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I’m going to talk about opioids again today. But I'm not going to talk about how they're used for pain. Some of what I’m going to say repeats information I gave in a previous post (https://www.sjdpsych.com/post/are-your-meds-making-you-sick-pain-meds-3-the-opioid-talk). But mostly I'm going to talk about some of the problems they cause.
Stop Treating Me Like I’m An Addict
Most of the people I see who are having trouble getting off these medications never did anything wrong. They took their medications only the way they were prescribed. Never took too much. Never asked for it early. Never gave it away or sold it.
And they feel betrayed and angry when they’re told they shouldn’t be taking these drugs, or at least not the way they have been.
And they have reason to be mad. In many cases patients weren’t told, or it wasn’t emphasized, that these aren’t the best drugs for chronic pain. Plus, long term use can cause significant problems of its own.
One patient who came to see me was an 83 year old grandfather. His son and grandson had taken him to the emergency room when he had had terrible nausea and vomiting for several
days. He was dehydrated and weak.
In the ER, the doctor told him the only thing wrong with him was he was in withdrawal, that he was “addicted” to his Vicodin.
My patient denied this. He never abused the medication. He never shot it into his veins or snorted it up his nose.
There was no way that he was addicted.
After the ER physician explained a little more to Mr. S, my patient was furious at his doctor. He hadn’t been told this could happen. Plus, he was embarrassed. First that he was “addicted” to a drug and second that his family, especially his teenaged grandson, knew.
Drugs: tolerance, dependence, and addiction
Words make a difference. And when we’re talking about something as emotional as drug addiction, it’s especially true. Mr. S was not “addicted” to his medication. And he was angry that anyone would say otherwise.
I agreed with him.
When I talk to people about problems with pain medications, I’m careful about what I say. No one wants to be called an “addict.” And most people on opiate medications are NOT addicted to their medications.
I’ll explain.
DRUG TOLERANCE: When you take some types of drugs, like opioids, your body can get “used to” it. When this happens, you have to have more of the drug to get the same effect.
So, say you took Vicodin® 5/325 (5 mg of hydrocodone and 325 mg of acetaminophen) three times a day and it helped for your back pain.
Eventually, though, this amount doesn’t give you the relief you used to have. Now your doctor says take Vicodin® 7.5/325 three times a day. Again it helps for a while, but then that dose stops working. So you have to increase the dose. And then this helps for a while, but...
You might think this means your back problem is getting worse. And it may.
But it could also be that your body has developed “tolerance” to the hydrocodone, so you have to have more, then more, then more, for it to do what it used to do at a much lower dose.
It turns out, many people who take opiates chronically don’t always need to have more. But many do.
DRUG DEPENDENCE: this is when your body is so used to having a certain drug, that when it’s not there you have withdrawal.
And withdrawal can happen with a lot of different drugs.
Take caffeine, for instance. I drink several cups of coffee a day, except on the weekends. On Saturday and Sunday, I usually get up late and have a cup of coffee later than I do on a usual work day.
So now when I wake up on Sundays, I often have a headache. This is probably because I cut down my caffeine the day before and I haven't had any in me yet today.
My body is “used to” having caffeine early in the AM and then again later in the day, so I have headache, one of the symptoms of withdrawal. And I can cure the headache by getting a cup of coffee into me.
My headache is due to the fact that my body is dependent upon caffeine and in its absence, I’m uncomfortable. The quick "cure" is to have another cup of coffee. (The real "cure is to get off it and stay off it. But sorry, that's not happening any time soon).
DRUG ADDICTION: Being dependent on a drug or having tolerance to its effect is not the same as being addicted, and I’m careful to point this out. Tolerance and dependence are things that will happen to everyone who is on a specific drug at a particular dose for a long enough period of time.
Addiction implies that you’re craving the substance. You have an emotional involvement with it. You think about it all the time. You use the drug even when you don’t need it or when you shouldn’t, like if you’re going to be driving or operating heavy machinery.
You worry about running out or where you're going to get more. It becomes a center of your attention. You use it for the good emotional feeling it gives you, not for the relief of pain.
This is why I tell most of my patients that they aren’t addicted to their medications. Instead, their bodies depend upon them, because their bodies are used to the drugs.
Of course, some of my patients are addicted to their medications. When that happens, I try to help them find ways to get off their meds and find substitutes that won’t cause them trouble. Next post I'll spend the whole time talking about opioid addiction and what you can do about it.
A little history of opioid drugs
First, a little about the word “opioid.” We used to call these drugs “narcotics,” but don’t anymore. The reason for this is that “narcotics” is a law enforcement term. It lumps all drugs of abuse like cocaine and marijuana in with heroin so it’s really confusing as to what we’re talking about.
So in medicine, we started using the term “opioid” to describe only drugs that either come
from, or look like, opium. Some drugs, like morphine and heroin, are made directly from opium. Other drugs that work like morphine but are completely, or mostly, man-made
include such drugs as Vicodin ®(hydrocodone) and Oxycontin® (oxycodone) and methadone.
Opium comes from the fruit of the poppy flower. And it’s been used literally for thousands of years to help people sleep, sooth fussy babies, and relieve pain.
Fast forward to the 1800s. Chemists developed morphine from opium. It was much more powerful than opium. As a result, it was incredible for its ability to relieve pain quickly. Unfortunately, it was also really bad about causing addiction.
And since the first large scale use of morphine in the United States came in the Civil War, the
first people to get addicted to morphine were soldiers treated for battlefield injuries.
Pretty soon, the U.S. was demanding a lot more morphine. But it takes time and a lot of acres of land to grow enough opium poppies to make all the morphine we wanted in this country.
So scientists kept working on finding a way to make drugs that looked like, and acted like, morphine. And with this research came the drugs listed above, as well as others.
All of the medications among the opioids have been tremendously helpful in relieving pain for millions of people. And all of them, except heroin, have an important place in medical practice today. (Heroin is a “Schedule I” drug in the US. This means it cannot be prescribed under any circumstances and has no place in medicine. However, it’s used in Europe for pain management, and is quite good for that purpose.)
It was only when these medications began being used for treating problems that could have been treated better with a different set of drugs, that trouble started.
WHAT DO I DO NOW?
I’m going to talk about what to do if you find you’re dependent upon, or addicted to, your pain medications next time.
For now, though, I want you to be aware of a few important points:
1. If you’re on an opioid medication like one of the ones mentioned, have been on it
for a long time and are needing more, you have “tolerance” to its effects.
a. This is nobody’s fault. It can happen over time.
b. However, it’s not something to be ignored and should be discussed with
whomever is prescribing the drug.
2. Your body may be “dependent” upon one of the meds listed.
a. This means that if you cut back or miss a dose your body shows withdrawal
from the drug
b. If this happens, you should work with your provider or someone else to slowly
back away from that drug and get help finding something to replace it.
3. Being addicted to a drug can happen. It is no one’s fault. I don’t know of anyone
I’ve ever worked with who wanted to be an addict. But, there is help for addiction.
And I’ll talk about this more next time.
Image of old man and son by @Can Stock Photo Inc. /Zinkevych
Image of coffee cup by @Can Stock Photo Inc./philipimage
Image of opium poppy by © Can Stock Photo Inc. /crbellette
Image of battlefield injured by @Can Stock Photo Inc/ marzolino
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