Читать книгу Pain Recovery - Robert Hunter - Страница 18

2 Chronic Pain and Addiction: Double Trouble

According to a 2006 study, 90 percent of all people in the US receiving treatment for pain management receive prescriptions for opioid medication. These medications carry with them a risk of dependency and addiction. For those with chronic pain who become addicted when they take opioids for pain relief, the two conditions exacerbate each other, making both worse than either would be alone. Many professionals believe the benefits of opioid treatment far outweigh the risk of developing addiction, but people who do become addicted find themselves in a conundrum: They need opioids to treat pain, but when they take them, they experience horrible consequences.

Given the complex and multifaceted nature of chronic pain and addiction, it is essential to address all the aspects of the condition—the physical, mental, emotional, and spiritual components—in order for the individual to recover. First, let’s look at addiction in some detail.

Addiction Explained

Addiction is a complex brain disease. The symptoms of addiction include physical, emotional, spiritual, and thought disturbances with manifestations that affect behaviors and relationships. Use of drugs over time induces changes in the structure and function of the brain that can be long-lasting and produce a host of harmful effects. Studies have shown that in drug-addicted individuals, the areas of the brain that undergo physical changes are critical to judgment, decision making, emotion, memory, and behavior control. This may help explain the destructive behaviors of addiction. As the disease progresses, a person becomes increasingly unable to control his or her drug seeking and use even in the face of terrible consequences.

There is no way to predict with certainty whether a person will become addicted to drugs, but there are several known risk factors. These include:

Genes: It is estimated that genetics accounts for 40 to 60 percent of a person’s vulnerability to addiction.

Environment: Frequent exposure to drug use in home, work, school, or social life can influence a person’s use of drugs, which may become problematic.

Early use of drugs: The earlier a person starts using drugs, the more likely he or she is to develop problems with abuse and addiction.

Mental illness: Anxiety, depression, and other mood disorders are commonly associated with addiction.

Traumatic childhood experiences: Abuse, neglect, dysfunction in the family, or other trauma can leave a child more susceptible to addiction later in life.

TERMINOLOGY OVERVIEW

Addiction is a chronic, relapsing brain disease characterized by compulsive drug seeking and use, despite harmful consequences. At one time, addiction was a pharmacologic term that referred to a person’s using enough drugs to cause tolerance and physical dependence. In fact, we now know a person can have addiction without developing tolerance or physical dependence.

Tolerance means that more of the drug is needed over time to experience the same effect, and it commonly occurs with long-term use of opioids.

Physical dependence is characterized by being unable to stop using the drug without feeling terrible and developing a syndrome known as withdrawal.

Drug dependence is a synonym for addiction and is a set of behaviors involving problematic use of mood-altering substances over a continuous period of time.

Symptoms a person might display include:

• Having problems with controlling use, and thus having an unpredictable outcome once he or she begins using a substance.

• Trying to cut down or stop, but being unable to “stay stopped.”

• Being preoccupied with the drug and continuing to use it even though it is causing problems.

• Not doing the things he or she used to do and “chasing the high”— spending time and energy getting the drug and using it.

With addiction, the problem exists not so much with the drug itself, but with the way that drug works in the brain and nervous system. Some of you are destined to develop addiction because of how “well” the drug works—both physically and emotionally.

You were probably wired differently from birth, and with continued exposure to a drug, particularly an opioid (whether you started taking it for pain or not), you eventually became addicted.

Some people develop tolerance and physical dependence. These phenomena occur with continued exposure to certain substances over time. With increased use of certain drugs (e.g., an opioid), the body reacts by decreasing the effect of the drug, in this case, pain relief. This is tolerance. Consequently, in order to achieve pain relief, you increase the dose of the drug. This adjustment works temporarily, but eventually the need for still-increased doses will occur. Eventually, the drug seems not to work any longer, which results in using stronger, more potent drugs in an escalating upward spiral.

If you become tolerant to the drug, this indicates that your body is “normalized” in the presence of the drug. In fact, you may become so used to the drug that you need the drug to feel normal. Without it, you feel terrible. This is physical dependence.

When the drug is discontinued abruptly, you will feel withdrawal—in effect, the opposite feelings that the drug caused. So if opioids cause decreased pain and some amount of calm and well-being, then withdrawal consists of increased pain and anxiety, body aches, stomach and muscle cramps, diarrhea, nausea, vomiting, insomnia, and agitation. This outcome is one of the main reasons some of you will feel the need to continue the opioid, since, when you try to stop or even reduce the dose, you feel terrible.

So what is the solution to this awful problem? You feel that you have to take the drug to feel any level of pain relief, even though it barely works. In fact, as you’ll learn, it actually may be making the pain worse due to a phenomenon known as opioid-induced hyperalgesia. You might consider cutting down the dose of the opioid; however, that presents the immediate problem of withdrawal. In the short run, cutting down or stopping will make you feel much worse. This is because the withdrawal of the opioid from your system inevitably causes a temporary increase in symptoms, including pain. This effect makes the process of coming off opioids challenging but not impossible. You may be tempted to substitute one opioid for another, which may temporarily delay the process.

We have treated hundreds of people with pain who are tolerant to and dependent on opioids. The withdrawal process is best done under medical supervision and temporarily, you are likely to feel worse. But on the other side, when the opioids have left your system for a week or two, your pain will diminish and you will start to feel better. The discomfort of withdrawal may continue for a while, even for several months in some, but eventually your nervous system will readjust to the absence of opioids and you will return to a state of well-being that has escaped you for years.

Addiction is a chronic disease similar to other chronic diseases such as type II diabetes, cancer, and cardiovascular disease. –National Institute on Drug Abuse

Four Stages of Addiction

As with many illnesses, to understand the progressive nature of the disease of addiction, we have broken it down into stages. People who have addiction started in stage I and will inevitably end up in stage IV if not treated. The progression from stage I to IV may occur rapidly or may take years or decades. Stopping drug use might halt the disease process, but treatment is still necessary. Further, if use is restarted, the disease process will pick up where it left off. Like a passenger on a train traveling from New York to California, if you get off in Chicago (stage II), you will “reboard” in Chicago and continue west, heading inevitably toward stage IV, disability, and eventually death. Here are the stages in further detail:

STAGE I

Stage I addiction begins with the first ingestion of a mood-altering drug. The feelings that occur are related to mood change. This is often a sense of “normalizing” the world, euphoria, or an energized sense of well-being. This sensation may be especially true of the first use of opioid painkillers. The pain goes away—both the physical and the emotional pain. Although there may be no outward behavioral changes yet, such drug use cannot be considered “safe” because in persons with the neurobiological risk for developing addiction, subsequent use may result in substance abuse and life changes beyond the person’s control.

At this stage, family members generally have a greater awareness of the problematic use of substances than the addict. The developing addict may have an uneasy sense that there is something wrong, but denies it to him- or herself and others. The addict in stage I may cut down or even quit using for periods of time, but without recovery or treatment, typically he or she eventually resumes use and the problems recur and escalate.

A person with chronic pain and addiction may be defensive about drug use and answer any criticism or questions about it by rationalizing, for example:

Explaining why drug use is necessary: I have to take these medicines for the pain so I can function, or The doctor said I need to take this.

Minimizing the consequences of drug use: It’s not that bad because I’m not taking that many, or I only take what’s prescribed and sometimes less (hoarding extras “just in case”), or I go to work every day, so I can’t have a problem.

Denying: I don’t have a problem with drugs.

Other characteristics of stage I may include:

Wanting the drug (craving).

Counting pills.

Worrying when the supply of pills is low.

Focusing on the time until the next dose (preoccupation).

Increasing the dose without a doctor’s order (tolerance).

Taking a pill or two in the morning to “get going” (using for purposes other than those intended by the prescriber).

Adding another substance to supplement the effects (commonly alcohol or other sedatives).

Using stimulants because of fatigue caused by the opioids.

This stage usually occurs in individuals who haven’t had chronic pain for very long but are beginning to develop problems with opioids.

STAGE II

In stage II, the addict begins to experience the negative consequences of drug use. This stage is characterized by problems in one of the following major functional areas: family or home life, job or school function, social function, legal status, or health. In stage II you experience problems in one of these areas, although several areas may be affected as time goes on. Examples of stage II problems include:

Fighting at home, neglecting familial responsibilities, or separation.

Being disciplined at work or decreased work performance.

Calling in sick frequently or missing work without calling.

Failing a major test at school or dropping classes.

Using illegal methods to obtain drugs (consulting other doctors but not disclosing this to each doctor, acquiring pills from illegal sources, using multiple doctors or pharmacies, driving under the influence), but not yet having been caught or arrested.

Experiencing a worsening of health problems, many of which are side effects of opioids, such as escalating pain, nausea, constipation, diarrhea, headaches, sleep disturbance, fatigue, or depression.

This stage usually occurs in individuals who have been dealing with chronic pain for some time, and though they may appear okay on the outside, they are beginning to experience deterioration of function.

STAGE III

In this stage, there is intense preoccupation with the desire to experience mood-changing effects of the drug(s). Daily drug use, depression, and thoughts of suicide are common. Family troubles increase. Legal problems may ensue. Stage III is characterized by any one of the following major consequences in any one major functional area. If family function is the problem area, these consequences include:

Being asked to move out for good, leading to the end of the relationship.

Getting a divorce.

Becoming estranged from close family members.

If the problem areas are outside the home, they could include any of the following:

Getting fired.

Failing out of school.

Going to jail.

Stage III physical changes include:

Being hospitalized.

Being physically dependent on drugs; suffering withdrawal when trying to cut down or stop.

Again, for it to be considered stage III, the addict must have only one of these problems, not multiple problems in all areas of his or her life, even though that may be the case. This stage usually occurs in individuals who have been dealing with chronic pain for years and the amount and variety of their medications has steadily increased, with progressive decrease in function, dependence on the drug(s), and general worsening of quality of life.

STAGE IV

Stage IV is considered late-stage addiction, where the effects of the disease have spread to all areas of the person’s life. Stage IV addiction, like stage IV cancer, is the period that precedes death from the disease. The length of time people can survive in this stage varies, but if the disease is treated, even at this point, the destructive process stops, life expectancy increases, and quality of life improves. Common causes of death from addiction include overdose, liver failure, accidents, suicide, and infections that would be preventable or treatable in nonaddicts. Those who have reached this stage need increasing quantities of drugs just to feel normal. Physical signs, such as damage to the heart, liver, and brain; malnutrition; lower resistance to pneumonia or tuberculosis; and overdoses are common.

Stage IV addiction is characterized by multiple problems in more than one major life area. Generally it means the person has no meaningful family life or relationships left, has no job or school life, is cognitively impaired by drug use, and has severe long-term, often permanent health consequences, including brain dysfunction. In stage IV, pain and addiction are deeply entrenched in a person’s life and the person is alienated from loved ones and medical professionals alike. People with stage IV addiction fit the stereotype of those with addiction and are commonly homeless, in jail, or in an institution.

Individuals with chronic pain often have histories of overdosing on drugs, either accidentally or on purpose. The acetaminophen in their opioid medications has caused liver damage. Their lives consist of unending pain, periods of sleeping and sleeplessness, staying in bed most of the time, and trips to the emergency room, either to try to get drugs or for treatment of complications of the advanced disease.

Hopefully by now, you are beginning to understand addiction more clearly. In the next chapter, we will invite you to look at your use of substances and try to make sense of how these substances have affected your pain and your behavior. So open your mind and your heart and get ready to find some answers.