Addiction and Pain Management

Four years ago, Peter Grinspoon, MD, slipped on the ice and tore a tendon in his left thigh so badly he had to be operated on to reattach it. He was sent home with a prescription for an opioid oxycodone for pain relief. Still, Grinspoon was reluctant to refill it, for good reason: he had become addicted to the painkiller more than a decade earlier and had spent 13 years determined to avoid opioids at all costs.

But now he felt like he had no choice: “If I took an over-the-counter pain reliever like Tylenol or Motrin, it would be like going after Godzilla with a Nerf gun: pretty useless,” Grinspoon says, an internist at Massachusetts General Hospital in Boston. “In the end, my nerve receptors made the decision for me: my leg was hurting so much, it felt like it was burning.”

Fortunately, Grinspoon was able to take the oxycodone without any problems. He asked his wife to save the pills and manage her doses so that she did not take more than she was prescribed. He was pleasantly surprised to find that he had no urges, and he was able to easily stop taking the medication once the pain subsided.

Yet it remains a problem, he says, for the 20 million Americans who have or have had a substance use disorder (SUD), whether with alcohol, marijuana or drugs. prescription drugs such as opioids. “Patients are afraid to talk to their doctor about a past or current addiction because they are afraid their pain will not be treated,” says Grinspoon. “There is still a lot of stigma associated with SUD, even among medical providers. But people struggling with addiction still deserve adequate pain control, and they can get it, provided certain precautions are followed.

Addiction and your brain

Certain things like alcohol and drugs stimulate a chemical called dopamine that triggers your brain’s reward center, says Robert Bolash, MD, a pain management specialist at the Cleveland Clinic. For some people, these feelings are so powerful that they want to feel them over and over again.

“Drugs like opioids activate the exact same circuit, so if you’ve ever had any kind of addiction, you’re at a greater risk of relapse,” says Bolash. The risk is greatest if, like Grinspoon, you were addicted to the same medicine. But you are still vulnerable whether you have a current or past addiction.

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The risk is probably greatest in the first 6 to 12 months after recovery, but “if you’ve been addicted before it’s important to recognize that it can still happen at any time,” says Bolash.

If so, you should:

Be frank with your doctor. If you need pain medication but have a history of addiction, be clear with your health care providers. “A lot of patients hold back because they worry about the stigma, but the reality is that a quality provider won’t judge them or deny them the drugs,” Grinspoon says. Instead, they’ll work with you to put together a treatment plan that meets your needs.

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Explore non-opioid medications. Other drugs have less addictive potential if you are in pain. These include:

  • Over-the-counter acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs). These are often used together for mild to moderate pain, Bolash says. You alternate between one or the other every few hours. The drugs work in harmony: acetaminophen is a general pain reliever, and the NSAID fights inflammation.
  • COX-2 inhibitors. These prescription drugs are stronger forms of NSAIDs. They block a specific enzyme, COX-2, which is responsible for making prostaglandins, chemicals that trigger inflammation or pain. Usually, you alternate a COX-2 inhibitor with acetaminophen, Bolash says.
  • Medicines for nerve pain. Medicines such as gabapentin (Neurontin) or pregabalin (Lyrica) can help calm neuropathic or nerve pain.
  • Peripheral nerve block. This is a type of anesthesia injected near a bundle of nerves to block pain sensations in a specific area of ​​your body. It can be used to treat pain from fractures or even during certain surgeries.

Think about cannabis. If you have chronic pain, medical marijuana, or cannabis, may be a safer option, says Grinspoon. Research has found that opiate prescriptions are lower in states that have medical marijuana laws. “Opiates and cannabinoids – the active molecules in marijuana – have similar mechanisms for relieving pain,” he explains. “But it’s a lot safer than opioids because it’s impossible to overdose and is much less addictive.”

What to do if you need to take opioids

In some cases, it may be difficult to avoid opioids: for example, after recovery from major surgery such as joint replacement. But there are guarantees you can put in place, says Grinspoon:

Create a pain plan. It should be in place before you even have surgery, Bolash says. A Cleveland Clinic study found that people who took a dose of three drugs before surgery (acetaminophen, gabapentin, and NSAIDs celecoxib), as well as ketamine anesthesia and nerve block during surgery, were much less likely need opioids afterwards. “It can help prevent the cascade of painful chemicals that originate in your central nervous system after surgery,” says Bolash.

Find a partner. This is a family member, friend or other person who has recovered from an addiction that you can check in several times a day while you are taking your opioid medications. “That way, if you start slipping at all – for example, you start to notice food cravings – they can help keep you on track,” Bolash says.

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You should also get someone else to dispense your pain relievers to avoid the temptation to take more than what is prescribed for you, Grinspoon adds.

Get rid of the leftover pills. Over 60% of Americans who are prescribed opioids and who don’t take them keep all the extras, according to one study. But if you have them in your medicine cabinet, you’ll be more tempted to pick them up, says Grinspoon. The best way to safely dispose of it is to use local “salvage” programs, which are usually found at police stations, DEA collection sites, or pharmacies.

The good news is that if you have a history of addiction, there are ways to manage your pain safely, even if you need to take opioids. “I was very reassured that I hadn’t encountered any problems when I had to take oxycodone for my pain relief,” Grinspoon says. “I didn’t have any cravings or feeling high. Taking two pills is very different from Snorting 10, which I used to do when I was addicted.

“Pain recovery and control don’t have to be mutually exclusive.”

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