A Q & A on prescription pain medications

Dr. Marvin Seppala, chief medical officer at Hazelden, offers advice

on managing pain while maintaining sobriety

Q: What's the danger of prescription pain medications?

A: Addiction to prescribed pain medications is the fastest growing addiction problem in the United States. Pain medications are second only to marijuana as the most commonly used illicit substance. There is the perception that these are safe medications, because they are prescribed by physicians. However, they are extremely reinforcing, highly addictive, and in the same class of drugs as heroin.

The pain medications that have the greatest potential for addiction are opioids. Some are derived from opium, such as morphine, and others are synthetics that are manufactured, such as methadone. The most commonly prescribed opioids are Vicodin and OxyContin. In fact, the 2008 Monitoring the Future Study (by NIDA) showed that 9.7 percent of 12th graders had abused Vicodin and 4.7 percent had abused OxyContin for nonmedical purposes at least once in the past year. Several other common opioids prescribed for pain relief include fentanyl, codeine and Darvon.

Q: Why the recent increase in use of pain medications for nonmedical purposes?

A: Since 1995, there has been a dramatic increase in the number of prescriptions written for pain medications. Historically, pain was not being adequately treated, so part of the increase in the use of this class of medications is justified. However, with the increase in prescribing, there has been a corresponding increase in associated problems, including addiction. Dramatic increases in emergency room admissions due to opioid overdoses, addiction treatment center admissions for opioid dependence, and deaths caused by overdose on these medications have occurred since the mid ‘90s. In some states, prescribed methadone used for treatment of pain (not for opioid addiction) has become the most lethal drug, exceeding heroin, methamphetamine and cocaine.

Most people using these drugs regularly for nonmedical purposes are getting them via "doctor shopping"--going to multiple doctors for prescriptions. According to the Monitoring the Future study, among persons 12 or older who used pain relievers nonmedically in the past 12 months, 56.5 percent reported that they got the drug from someone they knew and that they did not pay for it.

Q: What kinds of effects are produced by these drugs?

A: These medications are remarkably useful for the treatment of pain. In fact, they are the only medications that are effective for moderate to severe pain. Heroin is an opioid, and all opioids act in the same manner. They numb pain--both physical and psychological. They provide a euphoric, pain-free, calming sensation. Although they are known for causing people to "nod out," they often provide energy. Simply put, they make people feel very good. Anesthesiologists inject patients all day long with fentanyl, a very powerful opioid, and patients wake up asking what they were put to sleep with because it felt so good.

Taking a large single dose of pain medications can cause severe respiratory depression or death. These medications are only safe to use with other substances under a physician's supervision. Typically, they should not be used with alcohol, barbiturates or benzodiazepines.

Q: Who is at risk for becoming dependent on prescription pain medications?

A: Anyone can become addicted to these medications if they use enough of them. The most likely to become addicted are those with a family history of addiction or those in recovery from another addiction, such as alcoholism. Genetic risk is the primary risk factor, but a history of trauma, other mental illness, and use at an early age also contribute to risk. Those with chronic non-cancer pain appear to also have a higher risk of addiction.

Q: How might using pain medications threaten the sobriety of someone addicted to alcohol or other drugs?

A: Anyone in recovery from addiction needs to be very careful while using these medications. It is highly likely that people in long-term recovery will need them for relief of acute pain at some point in their lives. If they recognize the risk and take appropriate precautions, these medications can be safely used, but the risk of addiction can't be eliminated. If they do not, they may find themselves rapidly caught up in opioid addiction. This can happen because the neurobiological changes in the brain associated with past addiction remain intact and can be reestablished and triggered by the use of opioids. This can even happen when pain subsides due to the reinforcing nature of pain relief and the power of addiction.

Q: How can people in recovery manage their pain and protect their sobriety?

A: Managing acute pain may require use of opioid pain medication. If this is necessary, communication with one's physician about the history and risk of addiction is necessary. Structured use of the medications help reduce risk as well. The physician should make all the decisions regarding use of these meds, not the patient. Those who are not in recovery can make good decisions about the use of one or two OxyContin tablets every eight hours, but those in recovery should never be put in the position of making such decisions. It's also important to have someone else control the use of the medication and to let your friends, your sponsor, your family and your Twelve Step group know what is occurring.

Q: How does Hazelden help patients manage their chronic pain while in primary treatment?

A: During treatment we evaluate pain and, if necessary, use outside medical consultation. We evaluate the use of pain medication and determine alternative means of relieving chronic pain. Physical therapy, massage, acupuncture, nonaddicting pain medications and exercise are among the options used. Cognitive behavioral therapies are also provided and are very effective for chronic pain. If people have extreme pain, they may have to transfer to a chronic pain program such as that found at the Mayo Clinic.

Q: What are some suggestions for preventing abuse of and addiction to prescription pain medications?

A: We need increased awareness about the misuse of prescription painkillers. State medical boards need to examine the problem of overprescribing and offer training about addiction and appropriate prescribing of pain meds. More training is needed for medical students, nursing students and other caregivers. Law enforcement needs laws and resources to shut down "pill mills," Internet prescribers and unscrupulous physicians.

For the individual, it is important to obtain prescriptions from only one physician and to use medications only as prescribed.

Published in The Voice, October 2009