There has been a lot in the news about opioid addiction over the last few years, especially in America and primarily about people who have had a legitimate prescription and need for painkillers. The standard storyline is that someone has an acute injury, has been prescribed opioid painkillers, gets addicted and then takes them without a pain need. Whilst this common tale is an important one, it can be hard for those of us who have a legitimate need for long term opiates because of chronic pain. We can find ourselves having to justify our need for pain relief, having that need doubted and minimised, and in some cases have much needed medication stopped.
My position in this debate is a very complicated one. I use opiates daily. I can only function because of the pain relief they give me. I can only write this because of the pain relief. Even with constant pain relief, I still experience high levels of pain and very reduced function and ability to participate in normal daily tasks. I strongly defend my use of opioids. I don’t think I should have to justify my use of them repeatedly and I don’t think I should be treated in a degrading manner when I ask for them.
However. And this is a big however.
Someone close to me, who has a legitimate need for pain relief, is almost certainly addicted. And I’m having to watch this person essentially kill themselves.
What happens when someone who needs opioids on a long term basis, for a chronic pain condition, becomes addicted? It is probably because it is so complicated that this isn’t a story we hear as often. This story has many parts and I’m hoping to cover them in a few different posts, partly to educate myself about the effects of this addiction and to try and unpick how it happens and what can be done about it. For confidentiality and privacy, this isn’t going to be the story of the person close to me.
Statistics and definitions
Before we can talk about addiction, we need to try and find a definition for addiction, which turns out to be harder than expected. It seems that opioid addiction, especially in chronic pain patients, is something that science has yet to agree on a definition for.
What we do know is that physical dependence is not the same as addiction. Physical dependence is a physiologic adaptation to the continuous presence of certain drugs in the body. Physical dependence is an expected consequence of prolonged use. Tolerance to opioids is another expected consequence of long term use and is not a sign of addiction.
Addiction is characterised by behaviours including being unable to control drug use, compulsive use, cravings and using the drug despite knowing it’s harming you. It cannot be identified on the basis of one event, instead it is necessary to observe a number of behaviours across a period of time. Where physical dependence and tolerance are expected, predictable responses that occur with persistent use of opioids, addiction is not.
When it comes to defining addiction in the context of patients with chronic pain who are taking opioids, R K Portenoy has suggested the following definition of addiction:
‘‘Addiction is a psychological and behavioural syndrome characterised by evidence of psychological dependence, and evidence of compulsive drug use, and/or evidence of other aberrant drug related behaviours’’
The American Society of Addiction Medicine defines addiction as “a primary, chronic disease of brain reward, motivation, memory and related circuitry.” The psychological aspect and the compulsive nature are important in helping to figure out the grey area between appropriate use and addiction. With the latter, there is an intense desire for the drug, loss of control over drug use and compulsive drug use, and continued use despite significant side effects. As opioids impact the brain and can lead to a temporary feeling of intense pleasure, addiction can develop quickly.
It proved very difficult to identify statistics around addiction amongst people who have chronic pain in the UK so instead I took a look at statistics around opiates and drugs in England and Wales:
- Around 1 in 12 (8.5%) adults aged 16 to 59 in England and Wales had taken an illicit drug in the year 2016/17
- In 1993, there were 471 deaths from opioids but by 2017 there were 1985 deaths.
- 279,793 individuals were in contact with drug and alcohol services in 2016/17, with a majority of them having used opiates.
- In 2017, there were over 24 million prescriptions of opioids – an increase of 10 million since 2007.
- Fatalities from the synthetic opioid fentanyl were up by almost 30 per cent in 2017 from the previous year.
- In 1996, there was one death which mentioned tramadol use but by 2011 there were 154 deaths.
A 2014/15 survey for England and Wales looked at the effects of using prescription opioids which were not prescribed to the user. Whilst this is something slightly different to my focus, it can show some of the impact of addiction.
- Overall, 5.4 % of adults aged 16 to 59 years had misused a prescription-only painkiller not prescribed to them
- People with a long-standing illness or disability were more likely to have misused prescription-only painkillers and to have used an illicit drug in the last year.
- Among those with a long-standing illness, 8.5 per cent had misused prescription-only painkillers in the last year (compared with 4.8% without an illness) and 11.9 per cent had taken an illicit drug in the last year (compared with 8.1% without an illness).
Basically, in summary, opioid addiction is not rare, it can affect people who have a legitimate pain relief need and it can destroy lives.
In future posts I’m going to take a look at the effects of long term opiate use and abuse, how to tell if you or someone you know is addicted, how the risk of addiction could be managed and how someone who is addicted can be helped.
If you or someone you know is addicted to any kind of drug, please seek help and advice. If you or someone you know is in immediate danger, ring the emergency services.