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Dr. Patricia Yarberry Allen is a collaborative physician who writes a weekly “Medical Monday” column for Women’s Voices for Change.  (Search our archives for her posts, calling on the expertise of medical specialists, on topics from angiography to vulvar melanoma.)

This week, Dr. Pat has asked Megan Riddle, M.D./Ph.D., a psychiatry resident at the University of Washington and a graduate of the Weill Cornell/Rockefeller/Sloan-Kettering Tri-Institutional MD-PhD Program, to address the concerns of a woman suffering from chronic pain—and frightened about her chances of becoming addicted to her pain medication. Dr. Riddle is a member of  Women’s Voices’ Medical Advisory Board.

Dear Dr. Pat:

I am beginning to think I have a problem. It started nine months ago, when I was on a family skiing trip and put my back out. I have had chronic back pain for some time, but this was extreme. After spending three days essentially bedridden, with very little improvement, I went to my doctor, who prescribed Percocet.

That really made a difference. The pain was nearly gone, and I could go back to work and be a mom for my busy teenagers. But it did more than take away the back pain–I just felt better, more relaxed and happier. At first I was really good about taking the meds as prescribed, but then I found that that didn’t cut it—I would feel uncomfortable and take an extra for relief. My doctor wouldn’t prescribe any additional medication, and now I find myself obsessing over finding more. I’ve gone to a second physician for relief, and she gave me a prescription for Dilaudid. I thought that would be enough, but I am seeing the bottom of my pill bottle again and can’t get a refill for another week. If I don’t take any, I feel terrible, but when I have enough to make me feel well, I struggle to get things done at work and am worried that others may take notice. I’m also taking more of my Klonopin to deal with the anxiety. Things aren’t getting any better, and I’m not sure what to do. Please help!

Cindy

Dr. Riddle Responds:

Dear Cindy:

You are right to be concerned. What you are describing is consistent with what we call a substance use disorder. Individuals dealing with this disorder find that using substances causes significant problems in their lives. It sounds as if you have become both physically and psychologically dependent on these medications to make it through the day. In essence, you are on that slippery slope of addiction.

Opioids—like Percocet, Oxycontin, Dilaudid, Vicodin, and morphine— are powerful pain relievers. When the patient is suffering acute pain, such as directly after surgery, opioids can offer much-needed relief. However, in cases of chronic pain, using these medications for an extended period of time can lead to problems. Symptoms of an opioid use disorder include many of the features you describe, such as taking more opioids than you intend to, craving the drugs, being unable to cut down, spending excessive time obtaining and using the medications, signs of tolerance—like needing a higher dose to get the same effect—and having symptoms of withdrawal when you cut down. Although you say you are still able to go to work, you express concern that others may have realized that there is a problem. A key part of this disorder is that it can lead to trouble in your work and personal life, to the point that you are unable to function as you would want to. It sounds as if you have not escalated to that point, but it is critical that you seek professional help now, before your symptoms worsen.

Unfortunately, your problem is all too common among those who are taking prescribed chronic opioids. Some studies have found the rates of substance abuse as high as 1 in 4 among those on long-term opioids.

The consequences can be dire. In 2010, 16,652 deaths were caused by overdose of these prescription painkillers—five times more than deaths from heroin overdose. You mention that you also use Klonopin, a benzodiazepine, to help deal with anxiety. Taking benzodiazepines—Klonopin, Xanax, Valium, and Ativan are all popular—with opioids is a particularly deadly combination. Because both can be sedating and decrease your drive to breathe, overdoses can happen at significantly lower doses when they are used together. Of the deaths from opioids in 2010, 30 percent of those individuals had also taken benzodiazepines at the time of the overdose.    

You owe it to yourself—and your family—to seek professional treatment for your drug use. Be aware that although it can be tempting to go “cold turkey” when quitting, stopping benzodiazepines suddenly can be dangerous—potentially fatal—and withdrawal should be done under medical guidance. While withdrawing from opioids does not have the same danger as withdrawing from benzodiazepines, the symptoms can be very uncomfortable. Thus, it is important to find a physician you trust to help you through this process, and inpatient detox may be an appropriate step, but is not necessary for everyone struggling with addiction.

You, like many suffering with issues of prescription opioid dependence, are continuing to have problems with chronic pain. Paradoxically, chronic opioid use can actually make you more sensitive to pain. As you come off of the opioids, it will be important to work closely with your doctor to determine and address your ongoing needs for pain relief. It may be possible to manage your pain using non-opioid medications; these include medications that treat inflammation, spasms, and neuropathic pain. Even certain antidepressants have been shown to offer pain relief, independent of their effects on mood. You can also benefit from complementary therapies, such as physical therapy and massage.

The road ahead of you is not an easy one, but you do not need to go it alone. I would encourage you to seek support in recovery. This network can include friends and family, along with health professionals and recovery groups. These are people who can help you navigate the darker times and celebrate your successes. With treatment, you can begin on the path to the healthier, more fulfilling life you deserve.

—Megan Riddle, M.D./Ph.D.

References

Brown RL, Rounds, LA. Conjoint screening questionnaires for alcohol and other drug abuse: criterion validity in a primary care practice. Wisconsin Medical Journal. 1995:94(3) 135-140.

American Psychiatric Association (2013): Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association.

National Institute of Neurological Disorders and Stroke (2003): Low Back Pain Fact Sheet. http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm#260523102.

Strain. E (2014): Opioid use disorder: Epidemiology, pharmacology, clinical manifestations, course, screening, assessment, and diagnosis. http://www.uptodate.com/contents/opioid-use-disorder-epidemiology-pharmacology-clinical-manifestations-course-screening-assessment-and-diagnosis In: Saxon AJ, editor.

Tompkins DA, Campbell CM (2011): Opioid-induced hyperalgesia: clinically relevant or extraneous research phenomenon? Current pain and headache reports. 15:129-136.