Addiction: Addictive Potential of Pain Medications
Guest: Dr. Robert Mallin – Family Medicine
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I’m Dr. Linda Austin. I’m talking with Dr. Robert Mallin. We’re discussing the addictive potential and
abuse of pain medications. Dr. Mallin,
we were just talking about what constitutes addiction. When you have a patient who comes in to see
you for pain management and they’re on these medications, let’s imagine that
they’re using them appropriately, but they’re starting to request doses that
are higher than average, how do you begin to think about whether it’s
appropriate, actually, to increase the dosage?
Dr. Robert Mallin: The first thing to think about is that
tolerance always occurs with the use of these medicines. And what tolerance means is that you take the
same amount of medicine but you get less of an effect from the medication. So, we expect some amount of tolerance to
occur. The first thing I want to know,
is the amount of tolerance that the patient is experiencing average and
reasonable for the circumstances? And
once I feel comfortable that that is the case, the next thing I look for is
their progression of the underlying illness that’s causing the pain. If the patient is having worsening arthritis
or worsening cancer problems, or whatever the underlying reason that they’re on
the pain medicine for, we really need to address that in addition to the pain
medication and the dosages of that.
In some patients, and
this is particularly true of patients with addiction, their tolerance moves
very rapidly. So, whereas you may be
used to taking care of a patient in whom three of four months go by, and they
have good control of their pain, and then come in and say, you know, it’s
just not lasting long enough for me now, that seems pretty reasonable. But the patient whose pain is under control
on week one and is back to you on week three or four saying it’s completely out
of control, that really raises a red flag.
His tolerance seems to be moving much more quickly than I would want it
to. Then once I know that the disease
isn’t progressing at that same rate, I back off to see, could this be a
manifestation of addiction?
Dr. Linda Austin: And what do you say to that patient?
Dr. Robert Mallin: Well, normally what I say to that patient is
kind of what I just said to you. I try
to be very open with my patients about the addictive potential of these
medications and that we have to be on the lookout for both the possibility that
their disease is progressing and/or that another disease has reared its head,
in terms of addiction. So, I will
typically ask them more questions about their behavior and look a little harder
at how they’re managing their medication.
Dr. Linda Austin: What do you do in a situation where, let’s
say, somebody has a past history of substance abuse, such as alcoholism, you
know that they’re very vulnerable, you also know that they have a very genuine
pain syndrome, let’s say, due to an injury or something like that, how do you
Dr. Robert Mallin: Oh, this has got to be the most difficult
patient I have to deal with, and not because of anything negative on their
part. A patient, for instance, in
recovery from alcoholism who has a problem that requires pain medication really
provides us with a dilemma, because we know that addictive medications can
result in either relapse of their alcoholism or the potential of an addiction
to a new medication. And we also know
that there is no guarantee about whether that will happen or not. And even those who maintain a very vigorous
recovery program are at risk. So, I have
a very serious conversation with them about that, and to let them know that
even if they do everything right, in other words, they take their medicine
exactly as directed, do all the other things they’re supposed to do for their addiction,
there’s no guarantee that it won’t turn that switch that resulted in their
alcoholism or other drug addiction to begin with and could send them off to the
races very quickly.
So, it becomes a risk
versus benefit problem. We can do some
things to reduce the risk of that. One
of the major ones is that they don’t become the purveyors of their medication,
that somebody else in their life who understands this situation will be the
person to actually deliver their medicine to them and talk to them if they are
not getting adequate pain relief, and often come to the physician with them to
help keep that under control.
Dr. Linda Austin: This may not be an easy question to answer,
not that any of the others have been either, but with a person in that
situation, let’s say, where they begin to need more medication and they have
had a history of addiction, do you have the sense, actually, that their
tolerance to the medication, that they’re going through that much more quickly
and that their pain levels really are rising, or do you, more, have a sense
that they’re craving the physiologic high that they’re getting from the drug,
or is that just not even an answerable question?
Dr. Robert Mallin: Well, it may not be answerable, but I think
about it all the time. What’s
interesting is, at least in my experience, some patients misperceive pain
relief with euphoria. They mix that
up. The euphoria that they get from the
medication, which is very common with people who are addicted, as opposed to
people who are not addicted, who often have dysphoria with medication, they
misinterpret that euphoria with pain relief.
So, they get very confused about am I in pain or am I not in pain? And, of course, our only way to determine if
a patient is in pain is to ask them. And
when they tell us, we are stuck with, is that the case or have they
misinterpreted what’s going on with them?
So, it can be a real struggle.
And, yes, the people who are in recovery from addiction, also, their
tolerance moves much quicker than people who don’t have the disease.
Dr. Linda Austin: Dr. Mallin, thanks so much. In another podcast, we will go on and talk
about the treatment of narcotic addiction.
Dr. Robert Mallin: Thank you.
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