isn't safe.
"Our culture encourages the attitude that if one pill is good, two is better," Webster says. "With opioids, that can be lethal."
The risks of drug addiction and abuse don't seem to be the same for everyone.
"It's not the pills alone that make an addiction," Miotto says. She points out that addiction develops from a number of physiological, psychological, genetic, and social factors. A personal history of substance abuse also seems to increase the risk.
Mixing drugs also increases the risk of problems. "If you're taking your pain medicine along with other prescription drugs, you ratchet up the risk of addiction enormously," says Miotto.
Webster says that pain itself is a risk factor: the greater the severity of the pain, the higher the risk of drug abuse and addiction. "After years of living with severe chronic pain, people will do anything to get rid of it," he tells WebMD.
Miotto says that drug addiction may seem to start innocently. A person might just occasionally call in a prescription early, or take a spouse's medication as 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't realize it. "Addiction is a disease of denial," Miotto says. "It can take years before people realize what's happening to them." It pushes people to horrible extremes. Miotto knows one patient who eventually admitted that she pushed for surgery solely because she wanted the opioid painkillers she knew she'd get afterward.
There's also another dimension to prescription drug abuse you should consider. 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 for legitimate pain," says Webster. "People need to understand the potential harm that they can do to communities if these medications aren't properly secured."
In part because of the stigma of prescription drug addiction, chronic back pain can sour even the best doctor-patient relationships. The patient can become 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 of powerful opioids.
"Doctors are getting sued from both ends," says Miotto. Some have been sued for providing opioid painkillers that lead to addiction; others get sued for not prescribing them to relieve debilitating pain.
People with a past history of addiction face the most skepticism from their doctors.
"I hate to say it, but when people walk in to the doctor and mention an addiction history, they may not be able to get these painkillers," says Miotto. "The doctor may just not trust them."
Miotto says that some people with serious pain become too focused on opioids. 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 is still 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 actually make your pain worse -- a condition called opiate-induced hyperalgesia.
In addition to NSAIDs and other drug treatments, there are non-drug options for coping with chronic pain. Physical therapy can be invaluable. Miotto notes that treatments like massage, water therapy, and biofeedback can make a big difference with chronic pain. Unfortunately, it can be hard to get insurance to cover these sorts of treatments, Miotto says.
It's also important to treat any other conditions that might be exacerbating your pain. For instance, experts say that many people with chronic pain also struggle with depression and anxiety. "People who feel an increased amount of anxiety also feel an increased amount of pain," says Webster. Even those who don't have diagnosed psychological condition can benefit from support groups or therapy.
Of course, some with chronic pain will bristle at that suggestion. They believe that it implies that the horrible pain they feel is "all in their heads."
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."
Clearly, there's no simple advice when it comes to balancing the benefits and risks of opioids for back pain. But if you and your doctor decide to use these medicines, here are some tips for taking them safely.
Finally, the most important way to assure that you're using your medicine safely is to have a trusting and open relationship with your doctor.
"Anyone with chronic pain needs to find a physician who is compassionate and understanding," says Webster. Trust between a doctor and patient is the basis of any good pain management.
SOURCES:Deshpande A et al, Cochrane Database of Systematic Review, 2007; pp 1-26.Martell BA et al, Annals of Internal Medicine, 2007; vol 146: pp 116-127.Karen Miotto MD, addiction psychiatrist; associate professor, UCLA Neuropsychiatric Institute.SAMHSA web site: "Results from the 2007 National Survey on Drug Use and Health: National Findings."Lynn Webster MD, medical director, Lifetree Clinical Research and Pain Clinic, Salt Lake City.Jim Zacny, PhD, professor, department of anesthesia and critical care, University of Chicago.
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