I'm not an Addict

Stacy had been my patient for just a few months. Her previous physician had prescribed moderately high doses of opioid pain medicine for several years. I had encouraged Stacy to consider weaning down, but as she was within our clinic dosing guidelines I did not force the issue. Then on her third visit with me Stacy had a urine drug screen that showed not the oxycodone that I had continued to prescribe for her, but instead hydrocodone, another opioid pain medication that she did not have a prescription for. I asked her about this and one of the first things she said was, “I’m not an addict.”

And most likely neither are you. An addict that is, even if you have been on opioids for many years. But sometimes chronic pain patients will start to exhibit behaviors that the ill-informed will interpret as addiction. They are, after all, under the influence of a powerful substance that is known to cause dramatic changes in both the anatomy and chemistry of the brain. These changes in brain form and function can sometimes lead to undesirable behaviors.

Things like taking more medication than was prescribed. Running out of medication before the next prescription is due to be filled. “Borrowing” pain medication from a friend or relative. Buying medication off the street. All of these behaviors are consistent with a diagnosis of addiction, but they are also consistent with just being a person who is suffering from one of the known side effects of opioids. It goes by a fancy name: Opioid Induced Hyperalgesia. Increased pain caused by pain medication. Sounds like an oxymoron, doesn’t it? Except it’s not – pain medication actually can and often does increase pain.

Tolerance is the issue. The brain has simply adapted to the opioid and is essentially canceling it out – the opioid no longer works very well if it works at all. But as each dose wears off, the brain’s “pain meter” swings wildly to the side of over-reporting pain and the pain levels spike. If you are that patient, what can you do? If it were me I would be very tempted to take a dose even if it wasn’t time for the next dose. To use more. To run out just to keep from suffering for at least a while. Somewhere in the back of my mind I would know that taking more would mean I would run out early and have nothing left to dampen the pain, but I might not care. The pain just has to stop right now. And when I did run out – what then? What would I do if my sister says, “Here, do you want some of mine?”

I call this place of purgatory “pseudo addiction.” Literally “false addiction.” There are other definitions for the word, but this definition works for me: Chronic pain patients suffering from opioid induced hyperalgesia who engage in behaviors that look like addiction, but all they are trying to do is stop the pain. If that person is you, then know that there is hope. If that does not describe you, then be thankful and resolve never to take a dose of opioid so high that it causes this dreadful condition. In my experience ALL patients taking higher dosages of opioid pain medication suffer from opioid induced hyperalgesia and are thus at risk for developing pseudo addiction.

Stacy, the patient I told you about in the first paragraph, had violated her pain contract. She had taken another person’s pain medication. Although the chances of law enforcement catching her in this act are extremely slim, this behavior was technically a felony. It is against the law in every state to share a controlled substance like an opioid. I had every right to “fire” Stacy. To ask her to seek medical care elsewhere. But that’s not what I did. Because in talking with Stacy I came to believe that she was suffering from pseudo addiction. She was suffering from excessive pain as a consequence of her dose of opioid being too high. What she needed was understanding and compassion and a change in her treatment.

In this case, as I have done for many others, I started an alternative opioid medication, one that is very underutilized in the pain treatment community because it is considered too “weak.” Unlike other commonly used opioids, this drug ends the cycle of desperation. Stacy’s pain is more consistent now – the lowest level of pain is not as low as after a dose of her old oxycodone, but the highest level of pain isn’t anywhere near how severe it used to be. She’s more active, more engaged, happier with her life. Sometimes she still asks, “Can’t I take more?” But then, after we talk about what it was like on a “stronger” opioid, she’ll say, “There’s no way I could ever go back to how it was. Yes, I still have pain, but my life is so much better.”

What about you? If any of Stacy’s experience resonates with you, then know that there is hope. There is a way forward that leads to a better life in spite of the pain. 

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