Pain is a warning sign that an individual either has damage to an area of the body or is about to experience significant damage. The perception of pain is a combination of both physical mechanisms and psychological/emotional components. Not all forms of pain represent the same combination of these mechanisms, and everyone experiences pain differently. There is no way to objectively measure an individual’s level of pain; there are no medical tests, medical instruments, or other objective techniques to actually determine how pain is experienced in any one person and how one person’s pain compares to someone else’s pain.
Because there are different types of pain, and pain is a subjective experience, there are a number of different classes of medications that can be used as painkillers. Not all of these classes of medication are potentially substances of abuse. For the most part, over-the-counter pain medications are not significant drugs of abuse, and the medications that are often serious drugs of abuse constitute one specific category of pain medications that should only be taken with a prescription from a physician.
A number of medications can be used to control certain types of pain. These include:
- NSAIDs: The nonsteroidal anti-inflammatory drugs make up a large class of drugs that include familiar over-the-counter medications, such as Advil and Tylenol. There are drugs in this class that require a prescription to obtain, such as the drug Celebrex (celecoxib). These drugs do not appear to be significant drugs of abuse.
- Sedatives, anxiolytics, and muscle relaxants: There are a number of medications that are used as muscle relaxants and sedatives that can only be legally purchased with a prescription. One such drug is a muscle relaxant Flexeril (cyclobenzaprine). In addition, benzodiazepines such as Xanax (alprazolam) that are primarily prescribed for the treatment of anxiety or for seizure control are sometimes used as muscle relaxants and to control pain associated with muscle tension. Sedative drugs that are similar to benzodiazepines but not classified as benzodiazepines that are often used to initiate sleep, such as Ambien (zolpidem), may also be used for pain control. These drugs can be significant drugs of abuse; however, the drugs in these classes of prescription drugs are not generally classified as painkillers.
- Antidepressant medications and anticonvulsant medications: A number of medications that are primarily designed to treat depression (selective serotonin reuptake inhibitors like Prozac [fluoxetine] or tricyclic antidepressants [e.g., Tofranil [imipramine]) or drugs that are used to treat seizures (e.g., Neurontin [gabapentin]) are also sometimes used to treat certain types of pain (e.g., the pain associated with fibromyalgia or neuropathic pain). The primary function of these drugs is not for pain control, and for the most part, these drugs are not significant drugs of abuse.
- Opiate drugs (opioid or narcotic drugs): Narcotic or opioid drugs comprise a large class of drugs that are primarily designed for pain control, although they have other uses as well. These drugs are derived from opium or synthetic substances that are analogs of opium. These drugs include familiar drugs like morphine, OxyContin (oxycodone), Vicodin (hydrocodone), codeine, and heroin. They can only be purchased legally with a prescription (and in some cases, such as with the drug heroin, cannot be legally obtained at all except with special governmental permissions for research purposes). These drugs are tightly controlled by the United States Drug Enforcement Administration (DEA) and represent significant drugs of abuse. The abuse of prescription medications is a major problem in the United States, and abuse issues associated with this class of drugs represents a significant concern. When people refer to “painkiller addiction,” they are referring to these opiate drugs.
Addiction to Painkillers
Similar to the experience of pain, the development of an addiction also represents a complex interplay of physiological and psychological mechanisms. There is no such thing as a pure physically based substance use disorder or a purely psychologically based substance use disorder. These disorders represent a complex interplay between a person’s biology and psychological or emotional makeup.
The first issue to discuss is the notion that certain types of drugs, including narcotic medications, can result in the development of physical dependence in individuals who use them for significant periods of time (typically over 5-6 weeks). Not everyone will develop significant physical dependence on these drugs, but most individuals who take narcotic medications for an extended period will develop some level of physical dependence on them. Physical dependence, is a condition that represents the development of two syndromes: tolerance and withdrawal.
- Tolerance occurs when the dosage of a drug that a person has been using no longer produces the same effects it once did. The individual needs to take more of the drug to experience the same effects that they got previously. Tolerance to narcotic medications develops rapidly. As one develops higher levels of tolerance, they become more prone to developing a withdrawal syndrome.
- A withdrawal syndrome occurs when a person’s system adjusts itself to account for the presence of a specific substance in its tissues. The body mechanisms regulate their levels of hormones and neurotransmitters to account for the drug in the system. Foreign substances, such as drugs and other waste products, are constantly being removed from the body as a result of normal detoxification. When the person stops using their substance of choice, the levels of the substance in the system will decline, and this will throw the individual system off balance, producing a number of negative physiological and psychological effects.
- Physical dependence represents a complex combination of physiological and psychological mechanisms. Individuals who abuse opioid drugs will typically develop significant levels of physical dependence on these drugs, and this physical dependence results in an exacerbation of their substance use disorder. By developing significant tolerance to the drugs, individuals take very high amounts of them, and this results in the development of very severe and discomforting withdrawal symptoms. Once the individual stops taking the drug, withdrawal symptoms begin to appear, and the person becomes very motivated to take more of the drug to stop these symptoms. This situation results in a very serious downward spiral for many people who have opiate use disorders.
According to the diagnostic criteria for substance use disorders used by the American Psychiatric Association (APA), the development of withdrawal symptoms and/or tolerance to any substance represents potential symptoms of a substance use disorder. However, it is neither necessary nor is it sufficient to have either of these symptoms to be diagnosed with a substance use disorder. The clinical definition of a substance use disorder is based on the notion that the person uses the drug primarily for non-medicinal purposes and demonstrates significant issues with controlling their use of the drug, leading to a number of dysfunctional effects in their lives. Patients using opiate drugs for long periods of time under the supervision of a physician and within the confines of their prescribed uses, such as for pain control, are not abusing the drugs and therefore would not be classified as having an addiction or substance use disorder.
The Signs of an Opioid Use Disorder
Even though the development of a substance use disorder represents an interplay of biological and psychological mechanisms, there are no biologically based tests that can diagnose a substance use disorder in anyone. Instead, the diagnosis of a formal substance use disorder depends on an interpretation of an individual’s behavior. This interpretation can only be made by a trained, licensed, mental healthcare professional.
According to APA, significant signs associated with the development of a substance use disorder include:
- The development of tolerance
- The development of withdrawal symptoms
- Frequent cravings to use painkillers
Significant issues with controlling use of painkillers that can include one or more of the following:
- Wanting to stop or reduce use of the drug but being unable to do so
- Spending significant amounts of time trying to get narcotics, using narcotics, or recovering from their use
- Frequently using narcotic medications in situations where it is hazardous to do so
- Giving up activities that were once important as a result of one’s use of these drugs
- Continuing to use the drugs in spite of problems related to drug use that occur with one’s occupation, personal relationships, at school, or in other important areas of life
- Continuing to use the drug despite realizing that such use results in issues with health or emotional functioning
- Significant distress or dysfunction due to use of the drug
Who Is at Risk?
The National Institute on Drug Abuse reports that there are some significant risk factors that are associated with individuals who develop opioid use disorders. Individuals who are at a high risk to develop substance abuse issues with painkillers are people who:
- Also have some other mental health disorder, such as depression, a stress-related disorder, or an anxiety disorder
- Often use painkillers in conjunction with other drugs of abuse, such as alcohol, other painkillers, or benzodiazepines
- Have a method of getting the drug, such as getting it from friends, buying it illegally, or even stealing it
- Believe that use of substances is an effective means to cope with stress and/or do not view recreational use of drugs as inappropriate
- Are most often between the ages of 16 and 30 (although people in every age group abuse painkillers)
Treatment for Painkiller Addiction
APA and the American Society of Addiction Medicine, the largest association of physicians trained and specializing in the treatment of substance use disorders in the United States, have outlined formalized treatment protocols that act as blueprints to guide treatment professionals in helping individuals recovering from opiate use disorders. In general, treatment consists of the elements outlined below.
- Initial enrollment in a physician-assisted withdrawal management program is recommended. In this program, the client is usually prescribed opioid replacement medications (e.g., Suboxone or methadone) to control withdrawal symptoms. A number of other medications can also be used to control cravings (e.g., naltrexone) and other symptoms. Opioid replacement medications are administered on a tapering schedule, such that at specific intervals, the dosage of the drug is lowered to allow the person to be slowly weaned off the drug in a safe and relatively symptom-free manner.
- Medical management of any co-occurring physical or psychological conditions should be instituted along with the withdrawal management program.
- The use of support groups is highly recommended. These are not therapeutic interventions, as they are not typically run by licensed therapist; however, they do allow for the development of strong positive peer relations with other individuals in recovery and can also present the individual with a structured program of recovery. Twelve-Step groups, such as Narcotics Anonymous, can also be utilized during and after formal therapy is completed.
- Other interventions that apply to the specific needs of the individual should also be instituted. These can include help with living situations (e.g., a sober living home), occupational training or vocational rehabilitation, speech therapy, etc.