Opiods: Addiction vs. Dependence (and Getting the Meds You Need)

Pain patients are highly unlikely to be addicted to painkillers (opiods). They are, however, likely to become dependent on a drug, which is very different than addiction.

If you stop taking an opiod, you may have withdrawal symptoms, including nausea, vomiting, diarrhea, sweating, muscle twitching and aches and pains, and increased pulse and blood pressure. Even though this list is reminiscent of the withdrawal scene from Trainspotting, it doesn’t mean you’re an addict. It means that you have a physical dependence on the drug.

You can develop a physical dependence and experience withdrawal symptoms with many different meds, including antidepressants, but you aren’t addicted to them. It works the same way with opiods. Docs make a schedule for to reduce the amount of a drug we take slowly to avoid these unpleasant symptoms, but they may be inevitable. Just as you might be nauseated and dizzy when you stop taking an antidepressant, you may have diarrhea and a racing pulse when you stop taking opiods. (For a personal tale of dependence and withdrawal, read Chapter 19 in All in My Head by Paula Kamen.)

Tolerance is another physical phenomenon that may cause fears that you’re addicted to opiods. Maybe a small amount of a drug relieved your pain initially, but over time you need higher and higher doses to maintain the same level of pain relief. Like dependence, tolerance is not a sign of addiction.

Patients who take opiods may exhibit addict-like behaviors (called pseudoaddiction) — like hoarding pills and being preoccupied with taking the next dose at the precise time it is OK to do so. Understandably, seeing a patient with these behaviors make a doctor very cautious. However, pain patients stop behaving like addicts when they get adequate pain relief.

That deserves repetition and it’s own paragraph: Pain patients stop behaving like addicts when they get adequate pain relief!

Pain specialist Scott Fishman sums up the difference between patients who are dependent and those who are addicted well: “The difference between a patient with opioid addiction and a patient who is dependent on opioids for chronic pain is simple. The opioid-dependent patient with chronic pain has improved function with his use of the drugs and the patient with opioid addiction does not.”

You may be reassured that you’re not an addict, but that doesn’t mean it will be any easier to get docs to prescribe opioids. Here are some thoughts for patients seeking pain relief with opioids:

  • It will probably take multiple visits to a pain specialist to get a response. He or she needs to get to know you and your case before prescribing opioids.
  • A specialist at a pain clinic rather than a pain specialist in a solo practice or one in a team of many different types of doctors may understand your pain better.
  • Pain specialists may not give you the time of day if you haven’t seen a neurologist or headache specialist first.
  • Patients who say they’ve tried everything to treat their headaches often haven’t. There are so many preventives and abortives available that there are probably many that you’ve never considered. This may be a sticking point with a pain specialist. (Although I know that many readers have tried just about everything.)

And some recommendations:

  • If your neurologist agrees that the next step for you is opiods, ask him or her to call or send a letter to a pain specialist to explain this.
  • Have your neurologist’s office send your medical records to the new doc before your appointment.
  • Look for a doctor who specialized in pain medicine during his or her residency (probably through a fellowship).
  • Seek out doctor who finished residency recently. He or she may be more afraid of legal repercussions, but may also have more current attitudes about pain management.

P.S. I’m afraid this reads like a tip sheet on feeding a prescription painkiller addict’s habit. Chronic pain management with opiods is absolutely necessary for so many people that I’m publishing it anyway. So there.