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.

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.