Distinguishing Between Pain-Related Dependence and Addiction

The potential for becoming dependent on pain medications is well known, but it can be difficult to distinguish between pain-related dependence on medication and an addiction. Some fear becoming addicted to powerful pain medications so much that they will avoid using medication when necessary, allowing pain to interfere with recovery from surgery or ongoing medical treatment.

Dependence is an unfortunate side effect of opioid pain medication, but it is not the same as an addiction to opioids. Physicians can prescribe pain medications legitimately, while patients can use such medication appropriately and still develop a physical dependence that requires medical intervention when the drug is no longer needed to control pain. Patients on pain medication can become dependent and progress to addiction, but difficulty stopping pain medication does not in itself make the person an addict.

Understanding the difference is important for patients, their families and their healthcare providers because a misinterpretation can lead some to blame patients unnecessarily for a condition that is not within their control, as well as people avoiding pain medications that they need.

Opioid drugs bind to opioid receptors in the brain, spinal cord and other areas of the body. The drugs interfere with the transmission of pain messages to the brain and reduce feelings of pain. Opioids treat moderate to severe pain, such as the pain after surgery, as well as for painful illnesses such as cancer.

Almost all patients who use an opioid pain medication like fentanyl, hydrocodone, morphine, oxycodone, OxyContin and Dilaudid for more than a month will experience physical withdrawal symptoms when they stop taking the medication. Only about 15 percent of patients using opioid pain medications become addicted. People taking opioid pain medications for long periods often wonder if they are addicted. Patients often will tell their doctors that they’ve been taking the drugs so long and are so dependent on them that they don’t know any more if they are just taking the drugs for pain or because they are addicted.

Loss of control, use despite knowing the harm, preoccupation and craving all signal addiction to pain medication. Those addicted to pain drugs may or may not be physically dependent. Abuse of prescribed opioid medications is not rare, but patients with prescriptions usually do not abuse the drug. The Substance Abuse and Mental Health Administration (SAMHSA) reports 70 percent of those abusing pain relievers obtained them illegally.

Withdrawal symptoms include agitation, anxiety, muscle aches, insomnia, runny nose, elevated blood pressure, dilated pupils, rapid heart rate, sweating, abdominal cramping, diarrhea, nausea and vomiting. Although painful, withdrawal from opioid medications is not usually life threatening. Physicians can ease the discomfort with treatment for anxiety, cramping, diarrhea and other symptoms. Once withdrawal symptoms pass, which could take several days, the person is free of any physical drug dependence. Physicians prescribing opioid pain medications usually will try to minimize the effects of withdrawal by tapering the patient’s dosage once pain is no longer an issue. Physicians progressively lower the dosage to zero, which helps many patients avoid severe withdrawal symptoms.

Dependence and physical withdrawal symptoms are the body’s reaction to opioid medications and have nothing to do with mental weakness, will power or lack of character. Patients taking pain medication may also fear that their need for increasingly higher doses indicates an addiction, which is not the case. As with many other drugs, patients develop a tolerance for opioid pain medication over time and need a higher dose to receive the same effect. Patients who use opioid pain medication also may develop a condition called opioid-induced hyperalgesia, in which pain medications create more pain instead of relieving it. Patients who suffer from opioid-induced hyperalgesia may experience increased sensitivity to painful and non-painful stimuli, worsening pain and a decreased pain threshold. This condition will ease and disappear as physicians wean the patient off the opioids.

The vast majority of opioid users will be able to stop taking the drug when appropriate, travel with their doctor down the road of withdrawal road and eventually lose total interest in the drug. But an addict will continue craving and obsessing over the drug after the pain and withdrawal symptoms subside. That is the distinction between two starkly different patient populations: both may share similar experiences with the drug up to the point at which someone cuts off the medication, but the addict cannot let go. Everyone else is able to put the experience behind them and move on.

Some behaviors indicate a patient is at higher risk for addiction to pain medications. An “unsanctioned dose escalation” means the patient takes an extra pill once or twice without the doctor’s approval. When the physician realizes the patient is short a couple pills before time to refill the prescription, he or she will explain that what the patient did is unacceptable and that the patient must never repeat it. An ordinary pain patient will not take an extra pill again, whereas a patient with an addiction problem won’t be able to resist temptation.

Other behaviors suggesting addiction include selling medications, obtaining drugs from other people, falsifying prescriptions, injecting medications meant for oral use, use of illegal drugs or controlled substances that are not prescribed for the patient, repeatedly reporting lost prescriptions and requests for early refills.

A normal pain patient usually will not break the law to obtain medication, but the addict may doctor shop, steal prescriptions, obtain drugs illegally online and use illegal drugs when they can’t obtain prescription pain pills.

Another indicator of a substance use disorder is when a patient claims that an increase in dosage had no effect. Providing more opioids is bound to provide at least some small amount of pain relief, so regard patients who claim no benefit with caution. The patient is not lying just to obtain more pills; he or she truly did not sense any improved pain relief. A regular patient gets better when provided more pain medication, but a drug addict gets worse.

Physicians must handle carefully pain management for patients with known substance use disorders. These patients deserve good pain management as much as anyone else. Enduring pain without medication is not a healthy option because pain causes stress and physiological reactions in the body that can interfere with recovery. Physicians might prescribe opioids for these patients after surgery or an injury, but regardless of the patient’s substance of choice, he or she will be at high risk of abusing the drugs without strict safeguards. Surgeons or other physicians should work closely with the patient’s addictionologist to develop an opioid program that effectively relieves the addict’s pain but also minimizes the chance of drug abuse. Specific strategies include trusting someone besides the patient to possess and control pain pills, forbidding the patient from touching the pill bottle or prescription, destroying any remaining medication after the patient no longer needs it and reinforcing substance abuse therapy afterward in case the pain medication awakened old urges.

However, avoid opioid pain medications for chronic pain treatment in patients with substance abuse disorders. Opioids tend not to be as effective for chronic pain, regardless of whether the patient is a substance abuser, and the ongoing access to such drugs can be too tempting to those in recovery. In these cases, the patient in recovery should address chronic pain with non-opioid medications and other methods such as yoga, meditation and physical therapy. If those alternatives do not provide adequate relief for chronic pain, the best opioid option for patients in recovery are long-lasting opioids such as buprenorphine, which helps patients end their dependence on other opioids.

Further reading:

Issa M, et al. Issues associated with opioid use. In: Benzon HT, Rathmell JP, Wu CL, Turk DC, Argoff CE, Hurley RW, eds. Practical Management of Pain. 5th ed. Philadelphia: Elsevier Mosby; 2014:chap 51.
https://www.ncbi.nlm.nih.gov/pubmed/17449178/