Narcotic Addiction: Addictive Potential of Pain Medications

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Narcotic 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 proceed then?


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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