Opioid addiction and chronic pain: How to tell when someone is addicted

Because of the legitimate pain and need for pain relief, identifying when a chronic pain patient is addicted is a very difficult area.  It is common for someone taking opioids to become physically dependant and tolerant of them over time but this isn’t the same as an addiction.  For addiction to be present, you’d expect behavioural changes in addition to the dependence.

The behavioural changes in a person addicted to necessary prescription medication tend to be harder to spot than those in a person addicted to unprescribed substances.  As they have a legitimate need, it’s easier to cover up or explain away possible signs of addiction and some of the sings of addiction are also explained by the chronic pain itself.  However, a cluster of signs can indicate the need for concern and to explore the possibility of someone being addicted.  These signs include:

  • Frequent contact with doctors, whether that’s visits or phone calls
  • Having appointments about a different issue and asking for a prescription at the end of the appointment
  • Doctor shopping – contacting or visiting different doctors so there is less continuity and the person can play the doctors off each other a bit to try and get more opiates.
  • Manipulating care providers
  • Frequently complaining about medical conditions which justify the need for the drug use and which also justify the need for increasing dosages.
  • Complaining about new medical conditions and pain.
  • Reporting certain drug allergies and lack of therapeutic effect of alternative drugs which mean that the opioid is the only option for pain relief.
  • Frequent reports of losing medication and prescriptions.
  • Declining work or school performance
  • Relationship dysfunction
  • Decreased interest in other pain relieving options such as regular physiotherapy and other ‘health’ work needed to improve quality of life
  • Defensiveness when talking about prescriptions.
  • Increased irritability and anxiousness especially about the availability of the drug, when the next dose is etc
  • Overwhelming concern about the amount of medication etc
  • Mood swings, irritability, anxiety etc
  • Concern from friends, family and other observers
  • Insisting on managing own medication, especially in hospital settings
  • Increasing side effects and lack on concern about them
  • Signs of withdrawal

The physical side effects of opiates can also be a warning sign, especially if they seem to be getting worse.  When it comes to opiates, there is a sedative effect which can be seen in confusion, poor judgement, poor memory, drowsiness and unsteadiness.

If the person is open to a discussion, it can be much easier to get an idea about addiction however the caginess that comes with addiction can make this very difficult.  Unless a person is very open with you, these are probably questions best asked by medical professional, or dropped into conversation more as thinking points.  Avoid making it seem like an attack as anyone attacked about any part of themselves is likely to just get defensive.

  • Quantity: Does the person take more medication than needed? Are they taking more than they used to? Are they taking it more frequently?
  • Attitude: Do they want to cut down or stop taking the medication? Are they using the meds despite knowing they are having dangerous effects on their body?
  • Time: Do they spend a lot of time thinking about the drugs and when the next dose can be taken? Do they spend a lot of time getting and using the drug?
  • Social effects: Are they able to manage their responsibilities? Is drug use affecting any of their relationships?  Are they socialising as much as they used to?  Are they withdrawing from activities?  Has their circle of friends changed?
  • Do they get cravings and urges to use the drug?

Again, I want to reiterate that this is a grey area and it’s hard to identify when legitimate use for chronic pain turns into and problem.  It happens slowly and insidiously.

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.

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Opioid addiction and chronic pain: Long term effects

There are a number of common side effects of opiate use including feelings of euphoria, feeling spaced out and ‘high’, and drowsiness.  According to the RCOA, between 50% and 80% of patients in clinical trials experience at least one side effect from opioid therapy.

“Evidence shows that chronic opioid therapy is associated with constipation, sleep-disordered breathing, fractures, hypothalamic-pituitary-adrenal dysregulation, and overdose… Opioid-related adverse effects can cause significant declines in health-related quality of life and increased health care costs.”
A Review of Potential Adverse Effects of Long-Term Opioid Therapy: A Practitioner’s Guide

To understand the effects of long term use, you need to know that opiates work by depressing everything, including the pain, but also natural bodily functions such as breathing, blood pressure, heart rate and alertness.

Breathing

In terms of breathing, there are a number of ways that opiates affect this vital function.  They slow down your breathing, they are associated with central sleep apnea, atiaxic breathing hypoxemia and carbon dioxide retention.

Let’s bring in some definitions to help explain what these terms actually mean for the patient:

  • Central Sleep Apnea: pauses in breathing while asleep during which the body does not attempt to breathe. A certain number of pauses in sleep are normal but with CSA, the pauses are longer and more frequent and are the result of the brain not sending the right signals to the muscles related to breathing.
  • Ataxic Breathing: an irregular, uncoordinated breathing pattern.
  • Hypoxemia: Low blood oxygen which can cause low oxygen levels in your tissues.
  • Carbon Dioxide Retention: abnormally high levels of carbon dioxide in the blood.

Essentially, breathing is no longer an automatic reflex.  All of these can lead to additional health issues, for example if you aren’t getting enough oxygen there is a risk of brain damage as well as damage to other vital organs.  Deprived of oxygen over a period of time can result in organs shutting down and for some patients, their breathing is so depressed that they fail to wake when they don’t breathe.  It is this, and organ failure, that is behind many opioid overdoses and deaths.

For patients on around the clock opiates for at least six months, sleep disordered breathing issues were found to be as high as 75%, as opposed to 3-20% in the general population.  These effects appear to be related to the dose strength, with ataxic breathing observed in 92% of people taking a morphine equivalent dose of 200mg, 61% of people taking under 200mg and 5% of people not taking opioids.

We will see the effects on the brains performance when we consider the mental effects of long term use.

Gastrointestinal

Just as the breathing system is slowed down, so too is the gastrointestinal system.  The urge to pass stools reduces causing constipation and even impacted bowels.  Opiate use can also cause vomiting, cramping and bloating.

Hormones

One of the things that shocked me when I was looking into the effects of opiates was the impact on the hormonal system.

When you think hormones you tend to think sex so I’m going to start there.  Opiate use can decrease your sex drive, can cause infertility, can cause erectile dysfunction and can cause issues with menstruation.  Fatigue and hot flashes, inappropriate milk production can also occur.

Hormones are also involved in other bodily functions and can affect bone density causing osteoporosis and impaired healing.  Growth hormones, thyroid stimulating hormones and many others are also affected.

Mental

As an organ, your brain is affected and thus your mental wellbeing and functions are impaired.  Opiate use can cause confusion, lack of concentration, drowsiness, depressed alertness, depression and other mental illness.

As the person’s judgement is affected, they can make decisions that they wouldn’t otherwise.  There are impulse control issues as well as impaired insight and issues with reasoning.  Demotivation and apathy can lead to social withdrawal and the persons world can become smaller and smaller.  Moodswings, hostility, increased secrecy and a change in personality can all come about because of opioid use.

Due to the reduced oxygen levels, the brain struggles to perform even basic tasks (such as breathing) and the person can experience agitation and disorientation. Impaired memory is another common effect.

Muscular skeletal

The combination of the confusion and the bone density issues, muscular skeletal issues are common.  Impaired coordination can lead to an increased fall risk, as can dizziness and a sedative effect.  When falls occur, fractures are more likely.

Hyperalgesia

Possibly one of the most counterintuitive effects of long term opioid use is hyperalgesia, that is a heightened sensitivity to pain.  This feels like the most insidious of the effects as it likely leads to more opiate use and makes the whole situation worse…

Pain associated with hyperalgesia tends to be more diffuse than the pre-existing pain and less defined.

Other

Other effects include a reduced immune system responsive, slurred and slow speech, falling asleep mid conversation and not realising it, blackouts and forgetfulness.  Increased sensitivity to sights, sounds and emotions may also be present.  Dry mouth that can cause tooth decay is yet another possible effect as is a suppressed cough reflex.

Whilst one person is unlikely to experience all of these effects, in general the risk increases as the dose increases. Please do not let this put you off taking pain medication that you need, but monitor your use and your mental state and discuss any concerns you have with your doctor.

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.

Part one: Opioid addiction and chronic pain: Statistics

Opioid addiction and chronic pain: Statistics

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.

My thoughts on disability benefits…

I’d like to start by saying I am incredibly grateful that I live in a country which does offer welfare benefits for those of us who are ill, disabled, of retirement age and so on.

However.

You must fight a system based on fear, on penalties and on paranoia.

You must face a system where the starting point seems to be that you are guilty of fraud until you prove otherwise.

You must battle a system which seems to be designed to reduce claimants as much as possible.

You must meet a rigid timetable set by the benefits system but don’t expect them to do the same.

You must repeat yourself over and over again to different people, on different forms and don’t you dare forget to say something because that could make or break your claim.

You must provide full and detailed information, you must alert them to any changes and yet, in return, you do not get a transparent system.

You must deal with staff whose sole purpose seems to be to misunderstand you, to invalidate you, you minimise or erase your health issues and to treat you like a liar.

Don’t be foolish enough to have co-existing illnesses or disabilities.  Don’t be foolish enough to have a complex multisystemic disorder that affects you in multiple ways.  Don’t be foolish enough to have a fluctuating or unpredictable condition.  They will intentionally fail to understand.

Expect to be treated disrespectfully.  Expect to be taken to task on every little thing you do.  Expect your words to be manipulated.  Expect to argue about pedantics.

Prepare for paranoia.  Prepare to be scrutinised.  Prepare to feel judged and worthless.  Prepare for your mental health to suffer, even if you had no mental ill health previously.  Prepare to feel like you’re banging your head against a brick wall.  Prepare for a system which is devoid of common sense and compassion.  Prepare for your assessment to state that you are absolutely fine.  Prepare for an appeal to declare otherwise.  Prepare for the stress that this long, drawn out process involves.  Prepare to feel guilty on good days.  Prepare to feel paranoid if leave your home.

Do not expect to be treated humanely.  Do not expect to be treated as a human.

What is place?

Where lies your landmark, seamark or soul’s star?
– Gerard Manley Hopkins, 1886

Of course, everywhere is a place in the very traditional, dictionary definition sense, so what I am talking about here?  This month I plan to consider sense of place, placelessness, space and landscape whether that is urban or rural.  At the heart of this is the human connection with somewhere and the emotional relationship to a specific site but I shall begin by exploring a few words and phrases.

Place

Place can mean different things depending on context but the definition most relevant here is “a particular position, point, or area in space; a location.”

You’ll note here then that there is an difference between place and space with place being a part of space.  Space exists without humans to mark it or claim it or know about it, whereas place is a human filter on that space.  Milan Kundera uses the examples of highways being spaces and roads being places, roads have meaning and associations where highways tend not to.  It is imaginative possibilities, cultural histories and stories which help to turn spaces into places.  The difference between house and home might be something to lean into to try and grasp the intangible nuances here.  Similarly, we invite people back to our place, not space.

Lawrence Buell defines place as “a space that is bounded and marked as humanly meaningful through personal attachment, social relations and physiographic distinctiveness” and it is these aspects which can create a sense of place.

Sense of place

The term sense of place refers to a quality of characteristic that some places have and some do not.  It might be a feeling or perception that people have of the place rather than something inherent in the place.  It might be unique characteristics which make a place feel special and which create a sense of belonging in the human who is experiencing sense of place.  There is a sense of meaning in the place, it might be memories for example.  Sense of place, feeling intimately and personally connected to a place can foster a sense of belonging.  And it is important to note that a sense of place doesn’t always mean it is a positive experience.  Negative sense of place also exists.

Spirit of place

Spirit of place is similar but seems to be more focused on positive aspects of a place and goes beyond the personal experience to include the celebration of place in folktales and festivals.  It is a meeting of culture and the physical.  It may be created from stories, art, memories, folklore, pathways, rivers, woods, the presence of family and friends and the history of the place.

There seems to be a convention that sense of place applies to urban landscapes whereas spirit of place applies to rural spaces.  Personally, I don’t feel that we should, or can, create a hierarchy of place – if spirit or sense of place is an emotional, felt experience, then how can we distinguish between the two.  If you were to talk about a garden in a city, would that be spirit or sense?  I will probably stick mostly to sense of place for no other reason than consistency.

Local distinctiveness

Local distinctiveness is a phrase used by Common Ground to capture the “particularity in the buildings and land shapes, the brooks and birds, trees and cheeses, places of worship and pieces of literature. It is about history and nature jostling with each other, layers and fragments, old and new. The ephemeral and invisible are important too: customs, dialects, celebrations, names, recipes, spoken history, myths, legends and symbols.”

Genius Loci

Sometimes genius loci gets used synonymously with sense of place but there is a distinction.  This phrase from ancient Rome refers to the protective spirit of a place, often a guardian but in The Somnambulist by Jonathan Barnes we find a negative genius loci:

“He could feel the weight of the past pressing down upon him as he walked…He found himself recalling the notion of genius loci, that fanciful conviction that a place itself materially affects the individuals who pass through it. If this place had any tangible effect upon its inhabitants then it was surely a malign one.”

Placelessness

Implicit in the idea of sense of place or local distinctiveness is the idea that not all places possess this magic quality.  Whatever language we are using to attempt to capture this feeling or relationship, to put it in words as existing implies the lack of existence or it would be enough to call a place a place as sense of place would be tied up in the word.

Places that don’t have a sense of place are sometimes called placeless or non-places.  Gertrude Stein’s quote “there is no there there” feels like an appropriate description.  Examples of places without sense of place may include shopping centres, supermarkets, chain stores or chain restaurants.  New housing estates often feel like the lack a sense of place and even some tourist attractions have been criticised because over commercialisation has lead to the loss of sense of place in the eyes of some people.

Because sense of place is such a personal thing, I don’t think you can automatically rule out certain types of place as being without sense of place – if you have powerful emotions about a particular branch of chain of restaurants eg it was where someone proposed to you, then you may experience a sense of place there.  That said, there are certain qualities which make some places more likely to have a sense of place – local features, use of local materials in buildings, a strong local culture, historical stories and something unique about the place.

Landscape

Any discussion on place will inevitably come to landscape at some point and again the definition of landscape isn’t as easy to pin down as you might think.  Annie Proulx argues that:

Landscape is geography, archaeology, astrophysics, agronomy, agriculture, the violent character of the atmosphere, climate, black squirrels and wild oats, folded rock, bulldozers; it is jet trails and barbwire, government land, dry stream beds; it is politics, desert wildfire, introduced species, abandoned vehicles, roads, ghost towns, nuclear test grounds, swamps, a bakery shop, mine tailings, bridges, dead dogs.  Landscape is rural, urban, suburban, semirural, small town, village; it is outports and bedroom communities; it is a remote ranch.

As with sense of place, landscape goes beyond what is tangible and physically present.  There are elusive hands which touch and shape how we experience landscape.  There are the physical, geological elements, the plants and animals which live there but land is a map through time of human influences.  Traces of human history can be seen in managed forests, coppiced trees tell stories and shape the land.  Further, how we see the landscape depends on our history, on our values, our religious beliefs, our political affiliations, our professions even – a forest changes simply by being viewed by a timber mill owner.

This month I’ll be looking at how these concepts of place, sense of place, placelessness and local distinctiveness have been used by writers in novels and poetry and how these portrayals have changed.  I will also be trying to create my own alphabet of local distinctiveness and thinking very local in my own creative writing.

Winter Solstice, or Mana’s Birthday

We’re back to my house of helens, see previous posts for context:

This time it’s Mana’s birthday.  She is the materal or grandmother figure.  She is not a helen I know that well yet.  She is sort of there in the background watching and offering hugs and nudges where needed.

Today, to celebrate her, we will be lighting a candle as the longest night begins and offering her hugs and kisses.  There will be yummy tea drunk by a roaring fire.  Stories will be told.

We will thank the sun for returning and thank the darkness for the chance to reflect, to restore, to rest.  This has been a really important part of my change in perspective of winter, that is to honour the unique and vital aspects of the darker time of year rather than just berating it for existing.

Alone, myself and Mana will do a tarot reading.  One fitting to her wisdom and knowledge as well as the time of year.  It will reflect, pause and look to the coming light.

Whilst this is a post about the house of helens, I also want to make it relevant to my nature and writing project so I’m sharing some things I have found or know about winter solstice, the longest night of the year.

During the winter solstice, the north pole is as far away from the sun as it can get.  This means that at the same time the south pole is as close to the sun as it can get and the southern hemisphere celebrate the summer solstice.

The word solstice comes from Latin sol “sun” and sistere “to stand still.”

There are numerous stone monuments which are configured in such a way as to show when it is the solstice.  Whether they were built for this purpose is a matter of debate but given how important the passing of the year would have been for our ancient ancestors I think it’s a strong possibility.  If you live in a time when farming and hunting are your lifeline, it’s going to be very reassuring to know that the shortest day is here and from now on everything is going to get easier.

For the Mayans, the sun was incredibly important as it allowed them to create their complex calendars and “entire ceremonial complexes that were positioned specifically for the celebration of the solar cycle”.

Around the world, people celebrate the winter solstice. China’s Dongzhi (literally “the extreme of the winter”) Festival celebrates the winter solstice, along with the imminent return to longer days. At the ancient ruins of Stonehenge in England, thousands gather before sunrise to celebrate. In Japan, some partake in a traditional hot bath, soaking with a Japanese citrus fruit, called yuzu, to greet the winter solstice while protecting against common colds.

Futurity

Whether you mark the solstice or not, I hope you have a lovely day!

December: A pre-introduction – coping with the weather

The darkness has arrived.  It is engulfing us.  And it is crushing some of us.  Winter can be a difficult time for some of us, for our mental health and our physical health.  Winter weather can restrict and isolate us.

Before I get onto this month’s topic, I want to say a bit more about how I am currently thinking about winter this year.  In the past I have battled against it, I have set myself up to fight the winter.  This has involved SAD lamps, meal plans, cooking and freezing in bulk and late winter holidays to sunnier places.  But I was constantly on the defensive and to be honest, my success was limited.  I would still get to the end of winter having faced worse depression and increased physical pain.

Then last winter came and it was my first winter not working and so I wasn’t going out and seeing people and wasn’t feeling useful and so on.  All great things for your mental health.  In addition to that, most people I knew were working full time and I can’t go out in the rain on my own because I can’t put on my own wheelchair waterproof.  On the whole, these things are still the case.  I do now know people who don’t work which is good but I still can’t go out in the rain without help and the cold is bad for pain and the dark is bad for mental health.

Then, last Christmas, an amazing friend of mine gave me the wild unknown animal spirit deck.  And shortly after, I started my blog series, looking at each animal more closely and getting to know them.  The first card was the bear.  And it was one of a few things that really transformed my approach to winter.

Instead of battling, the bear teaches us to go with the seasons, to let the rhythms flow with us not against us.  We can embrace the urge to hibernate, as long as we balance it with more active times in the spring and summer.  I’ve already repeated a lot of the bear post in many other posts so I’m not going to talk much more about it, but I do recommend looking at it.

Along with the bear, I was also finding I was reading about the necessity of the darkness.  The need to have space and time to go within ourselves and to nurture ideas and seeds which aren’t ready to be externalised and made vulnerable.

Some of what I was reading was talking about changing the way we think of darkness.  It is not the absence of light, but something immensely valuable in itself.  Without the dark, we cannot see the moon, we cannot see the stars and we do not appreciate the light.  This is a time of rest, of restoration, of recuperation.  A necessary part of the year.

But of course, the winter can feel long and this is why we have festivals and celebrations.  December has long been considered a holy month, holding as it does the winter solstice and later the Christian Christmas as well as Hanukkah, and various other feast days.

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