Addiction and pain management

A few years ago, Peter Grinspoon, MD, slipped on the ice and tore a tendon in his left thigh so badly that he needed surgery to replace it. He was sent home with a prescription for the opioid oxycodone to ease his pain. But Grinspoon was hesitant to fill it out, for good reason: He had become addicted to the painkiller more than a decade earlier and for years was determined to avoid opioids at all costs.

But after tearing the tendon, he felt he had no choice: “Taking an over-the-counter pain reliever like Tylenol or Motrin would be like going after Godzilla with a Nerf gun: pretty pointless,” Grinspoon says. internist at Massachusetts General Hospital in Boston. “In the end, the nerve receptors decided for me: my leg hurt so much, as if it had been burned.”

Grinspoon was able to take the oxycodone without any problems. He asked his wife to stick to the pills and manage the doses so she didn’t take more than prescribed. She was able to take the medication without experiencing cravings or heightened sensations and stopped taking it once the pain subsided.

Still, it remains a problem, he says, for the 20 million Americans who have or have had a substance use disorder (SUD), whether it involves alcohol, marijuana, or prescription drugs like opioids. “Patients are afraid to tell their doctor about their past or current addiction because they fear that their pain will not be treated,” says Grinspoon. “There is still a lot of stigma around SUD, even among health care providers. But people who struggle with addiction still deserve and can get adequate pain relief if certain precautions are taken.”

Certain things, like alcohol and drugs, increase dopamine, a chemical that triggers the brain’s reward center, explains Robert Bolash, MD, a pain management specialist at the Cleveland Clinic. For some people, these feelings are so strong that they want to experience them over and over again.

“Drugs like opioids turn on the exact same circuitry, so if you’ve had an addiction in the past, you’re at a higher risk of relapse,” says Bolash. The risk is greatest if, like Grinspoon, he was addicted to the same drug. But you are still vulnerable if you have any current or past addictions.

The risk is probably highest in the first 6 to 12 months after recovery, but “if you’ve ever been addicted, it’s important to realize that it can happen at any time,” says Bolash.

If this is the case, here’s what you need to do:

Be upfront with your doctor. If you need pain medication but have a history of addiction, talk to your healthcare provider. “A lot of patients hold back because they’re worried about the stigma, but the reality is that a quality provider won’t judge them or deny them medications,” says Grinspoon. Instead, they will work with you to develop a treatment plan that meets your needs.

Explore non-opioid medications. Other drugs have less potential for addiction if you are in pain. These include:

• Over-the-counter acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs). These are often used together for mild to moderate pain, says Bolash. It alternates between one and the other every few hours. The drugs work in harmony: Acetaminophen is a general pain reliever, and NSAIDs fight inflammation.
• COX-2 inhibitors. These prescription drugs are stronger forms of NSAIDs. They block a specific enzyme called COX-2, which is responsible for the production of prostaglandins, chemicals that cause inflammation or pain. It usually replaces the COX-2 inhibitor with acetaminophen, Bolash says.
• Nerve pain relievers. Medicines such as gabapentin (Neurontin) or pregabalin (Lyrica) can help relieve neuropathic or nerve-related pain.
• Peripheral nerve block. This is a type of anesthesia that is injected near a nerve bundle to prevent pain in a specific area of ​​the body. It can be used to treat pain caused by fractures or even during some surgeries.

In some cases, it can be difficult to avoid opioids: for example, after recovering from major surgery, such as joint replacement. But there are safeguards you can put in place, says Grinspoon:

Create a pain plan. It should be in place even before surgery, says Bolash. A Cleveland Clinic study found that people who took three medications (acetaminophen, gabapentin, and the NSAID celecoxib) before surgery, anesthetized with ketamine, and received a nerve block during surgery were much less likely to need opioids. “It can help prevent the cascade of pain-relieving chemicals that come from the central nervous system after surgery,” says Bolash.

Find a partner. This is a family member, friend, or someone else in recovery who you can check in with several times a day while taking your opioid medication. “That way, if you start to slip at all—like you start noticing cravings—it can help you stay on track,” says Bolash.

You should also have someone else dispense the pain medication so you can avoid the temptation to take more than prescribed, Grinspoon adds.

Get rid of leftover pills. According to one study, more than 60% of Americans who are prescribed opioids and do not take them all keep the extras. But if they’re in your medicine cabinet, you’ll be more tempted to take them, Grinspoon says. The best way to get rid of them safely is on the local road “take it back” programs, which are usually found at police stations, DEA collection points, or pharmacies.

Remember that if you have a history of addiction, there are ways to safely manage your pain, even if you need to take opioids. “It was very reassuring that I didn’t run into any problems taking oxycodone for my pain,” says Grinspoon. “Recovery and pain relief need not be mutually exclusive.”