Narcotic Treatment of Chronic Pain

Posted on Wednesday, July 21, 2010
By Stephen Daniels, MD

Should you or your relative take narcotics for your chronic pain? Should you be worried if you or someone you love takes narcotics regularly? Is your loved one that takes prescription narcotics addicted, or just treating his or her pain?

These are important and difficult questions.

There have been widespread reports of Oxycontin abuse, and numerous celebrities have entered rehabilitation to treat their addictions to Vicodin.

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), prescriptions drug abuse increased 400% from 1998 to 2008. And almost 14% of 18-25 year olds admitted to abusing prescription drugs in 2008, compared to 1.5% in 1998.

On the other hand, the incidence of chronic pain is increasing as our life expectancy increases, and many studies show that patients report inadequate pain relief from their doctors.

In addition to Vicodin and Oxycontin, prescription narcotics include codeine (often in cough syrup), Norco, Lortab, Kadian, morphine, and methadone.

First some definitions: "Addiction" means compulsive use of a drug to "get high" and in a way that is detrimental to the user's life. "Habituation" and "dependency" describe drug use that is difficult to stop, usually because stopping will cause unpleasant withdrawal symptoms.

Virtually everyone who takes narcotics daily for 3 or more months (the definition of chronic) will become habituated. But only a small percentage will become addicted.

Recently a 25-year old man came to me requesting high doses of methadone for his chronic low back pain. He'd had back surgery, and had been prescribed narcotics for over three years.

This was worrisome. Although methadone (a long-acting narcotic, also used to "treat" heroin addiction) is an excellent pain reliever, it also has serious potential heart, respiratory and kidney side effects, and can lead to drug addiction.

Most important were the man's condition and age. Since back surgery had not eliminated his pain, he will likely need painkillers for the rest of his life. And since narcotic pain killers tend to gradually become less effective with chronic use, their doses (and side effects) will likely increase as he ages.

And, this young man did have a history to "recreational" methamphetamine use, making him at higher risk of narcotic addiction.

So, what should you do and what should you be worried about if chronic pain and narcotic use affects you or a loved one?

Use the least potent narcotic that works. From weakest to strongest: codeine, Vicodin, morphine, Percocet, Oxycontin, oxymorphone, methadone, Fentanyl.
In some situations, long-acting narcotics (methadone, oxycontin, sustained release morphine) are less addicting than short-acting narcotics (Vicodin, Percocet).
Take just enough to relieve the pain. Sometimes taking other types of pain relievers (e.g., Motrin, Ultram & others) with the narcotic can minimize side effects and avoid increasing narcotic doses.
Always get your narcotic prescriptions from the same doctor and the same pharmacy. Avoid the ER for refills.
If a loved one taking prescription narcotics has a history of street or illegal drug use, has slurred speech, seems unusually sleepy, or seems withdrawn or confused, call his or her doctor.
Guard narcotics carefully. Don't tempt relatives or the cleaning lady. And don't make your doctor suspicious of addiction by asking for extra because they "disappeared."

Dr. Daniels practiced family medicine at the Concord and Pittsburg Health Centers, affiliated with Contra Costa Health Services, the county health department.