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Now that we have explained addiction, we would like to help you answer this question. We’ll explore, in some depth, the reluctance, perhaps even overwhelming fear, that many with chronic pain have about addiction and the term “addict.” If you don’t consider the possibility that you have addiction, you may miss the opportunity to get better. In this chapter, we will not tell you whether or not you are an addict, but we will provide you with facts so that you can make an accurate and informed assessment.

The Stigma of Addiction

Why are the words “addiction” and “addict” so problematic for so many people? Much of this difficulty can be attributed to the stigma that is assigned to them. Merriam-Webster’s Collegiate Dictionary defines stigma as “a mark of shame or discredit.”* It is often attached to social judgment and cultural norms. The stigma attached to “addiction” and “addict” makes them “dirty” words. Despite volumes of research on drug dependence and scientific evidence to the contrary, addiction is viewed by many as a moral failing or weakness. Addicts and their families are subjected to social, legal, and financial discrimination, making it difficult for them to obtain the help they need. When addicts do access help, insurance is inadequate to cover the cost of effective treatment. Family members are often the most judgmental because they have experienced the consequences of the addict’s behavior, not realizing the addict is sick, not “bad.”

Addiction is one of the few diseases that carries such a negative emotional charge and is a source of shame or embarrassment. Who would want to have a diagnosis or label that carries such a stigma? For those with chronic pain who take opioids, attempting to discuss this topic is often met with resistance and denial.

{ exercise 3.1 }

Your View of Addiction____________________

When you hear the word “addiction” or “addict, ” what is your emotional response?

Do you believe either of these terms (addict, addiction) applies to you? Why or why not?

Addiction is a term that often conjures up negative stereotypes. You may relate to some and not to others. Write your stereotypes about addiction. Where do these ideas come from?

I AM AN ADDICT

For some of you, there will be no question as to whether or not you are an addict—you already know you are. If you have experienced recovery you already understand it is extremely dangerous to put opioid painkillers in your system because eventually you will likely lose control and relapse, either with opioids or with other mood-altering drugs. For you, the main issue will be coming to terms with the fact that you can’t safely take opioids for your chronic pain. You will need to find alternative treatments if you are to stay clean (drug -free) and in recovery. This also pertains to you if you identify as having other manifestations of addiction (e.g., alcohol, stimulants, sedatives, etc.), since the use of opioids will cloud your thinking and make it that much easier to compulsively drink, take drugs, gamble, overeat, and so on.

Pain recovery will work for you by complementing the program you are already working with your sponsor and by helping you realize that you can live with a certain amount of pain without taking medication.

For those of you who know or suspect you are an addict, but have never experienced recovery, this book can serve as your entry point to beginning a program and changing your life. By working a program and implementing the concepts of pain recovery, you can live without drugs and in recovery from both addiction and chronic pain.

Whether you know you have addiction, are unsure, or are convinced you are not an addict, we recommend you read this chapter. We feel strongly that the information it contains is essential to the process of pain recovery no matter what your circumstances.

FRED’S STORY

At thirty-six years old, I was in great shape. I had been clean and in recovery for twenty-six months. I was diligently working my recovery program with my sponsor. I stayed physically fit working as a furniture mover. For the first time in my life, I knew and accepted who I was. I had fully accepted that I was an addict and was reaping the benefits recovery had to offer.

One day at work, I was lifting a heavy piece of furniture and I felt something pop in my back. This began an ongoing nightmare of medical appointments and surgeries. Over the next three years, I went from being physically active and fit to not even being able to pick up or play with my stepchildren. Getting out of bed was a chore, sitting too long hurt, standing too long hurt, and in essence, doing anything hurt. My life was changed dramatically.

Even when the pain was tolerable, it was like having a constant toothache. I had to practice the principles of my program daily so I wouldn’t act out in frustration, anger, and intolerance. Being inactive and unable to work resulted in weight gain and loss of self-esteem. Finances became an issue, and all this placed a tremendous strain on my relationships. I struggled not to play the role of victim even though my addiction told me I was a victim.

Then there was the issue of taking pain medication, which went against my basic belief in total abstinence. Part of me wanted to take something to relieve the pain, but I didn’t because I was terrified of relapsing.

For at least a year I waited for each medical appointment and test, hoping there would be answers and a solution to my pain. The first doctor I went to said I pulled a muscle. The next doctor said it was probably my sciatic nerve, and stretched me on a machine that to me looked similar to torture racks used in medieval times. After several MRIs, X-rays, and injection of dyes into my back, the final diagnosis was three severely ruptured discs. I had minor surgery followed by months of rehabilitation, but the problem only got worse.

The decision to undergo major surgery had been a difficult process, but I could not go on living in pain every day. The surgery involved the insertion of six-inch pins and plates in my back. After that, I was given morphine while in the hospital. This was as traumatic for me as the surgery. I had so much fear that once I used, I would relapse. This was despite the fact that my sponsor, the doctor, and my support group told me it wasn’t using; it was what I needed to heal. I prayed every night in the hospital, and my friends brought twelve-step meetings to me every day. I stopped taking morphine two days before I was released. Then the doctor told me I needed pain medication when I went home. Thanks to the advice of someone with a lot of clean time and experience, I filled only one prescription and never took more than I was supposed to. I called him every day to let him know how I was feeling and what I was taking. I was very aware of my addiction during this period because I was constantly focused on what time it was and when I needed to take the next pill. I wrote a list of pros and cons, did medication research, and ended up using only ibuprofen and a nonsteroidal anti-inflammatory drug when needed.

This experience taught me just how strong my addiction is, and that without the recovery support and experience, I would never have stayed clean. The support of my sponsor and friends kept me focused and helped me stay in the recovery process because I was, and always will be, an addict, whether I am in pain or not.

Is It Really about Choice?

Many view addicts’ use of substances and related behaviors as a choice. People who have addiction may have made a decision at one time to use a drug, but they never made a decision to become addicted. The addict’s brain was different before the first use of a drug, and scientific evidence has shown many of the significant ways the brain changes in response to chronic exposure to mood-altering drugs. According to Alan I. Leshner, Ph.D., former director of the National Institute on Drug Abuse (NIDA), “the evidence suggests that those long-lasting brain changes are responsible for the distortions of cognitive and emotional functioning that characterize addicts, particularly the compulsion to use drugs that is the essence of addiction.”

Even if you never used a substance in the past and only started taking medication for your chronic pain, you may develop addiction. Just as an addict who uses for the first time is not choosing to become addicted, an individual with chronic pain who takes his or her first prescription would never choose and never intend to become addicted.

For those of you who are resistant to exploring the possibility that you are addicted, the issue may be getting past the stigma of addiction and letting go of the need to be better than an addict. Addiction is a no-fault illness, just like chronic pain.

At this point we don’t want you to get stuck on whether or not you have addiction, but rather to focus on solutions to your problems. If you spend your energy trying to prove you are not an addict, you will limit the benefits you may receive from this book. We are not interested in labeling you. We are committed to helping you. You will decide for yourself in the long run.

If you are unsure at this point, we suggest you try a perspective such as “I am not sure if I am an addict or not, but I will have a clearer picture if I do the exercises and complete this book, ” or “Even if I decide I am not an addict, the solutions to addiction and chronic pain are so similar that I will benefit from this process and from applying what I learn to my life, ” or even “I think this is crazy, but I admit my way hasn’t worked so far, so what do I have to lose?” For right now, try to suspend judgments and do the work. The closer you get to balance, the clearer things will become.

There is no more shame in being an addict than there is in having chronic pain.

Arguments against Being an Addict

We realize at this point your head might still be saying, “But I’m not an addict. What are they talking about? I only used drugs as prescribed by my doctor.” Frankly, it doesn’t really matter. Or you may think, “I would never have developed problems with the drugs if I didn’t have the pain.” Again, it doesn’t matter. As we have said, we aren’t concerned with labels, and we also aren’t concerned with your motivation or specific circumstances. We only care about what is happening in your life as a result of drug use and what you want to do about your situation. How you identify yourself—as addicted, drug-dependent, having problematic drug use, or simply a victim of circumstances—only matters if it prevents you from getting better.

The purpose of this book is to help you discover solutions that work no matter which label you most identify with. To say “I am an addict” is a personal decision that only you can make. However, to effectively determine the truth will require work on your part. Denying that you are an addict without examining the possibility that you are will prevent you from growing and finding balance. The following exercise deals with some of the ways people deny the possibility that they have addiction.

{ exercise 3.2 }

I’m Not an Addict Because… _______________

____ I have a problem with medications but I have to take them for my chronic pain.

____ I use prescribed medication and not illegal drugs.

____ I don’t lie, cheat, steal, or live on skid row.

____ I’ve never snorted, smoked, or injected my pain medication.

PAIN IN RECOVERY SUPPORT GROUP (PIRSG)

The Pain in Recovery Support Group (PIRSG) was created to provide those already in a twelve-step fellowship with a safe place to discuss their chronic pain issues in a mutually-supportive environment. For those not already in a twelve-step fellowship and who are seeking an opioid-free solution to their pain, PIRSG provides a place to practice the principles of pain recovery. PIRSG also offers information on various twelve-step fellowships so people can decide which one best fits their needs.

For more information about the PIRSG, please email info@forrecovery.org or visit www.paininrecovery.org.

Below you will find a self-test provided by the Pain in Recovery Support Group (PIRSG). The purpose of this exercise is to assess your use of medication and the possibility of addiction. We suggest you tear it off and make copies, and after you complete the self-test, ask family or friends to complete it also, with regard to your use. Getting input from others can expand your view of what your use has been like. When we are too close to a situation, those who care for us may provide perspective. If you feel resistant to doing this, just acknowledge the resistance and do it anyway. Don’t prejudge what others may say; just get their input. Input is necessary to accurately assess and diagnose, and as with any medical condition, you need an accurate assessment and diagnosis to effectively deal with your problems. So stay open-minded and get as much information about your situation as you can. If you feel the information is inaccurate, be sure to discuss this at a later time with a trusted person, a counselor, or a professional.

{ exercise 3.3 }

Am I Addicted to My Pain Medication? Self-Test __________

The following questions may help you make that determination. Answer yes or no for each question.

____ 1. Have you ever taken more of your medications or taken them more frequently than was prescribed?

____ 2. Have you ever used another doctor because your doctor wouldn’t prescribe any more medication or increase your dosage?

____ 3. Do you find yourself looking at the clock to find out when you can take your medication next?

____ 4. Have you used alcohol while taking prescriptions to enhance the medications’ effect, even knowing you were not supposed to?

____ 5. Have you ever used illegal drugs while taking prescribed medications?

____ 6. Do you have more than one doctor who is prescribing medications for you?

If yes, are those doctors aware of all of the medications you are taking?

____ 7. Have you ever gone to an emergency room to get additional medications because the ones you had were not enough?

____ 8. Have you ever run out of a prescription before you were supposed to because you used more than was prescribed?

____ 9. Did you ever think “as needed” meant you could use as much as you wanted to, when you wanted to?

____ 10. Have you ever lied to a doctor about why you needed another prescription filled?

____ 11. Have you ever exaggerated your reported pain level just in case you had more pain later or to get another or a stronger prescription?

____ 12. Did you have addiction problems before your chronic pain?

____ 13. Have you ever thought, “I can’t live without medication”?

____ 14. Have you ever gotten a prescription and lied to your spouse or other family or friends about it?

____ 15. Have you ever lied to your spouse or mate or anyone about how much medication you are taking?

____ 16. Are you taking prescription medication and supplementing it with over-the-counter medication?

____ 17. Are you taking other prescriptions to deal with the side effects of your pain medication, e.g., sleep aids, stimulants, antianxiety drugs, or Soma?

____ 18. Have you ever taken anyone else’s pain medication?

____ 19. Have you ever stolen, forged, or altered a prescription, or called in a prescription by impersonating medical staff?

____ 20. Have you ever crushed, snorted, or injected your medication or taken it in a way other than the way it was intended to be taken?

____ 21. Have you ever overdosed or needed medical help because you took too much medication?

____ 22. Have you ever experienced a blackout (memory loss) caused by medication?

____ 23. Have you experienced legal consequences as a result of taking your medication, such as a DUI or assault and battery arrest?

____ 24. Have you had a friend, spouse, or family member express concern regarding your use of pain medication?

____ 25. Have you ever taken pain medications to deal with other issues such as stress or anxiety?

None of these questions necessarily defines addiction, but if you answered “yes” to any of these, you should not rule out the possibility of addiction. The more “yes” answers you have, the greater the cause for concern about addiction. Do not use this test to judge yourself negatively; use it as part of a process of learning and examining that is necessary for success in pain recovery.

Problematic Drug Use (PDU)

For many of you with chronic pain, addiction may be too much of a stretch. However, you may find it helpful to look at your use of medications as being either problematic or nonproblematic. Even before a diagnosis of addiction is established, you may conclude there is problematic use that may or may not evolve into addiction. The following table will assist you in defining problematic use.

Nonproblematic Prescription Drug Use	Problematic Prescription Drug Use
Pain is relieved or manageable with medications.	No appreciable decrease in pain.
No significant changes in functioning due to medication.	Significant decrease in functioning due to medication.
No significant effect on relationships; no concerns from family regarding use.	Ongoing relationship problems and concerns from family regarding use.
Able to work with no significant decrease in job performance.	Unable to work or significant impairment due to medication.
Stable or maintenance dose of pain medication.	Steadily increasing dose and frequency of medications with little or no decrease in pain.
Emotional stability and acceptance of any physical limitations.	Emotional instability and increasing lack of acceptance regarding physical limitations.
No significant cognitive impairment due to medication use.	Significant cognitive impairment due to use e.g., foggy thinking, difficulty concentrating, memory problems.
Using medications only for pain relief.	Relying on medications for emotional effect.

{ exercise 3.4 }

Use of Medications __________________________

Write about areas in your life related to the previous chart where you are experiencing problems.

________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

If you are experiencing PDU, what do you propose to do about it?

Usually people begin taking medication to manage physical pain, but at some point, often without realizing it, start using the medication to manage emotional pain as well. Eventually the medications no longer work for long or very well to ease the physical or emotional pain, and the side effects may actually cause more physical and emotional pain. This happens because long-term use of opioids can increase the body’s and brain’s pain signals. This is called pain rebound syndrome or opioid-induced hyperalgesia. In the end, medication use that started as a reasonable treatment approach to relieve suffering can be the cause of problems in all areas of your life.

From this point on, we will use the terms “addiction” and “problematic drug use” or “PDU” interchangeably. Use the term that feels right to you, keeping in mind that regardless of how you choose to label your situation, the principles of pain recovery apply.

Pain and PDU: Four Stories

1. JR had a history of alcohol abuse—twelve to twenty-four beers per day, shots on weekends, blackouts, and a DUI fifteen years ago. He also smoked and snorted one to two grams of cocaine per day for a few years. After his DUI, the court ordered him to attend twelve-step meetings. Much to his surprise, he attended, grew to like the meetings, got a sponsor, and worked the Twelve Steps. His recovery was going well—so well that he got married, got promoted, and was so busy with family and work that he stopped going to meetings. Six months later, he lifted a heavy box in his garage and sprained his back. An MRI showed no significant cause for his pain, and his doctor started him on Lortab and Soma, with Ambien to help him sleep. Before he realized it, he was taking the entire thirty-day prescription in the first nine days, and for the rest of the month he would beg and borrow more drugs, eventually resorting to stealing drugs from his ailing mother or buying them on the street. He would drink when he ran out of pills, which became a more frequent occurrence. Clearly, he had reactivated his addiction and required treatment, which got him reengaged in the recovery process. He also needed to acquire tools to deal with his pain without medications. He admitted that he had been taking the pills for all sorts of reasons, including to relax, to get energy, and sometimes just to get high.

2. Deirdre wonders how this happened to her. She was a regular working stiff, living in a nice house with her husband and two kids. She never used drugs to any great extent; she didn’t like them. She had tried cocaine and pot when she was younger and got drunk on weekends in college but that’s about it. She had hardly had more than a glass of wine with dinner once a month for the past few years. She lost her taste for alcohol when she started taking pain pills. Her mom was a pill addict, and she never wanted to be like her. Then she developed pelvic pain and adhesions after surgery for endometriosis. She found that one or two Lortab in the morning took the pain away and got her going better than a double espresso. So she started using the pills to get going, keep going, and relieve the pain. When the doctor gave her Soma, she could calm down, numb out, and sleep—she was hooked. The pain was a great excuse, and her doctors were perfect accomplices. She progressed from Lortab to Percocet, which she was getting from her pain doctor, internist, GI doctor, and gynecologist, and neither she nor they realized what was happening. She eventually found that chewing the pills gave her a more intense high. A few months ago she started buying from friends, and now she is spending $500 a month on pills. She’s up to twenty pills a day. She knows she is out of control, addicted, and needs help, but she’s mystified—how did this happen to her? After all, it just started with the pain! She’s not even sure if she’s in pain or not anymore.

3. May wants off medications, but feels she is not an addict. She never abused drugs, took anyone else’s prescription, or stole to support herself. Her medications are all prescribed by her doctor. She wants to try going off meds because they have significant side effects—she is not herself. She sleeps a lot and her pain is still pretty bad. The medications don’t work as well as they used to, and she’s taking stronger medications in higher doses. She heard that stopping meds may decrease her pain, although she finds that hard to believe. She developed fibromyalgia ten years ago and has no life. Her husband left and her grown kids don’t come around, and she doesn’t blame them. She sleeps most of the time, and when she’s awake she’s depressed, grumpy, and complaining. And the constipation is killing her! She thinks of an addict as someone who lives on the street. Addicts take medications to get high. They lie, cheat, and steal. She doesn’t do those things. Her dad was an alcoholic and she doesn’t ever want to act the way he did. He was abusive and downright hateful. She never drank because of that, and tried pot only a few times as a kid. She takes no other drugs except what is prescribed. She doesn’t buy that she’s an addict and doesn’t want to participate in addiction treatment, but she wants off the medications and doesn’t know how she’ll be able to live with the pain. She is consumed with fear all the time. She’s angry at herself for not being stronger, at her husband for leaving, and at the doctors for allowing this to happen.

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