The experience of pain is a complex physical and psychological phenomenon. There is no objective way to measure a person’s level of pain, and since the 1980s, physicians have been instructed to make pain control a priority in the treatment of their patients. Thus, physicians only have the patient’s self-report and a general idea of the significance of different types of injuries, conditions, illnesses, etc., with regard to the level of pain that these conditions are most often expected to produce.
Different types of pain often require the use of different types of medications. Pain-relieving medications can be purchased over the counter, or they may require a prescription from a physician. Prescription pain medications are often much more effective in their ability to reduce the experience of pain; however, they also carry a number of significant risks that require their use to be supervised by a trained physician. Therefore, they are classified as controlled substances by the United States Drug Enforcement Administration. These prescription pain medications fall into a number of classes.
- Some nonsteroidal anti-inflammatory medications, such as Celebrex (celecoxib), require a prescription. A large number of drugs in this class are available over the counter (e.g., Tylenol, Advil, etc.). For the most part, these drugs are not significant drugs of abuse.
- Certain muscle relaxants may be used to control pain that is associated with muscle tension, such as Flexeril. Many of these drugs may be abused, but they are not commonly associated with painkillers.
- A number of antidepressant medications have utility in the treatment of chronic pain. Antidepressant medications are not significant drugs of abuse although their use may produce low levels of physical dependence.
- Prescription drugs that are primarily designed for the treatment of anxiety and seizure control may have some effect in relieving certain types of pain. These include benzodiazepines (e.g., Valium [diazepam], Xanax [alprazolam], etc.) barbiturates (e.g., Seconal [secobarbital], Pentobarbital, etc.), and some anticonvulsant drugs (e.g., Neurontin [gabapentin]). Benzodiazepines and barbiturates have a high potential for abuse, but their primary function is not for pain relief.
- Opiate or narcotic medications (e.g., morphine, Vicodin [hydrocodone and acetaminophen], OxyContin [oxycodone], morphine, etc.) are primarily used as pain-relieving drugs. These drugs all have serious potential for abuse and the development of physical dependence. When sources discuss the abuse and development of substance use disorders to painkilling medications, they are generally referring to this class of drugs.
What Defines Addiction?
The term addiction is still used in a number of different sources; however, most professional organizations have refined the use of their terminology and now use the term substance use disorder to cover all notions of substance abuse and addiction. This is because the process of addiction is now viewed as occurring on a continuum between substance abuse/misuse and a formal addiction. The new term covers all notions of addictive behaviors associated with substance use.
It is important to briefly outline some qualifications regarding the actual definition of a substance use disorder. According to professional sources, such as the book Chemical Dependency:
- Developing physical dependence on a drug may be a sign that an individual is developing a substance use disorder; however, it is neither necessary nor sufficient to have a physical dependence on a drug to be diagnosed with a substance use disorder. Physical dependence occurs as a result of developing tolerance (needing more of the drug to achieve effects once achieved at lower doses) and withdrawal (negative physical and emotional effects that occur when the drug is discontinued or the dosage is drastically decreased). People who are prescribed prescription painkilling drugs for chronic conditions, and use them under the supervision of a physician and within the boundaries of their prescribed use, may develop physical dependence on these drugs; however, because they are not using them for nonmedicinal purposes, they most likely would not be diagnosed with a substance use disorder.
- A substance use disorder represents a defined mental health disorder that is diagnosed according to specific diagnostic criteria. A person with a substance use disorder uses medications or drugs primarily for nonmedicinal purposes, experiences a number of negative ramifications as a result of their use of these substances, and demonstrates a number of issues with controlling their use of the drugs.
- Given the above definitions, a minority of individuals who are prescribed prescription painkillers may actually develop substance use disorders (about 25 percent or less); however, the majority of individuals who are prescribed prescription medications do not develop substance use disorders as a result of their use even if they have developed physical dependence on these drugs.
Who Abuses Pain Medications?
According to the American Psychiatric Association (APA) and the National Institute on Drug Abuse (NIDA), the risk for developing a substance use disorder as a result of misuse of pain medications increases for individuals who:
- Have some other mental health disorder, such as clinical depression, an eating disorder, a personality disorder, an anxiety disorder, etc.
- Are between the ages of 16 and 30, although substance use disorders occur over all age groups.
- Often have deficiencies in coping with stress or with their social skills.
- Use pain medications for their psychoactive effects and in conjunction with other drugs, such as alcohol, cannabis, stimulants, etc.
- Typically have relatively easy access to the drug, such as from a friend or family member who has a prescription.
- Have family members or friends who also abuse alcohol or drugs.
- View using drugs as an appropriate means to cope with typical life stressors.
These factors increase the risk that an individual will abuse any type of drug or alcohol. According to APA and NIDA, the signs of an opiate use disorder include:
- Using the drug frequently even though its use results in detrimental effects that can manifest themselves in one’s career, personal relationships, physical health, or emotional health
- Spending a great deal of time using pain medications or recovering from their use
- Using the medication in greater amounts or for longer periods than originally intended
- Spending significant amounts of time trying to get pain medications
- Spending significant amounts of time recovering from the use of pain medications
- Having frequent cravings to use pain medications
- Giving up important activities as a result of one’s use of drugs
- Using pain medications in situations where it is dangerous to do so, such as mixing them with other drugs or using them while operating a motor vehicle or machinery, using them at work, using them when caring for children, etc.
- Being unable to cut down on use
- Developing tolerance and/or withdrawal symptoms in conjunction with one or more of the above signs
Treatment for Painkiller Addiction
The American Society of Addiction Medicine, the largest association of addiction medicine physicians and professionals in the US, has outlined a standard treatment protocol for individuals who develop substance use disorders to medications such as painkillers. The protocol includes the following:
- A physician-assisted withdrawal management program or medical detox: Because there is a significant probability that individuals who chronically abuse these drugs will develop physical dependence on them, it is important that the withdrawal process is monitored and controlled. This can be done on an inpatient or outpatient basis, depending on the specific case. Supervising physicians typically prescribe some form of opioid replacement medication that controls cravings and the symptoms associated with the withdrawal syndrome from the drug. The patient is slowly tapered off the opioid replacement medication to allow them to withdraw from their drug of abuse without experiencing any significant effects. This process also significantly reduces rates of relapse in early recovery.
- A formal substance use disorder therapy program: Medications designed to control cravings, withdrawal, and other symptoms are not a substitute for a formal behaviorally oriented treatment program. Such a program will assist the individual in understanding the driving forces behind their behaviors, developing coping skills, and forming and implementing a formal long-term program of relapse prevention.
- Support from others: Support can come from a number of sources that can include friends, family, and others who are recovering from substance use disorders. This support can be garnered in a number of different ways, including family therapy, attendance at social support groups like 12-Step groups, involvement with family and friends, and attendance at other community support groups.
- Treatment of any co-occurring mental health disorders and significant physical conditions: This can include therapy, medically assisted treatment, and other forms of intervention for these conditions. Individuals with co-occurring mental health disorders need to have these issues addressed concurrently with their substance use disorder treatment.
- Other forms of intervention and support as needed, based on the individual case: This may include getting the individual into a sober living home, enrolling in school or receiving tutoring, occupational training, vocational rehabilitation, physical or occupational therapy, case management, etc.