Bazelon Center for Mental Health Law
Painlaw.org
Using Opioids to Control Pain
Dispelling the Myths
- Pain patients very rarely become addicted.
- Distinguishing between "addiction" and "tolerance."
- There is no such thing as "too much" pain medication for a patient
in pain.
- Careful pain management does not kill.
- Prescribing pain medication properly is not illegal.
- Doctors and Patients Are Unnecessarily Cautious about Using Opioids to Treat
Pain
Most people facing a very serious illness fear dying in pain as much as they
fear death itself. But 95 percent of pain, including the worst cancer pain, can
be controlled. When lesser painkillers fail, morphine and
its synthetic cousins (opioids) should be considered.
Patients and American doctors (who should know better)
are unreasonably afraid of opioids. This "opiophobia" is not based on
fact, but is a product of outmoded knowledge and the 'War on Drugs'.
Medical
research demonstrates the utility and safety of opioid use for otherwise
untreatable pain. Major medical organizations have created policies and
standards to advise doctors on the findings and resultant practice guidelines.
A
recent joint statement by the American Pain Society and the American Academy of
Pain Medicine outlines current goals and standards for the use of opioids in
pain management.
Despite this activity at the top of the profession,
pain management in hospitals, nursing homes and doctors' offices in the United
States falls far short of the standard for medical care. Doctors only
recently had good pain management training available to them. They are often
very reluctant to use opioids effectively, even when a patient is dying. Many
never even consider opioids for long-term therapy for non-cancer pain.
Very sick patients are entitled to the best modes of
pain control. They, not their doctors, are the best judges of how much
pain they feel and whether a particular mode of pain management is working.
For
chronic pain patients the key is whether the medications make them better able
to function in their daily lives than do more frequently dispensed pain
medications.
Opioids are not the answer to every pain problem or even every severe pain
problem. However, every
patient should receive consideration of pain that is not clouded by ignorance or
unreasonable fear of particular medications.
ADDICTION and TOLERANCE
Pain patients very rarely become addicted.
An addict is a person who compulsively takes drugs for nonmedicinal purposes.
Addicts will continue to seek out the drugs despite bad effects on their ability
to function in the community, to hold a job, to care for their families and to
maintain social relationships.
In contrast, pain patients often take very large
amounts of opioids and other medications to improve their function, but do not
seek out the drug for its own sake or "crave" the medication. Their
ability to work, care for families and live productive lives is improved by
their medications.
A recent study demonstrates that fewer than one percent of pain patients
receiving opioids become narcotics abusers. No patient in pain should hear that
relief is barred because "you will become an addict." No patient in
pain should reject opioids out of fear of becoming addicted. Even former and
current substance abusers can be treated for severe pain by doctors with
experience in the field.
There is a critical difference between "addiction" and
"tolerance."
Tolerance
is a physical event that will always happen when a
patient takes opioids. Tolerance begins with even one dose. This physical fact
is not linked to harmful effects. It means only that, over time, pain patients
can be expected to need higher doses of the medication to obtain the same
relief.
A patient who has been receiving opioids for pain over time can tolerate
levels that would kill a person who is "opioid naive" (someone who has
not built up any tolerance). For this reason it is often
said that there is no theoretical upper limit to the amount of opioids than can
appropriately be prescribed to control pain. Careful physicians will
monitor dosage closely and increase it when necessary as tolerance builds to
maintain a good effect on pain control. Moreover, some medications mix opioids
and other pain relievers such as aspirin, acetaminophen and other non- steroidal
compounds. A patient taking these medications will reach a ceiling dose at some
point because the other drugs in the compound are toxic. Some pain relievers,
such as Demerol, should not be used for any extended period because of toxicity.
Confusion between "addiction" and "tolerance" is common
even among physicians
Identification of patients with substance abuse problems is even more
difficult. The best distinction between the two is the patient's ability to
function. Pain patients can expect to improve function with optimal dosages of
opioids.
Dependence
is another physical fact. It refers usually to the
need to maintain opioid levels in a tolerant individual or experience
withdrawal. Both addicts and legitimate pain patients will experience withdrawal
if the drug is withdrawn abruptly.
Until a patient achieves pain relief there is no such thing as "too
much" morphine or other opioids.
Pain experts agree that there is no "theoretical
upper limit" for opioid dosages for pain relief. The upper limit is
"what works." It is important not to assume that high dosages or a
large number of prescribed pills means that the patient is "an
addict." Of course, the doctor must monitor to make sure that the dose is
appropriate for that patient.
Morphine and its derivatives do have side effects. The most frequent is
constipation. Most side effects can be managed. A doctor may have to try a
number of pain medications or combinations of medications to reach the maximum
relief with minimum side effects. Patient and doctor need to work together to
reach an appropriate dose for the patient.
Careful pain management does not kill.
