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Therapeutic use of opioids in recovering people.

I'm told by some of my clinical colleagues that there is still a lot of misunderstanding about the use of opioids for treatment of chronic pain, and whether people become "addicted" to such medicines with long-term use.

The concept of "addiction to painkillers" is so touchy that some physicians (and patients themselves) even withhold adequate pain medications from the terminally ill, for fear of addiction! Some of this fear stems from an old concept that withdrawal from such medications is the main sign of "addiction," portending that a patient will become a permanent drug-seeker from such exposure. In actuality, there is plenty of evidence that long-term use of properly prescribed pain-reducing medications (particularly opioid drugs) has much more of an upside (pain relief) than a downside (a rather small potential for long-term dependence).

Clouding the issue is that many patients in chronic pain continue to use such medications for a longer time than the pain is expected to last based upon the condition. Such patients are then considered to be "addicted," since some physicians continue to believe (incorrectly) that the longer someone uses a medication, the more likely he or she is to become dependent. It is important for all health professionals to realize that the diagnosis of dependence does not recognize any criteria for length of use or amount of drug used in assessing dependence. Yes, long-term use of drugs does produce withdrawal signs, but withdrawal is only one of several criteria that must occur for the diagnosis of chemical dependence (see commentary in January 2003 issue).

Many patients can abuse pain medications (not the same as dependence), and thereby create problems for themselves, their physicians (frequent prescription requests), and pharmacists (overuse of medications). This should not be confused with "addiction," and is something that should be stopped. The answer is to educate pain patients thoroughly about the differences among drug abuse, drug dependence, withdrawal, drug-seeking, tolerance, and all the other ramifications of chronic drug use, along with adequate ways to measure pain reduction, and how to obtain pain relief without medications as the injury or condition begins to resolve.

The problem is that such education takes time and effort, and most health care professionals don't even have the knowledge to provide such education. Isn't it about time this subject is covered more heavily in medical schools, nursing schools and pharmacy schools?

Can people in recovery use chronic pain medications? Such medications are understood to affect the brain's endorphin system. Unless a recovering person has dysregulated endorphin function in the mesolimbic dopamine system (where chemical dependency occurs), then that person should be able to take chronic pain medications.

Alcohol-dependent patients, for example, are thought to have mesolimbic system dysregulations of dopamine, serotonin, endorphins, GABA, glutamate, acetylcholine, or endocannabinoid function. If the person in recovery has successfully achieved long-term sobriety, then abstinence is the best choice. The problem is that there are some medical conditions that require powerful pain relief (pain from heart attack, hip replacement, or cardiac catheterization are a few examples), and the benefit of pain relief far exceeds the likelihood of relapse due to the pain reliever matching up with the one brain chemical that can be trouble--endorphins. So pain relievers can be used, and the patient counseled and monitored for relapse or the very small chance that opioid dependence can occur.

What about an opioid-dependent person who is in recovery? The use of powerful pain medications in such a person is much more problematic, and requires either the use of non-opioid pain relievers (which often are a lot less effective) or the advice of an addiction medicine specialist who knows how best to handle such therapeutic issues.

Carlton K. Erickson, Ph.D., is director of the Addiction Science Research and Education Center at the University of Texas at Austin's College of Pharmacy.

Reference

Cowan et al. Pain Medicine 6(2): 113-121 (2005)

By Carlton K. Erickson, Ph.D.

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Title Annotation:Commentary
Author:Erickson, Carlton K.
Publication:Addiction Professional
Date:Sep 1, 2005
Words:654
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