"I wish this pain would just go away. I can hardly stand up to walk to the bathroom."
"What have you tried for pain relief?"
"I take a pain pill, and that helps. But I only take it when I can't stand the pain."
"It sounds like you have this pain that keeps you from walking pretty much every day."
"Yes."
"So, are you taking the pain pill everyday to relieve the pain so that you can walk?"
"Oh no. I don't want to get addicted or dependent on any pills."
People experience different types of pain from different causes, and various methods of pain relief may be discussed with or recommended by their healthcare providers. Some are procedural such as joint injections and radiation therapy; some are over the counter or home remedies such as menthol/lidocaine ointments and ice packs; some are complementary therapies such as massage or meditation; and some are medications such as acetaminophen (tylenol) or nerve pain medication.
This blog post is for the person whose pain has already been evaluated by their healthcare provider and prescribed an opioid as part of their treatment plan. The following three statements reflect the most common misconceptions I hear (read Post 1: What Exactly Does a Palliative Care Specialist Do?) about trialing opioids for pain relief.
Misconception #1. "I don't want to get addicted or dependent on anything."
Our bodies become dependent on many different kinds of medications when we take them regularly. Examples include steroids, a couple commonly used types of blood pressure medications, anxiety medications, and medications for mood or depression. Another example is opioids.
When a person is dependent on a medication, that means their body has physically changed and is now used to and dependent on the effects of the medication, whether it be a type of blood pressure medication or an opioid. Suddenly stopping that medication can result in physical withdrawal symptoms such as racing heart, high blood pressure, sweating, or tremors, and depending on the medication also diarrhea and vomiting or confusion, hallucinations, and seizures.
These medications can be safely stopped without withdrawal symptoms by gradually decreasing the dose over time, whether it be weeks or months.
Sometimes when a person takes a medication regularly, their body gets used to that dose and that dose is no longer as effective (or their side effects are no longer as bad). Tolerance can develop potentially in any person with potentially any medication.
In the case of someone who has been using an opioid regularly to relieve pain, they should be evaluated for the cause of increased pain rather than automatically assumed to have developed tolerance if the opioid no longer seems to be providing enough pain relief.
Substance use disorder (commonly known as psychiatric "addiction") is a medical disease. A person who is addicted to a substance compulsively uses the substance even if their day to day life is affected in harmful ways when using that substance. They are no longer taking the substance as medication for relief of a symptom. They take the substance even when they know it could cause problems (or continue activities such as gambling even when they know it is causing problems) with family, friends, and work.
People who have a substance use disorder/addiction have changes in their brain functioning that result in intense cravings and changes in judgment, decision making, behavior, and personality. They would take an opioid not as medication but for other purposes such as to feel a "high" (for example, intoxication) or to feel "numb" (for example, to feel distanced or to avoid confronting the reality of their situation).
The people who are at most risk for developing substance use disorder/addiction to an opioid are those who have a history of substance abuse to alcohol or illegal or legal medications, a family history of substance abuse to any of the above, history of severe depression or anxiety or other psychiatric illnesses, history of sexual abuse, history of legal problems or arrest, and frequent risk taking or thrill seeking behavior.
When a person is taking an opioid as a medication - that is, only as needed to relieve physical symptoms and only as discussed with and prescribed by their healthcare provider - they are not addicted. With regular use, their body may develop a dependence on the medication. This means when pain symptoms are improved and the opioid is no longer needed, then the medication should be tapered off over time instead of suddenly stopped.
Using an opioid medication appropriately minimizes the risk of developing a substance use disorder/addiction. It is up to an individual to decide if the potential pain relief benefit of an opioid medication outweighs the potential personal risk of developing this disease.
"When I take the pain medication, my pain goes from a level 8 to a level 5. I'm able to stand up and use the bathroom on my own. I'll take the pain medication every day."
"When I take the pain medication, my pain goes from a level 9 to a level 3. I can sit at the dinner table with my kids. If I have to take the pain medication four times a week, being with my kids would be worth it."
Misconception #2. "I'm allergic to pain pills. I took a pain pill before, and I became severely constipated."
Medication allergies are different from medication side effects. Allergic reactions are serious and can be life threatening. They include hives, rash, swelling, and trouble breathing. They indicate that the body's immune system is trying to reject the medication.
Medication side effects are common secondary effects that many people experience when taking a medication. The secondary effects may be unpleasant, but they are not life-threatening.
A person may choose not to take a medication because the side effects outweigh the benefit of the medication, or they may choose to take the medication because the benefit outweighs the burden of the side effects. This is different from when a person definitely should not take a medication to which they have had a potentially life- threatening allergic reaction.
Constipation is a known and common side effect of all opioids. When a person starts an opioid, or if they increase doses of an opioid, they will very likely experience constipation. It is a side effect that remains while the person is taking opioids regularly.
When a person is prescribed opioids, they are usually advised to take a laxative as well because constipation is such a common side effect.
Other common side effects of opioids are nausea, itchiness, and drowsiness that may appear when a person first starts an opioid or when an opioid dose is increased. Unlike constipation, these side effects usually improve after several days. If a person does receive pain relief from an opioid, they might want to continue the opioid for at least the next several days before determining if side effects outweigh the benefit of symptom relief.
"I started a laxative the same day I started taking the pain pill. I've had no problems with constipation this time around."
"I'm going to hold off for now because I'm just so scared of having to go back to the emergency room to get disimpacted. I know I'll have to try an opioid if the pain gets even a little bit worse, and I'll definitely stock up on laxatives then."
Misconception #3. "I don't want to take pills that make me loopy."
People can get "loopy," "fuzzy headed," disoriented, confused, or drowsy from an opioid medication. If this side effect occurs, it usually occurs when a person first starts an opioid medication or when the dose is increased, which then usually goes away within days when they develop a tolerance.
If a person continues to feel befuddled, confused, or drowsy, and they are otherwise experiencing good pain relief, the opioid medication dose can be decreased. These side effects usually improve within days after reducing the dose.
If it is difficult to find a good balance between pain control and side effect symptoms with one opioid medication, a different opioid medication can be attempted. People, with their healthcare providers, can also attempt other treatments and non-opioid medications to help minimize the opioid dose needed for pain relief.
As with all medications with their benefits and side effects, each individual must decide if the potential benefit of an opioid medication outweighs the potential side effects.
"I felt a little out of it the first few days, but that got better. I'm taking the pain medication every morning and every afternoon, and I can actually function now!"
"I felt a little out of it the first couple days, and I said, 'Nope, not for me.' I'm sticking with my tylenol three times a day. I found out if I sit there for a few minutes and say out loud each step I have to take to get to the bathroom, I can handle the pain. I can do it - slowly - but I can do it. It isn't worth it for me if I can't be clear headed."
The goal of pain medication is not necessarily to completely get rid of pain, but rather to give a person enough pain relief so that they can regain some control of their life. The goal is to increase their ability to move, their ability to take care of themselves, their ability to be present with family and friends, and their ability to continue meaningful activities.
As with all medical treatments (procedures, surgeries, chemotherapies, radiation, dialysis, tests, and medications), every person should weigh the potential benefit of an opioid against the potential burden to decide if it is the right time for them to attempt or not (read Post 16: Medical Decision Making 101).
I hope clarifying common misconceptions and misunderstandings that I hear from patients about opioid use will help you and your loved ones make informed decisions.