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Created: January 2001
Revision: May 2003
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Pain Management and IC
Myths and Issues of Narcotic Pain Management
"Opioid medications allow us to treat chronic pain as aggressively as we would any pathogen, but we must first overcome ingrained misconceptions about patients' motivations for seeking treatment and about the addictive properties of the drugs." Daniel BrookoffFor many patients with interstitial cystitis, pain is the prominent feature of their disease. Many IC patients with chronic pain find that traditional treatments and therapy are often unsatisfactory, therefore, causing them to seek alternative strategies for pain control.
There are a wide variety of pain management strategies available for an IC patient to consider. The use of opioids is the first line defense for chronic pain patients experiencing moderate to severe pain.
Short half-life drugs, such as codeine are used for mild to moderate pain. Hydrocodone or oxycodone are used for moderate to severe pain. Severe pain is often treated with long-acting sustained-release agents such as morphine, hydromorphine and levorphanol. Methadone and fentanyl are used for severe intractable chronic pain, and are usually prescribed by a licensed pain specialist.
(The Interstitial Cystitis Survival Guide by Robert Moldwin has an excellent discussion on pain management, flare management and the various drugs used to help IC patients in pain. It's a must read!)
Opioid prescriptions can bring up a wide variety of issues for patients and physicians, including appropriate use versus inappropriate use, drug abuse, addiction, dependency and tolerance. As an IC patient using opioids as a means for pain control, it is imperative to understand the underlying issues that face the chronic pain patient and the medical community.
Appropriate use versus inappropriate use:
An appropriate use of pain medications is to promote functionality in
a patient's life and provide comfort from symptoms so that they can return
to work and fulfill their daily responsibilities. In contrast, if the
patient is using the drugs to escape life, such as family, social and
financial problems or using them for purposes other than those for which
it is normally intended, or in a manner or in quantities other than directed,
than that patient is using the drugs inappropriately.
Addiction:
Drug addiction is a chronic and progressive psychiatric illness, which
arises from the inappropriate and compulsive use of one or more substances
that results in psychological and physical harm. Research has demonstrated
that chronic pain patients rarely become addicts.
"If a physician prescribes a pain medication in good faith for the treatment of pain, anyone who leaves the practice an addict was already an addict before treatment" Daniel Brookoff
"Patients in bad pain don't get high or europhoric. They use meds to get back into their lives. Patients not in pain, take the meds to get euphoric. Currrent research demonstrates that the risk for addiction is minimal for chronic pain patients." Daniel Brookoff
Pseudoaddiction
"Individuals who have severe, unrelieved pain may become intensely focused
on finding relief for their pain. Sometimes such patients may appear to
observers to be preoccupied with obtaining opioids, but the preoccupation
is with finding relief of pain, rather than using opioids per se."(1)
This is a common behavior of pain patients receiving inadequate pain medications. In this incident the patient is seeking pain control by increasing his/her medications without supervision from his/her medical care provider
"..one type of addiction can occur and will be caused by
physicians. Pseudoaddiction begins with poor pain management. The patient
is given some pain medications, which work for them. Encouraged, they
then ask for more and are met with anger from their medical care team.
The patient becomes angry and the team gets frustrated thinking "you only
want the medicine I don't want to give you." The team then avoids and
isolates the patient. Isolation is the worst form of suffering of all..
and leads to a crisis. This disease is caused by medical care providers.."
Daniel Brookoff
Physical Dependence:
In physical dependence, our bodies have adapted to the presence of pain
medications after continued use. When we stop those medications, we may
experience withdrawal symptoms. These symptoms are managed by gradual
lessening of the medication over time.
Tolerance:
Tolerance is a physiologic state resulting from regular use of a drug
in which an increased dosage is needed to produce the same effect, or
a reduced effect is observed with a constant dose.(2)
Reference:
(1) ASAM, Public Policy Statement on the Rights and Responsibilities
of Physicians in the Use of Opioids for the Treatment of Pain, April 16,
1997.
(2)Federation of State Medical Boards of the United States, Inc., Model
Guidelines for the Use of Controlled Substances for the Treatment of Pain,
May 1998