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Addiction and Pain Management

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Four years ago, Peter Grinspoon, MD, slipped on ice and tore a tendon in his left thigh so badly that he needed surgery to reattach it. He was sent home with a prescription for the opioid oxycodone to relieve his pain. Yet Grinspoon hesitated to fill it, for good reason: He had become addicted to the painkiller over a decade earlier and had spent 13 years determined to avoid opioids at all cost.

But now, he felt like he had no choice: “If I took an over-the-counter pain reliever like Tylenol or Motrin, it would be like going after Godzilla with a Nerf gun: pretty pointless,” says Grinspoon, an internist at Massachusetts General Hospital in Boston. “Ultimately, my nerve receptors made the decision for me: My leg hurt so much, it felt like it was burning off.”

Luckily, Grinspoon was able to take the oxycodone without any issues. He had his wife hold onto the pills and manage his doses so he wouldn’t take more than prescribed. He was pleasantly surprised to find that he didn’t have any urges, and he was able to easily stop taking the drugs once the pain eased.

Yet it remains an issue, he says, for the 20 million Americans who have or have had a substance use disorder (SUD), whether it’s with alcohol, marijuana, or prescription drugs such as opioids. “Patients are afraid to tell their physicians about a past or current addiction because they are afraid their pain won’t be treated,” Grinspoon explains. “There’s still a lot of stigma associated with SUD, even among medical providers. But people who struggle with addiction still deserve proper pain control, and they can get it, as long as certain precautions are followed.”

Addiction and Your Brain

Certain things like alcohol and drugs boost a chemical called dopamine that triggers the reward center of your brain, explains Robert Bolash, MD, a pain management specialist at the Cleveland Clinic. For some people, these feelings are so powerful that they want to experience them again and again.

“Medications like opioids turn on that exact same circuit, so if you’ve had any sort of previous addiction, you’re at greater risk of relapse,” Bolash says. The risk is highest if, like Grinspoon, you had been addicted to the same medication. But you’re still vulnerable if you have any current or past addiction.

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The risk is probably highest during the first 6 to 12 months post-recovery, but “if you’ve ever been addicted, it’s important to recognize that it still could happen at any time,” Bolash says.

If that’s the case, you need to:

Be up-front with your doctor. If you need pain medication but have a history of addiction, be clear with your health care providers. “A lot of patients hold back because they worry about stigma, but the reality is, a quality provider won’t judge them and won’t withhold medications from them,” Grinspoon says. Instead, they’ll work with you to set up a treatment plan that meets your needs.

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Explore non-opioid medications. Other drugs have less potential for addiction if you’re in pain. These include:

  • Over-the-counter acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs). These are often used together for mild to moderate pain, Bolash says. You alternate one or the other every several hours. The medicines work in harmony: Acetaminophen is a general pain reliever, and the NSAID fights inflammation.
  • COX-2 inhibitors. These prescription medications are stronger forms of NSAIDs. They block a specific enzyme, COX-2, that’s responsible for making prostaglandins, chemicals that trigger inflammation or pain. Usually, you alternate a COX-2 inhibitor with acetaminophen, Bolash says.
  • Nerve pain medications. Drugs such as gabapentin (Neurontin) or pregabalin (Lyrica) can help calm neuropathic, or nerve-related, pain.
  • Peripheral nerve block. This is a type of anesthesia that’s injected near a bundle of nerves to block pain sensations from a specific area of your body. It’s can be used to treat pain from fractures or even during some surgeries.

Consider cannabis. If you have chronic pain, then medical marijuana, or cannabis, may be a safer option, Grinspoon says. Research has found that opiate prescriptions are lower in states that have medical marijuana laws. “Opiates and cannabinoids — the active molecules in marijuana — have similar mechanisms to relieve pain,” he explains. “But it’s much safer than opioids because it’s impossible to overdose on and is much less addictive.”

What to Do If You Need to Take Opioids

In some cases, it may be hard to avoid opioids: for example, after recovery from major surgery such as a joint replacement. But there are safeguards you can put in place, Grinspoon says:

Create a pain plan. This should be in place even before you have surgery, Bolash says. One Cleveland Clinic study found that people who took a dose of three drugs before surgery (acetaminophen, gabapentin, and the NSAID celecoxib), along with anesthesia with ketamine and a nerve block during surgery, were much less likely to need opioids afterward. “It may help prevent the cascade of pain-causing chemicals that comes from your central nervous system after surgery,” Bolash says.

Find a partner. This is a family member, a friend, or someone else who has recovered from addiction who you can check in with several times a day while you take your opioid medication. “This way, if you start to slip at all — for example, you start to notice cravings — they can help you stay on track,” Bolash says.

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You should also have someone else dole out your pain pills so you can avoid the temptation to take more than prescribed, Grinspoon adds.

Get rid of leftover pills. Over 60% of Americans who are prescribed opioids and don’t take them all keep the extras around, according to one study. But if you have them in your medicine cabinet, you’re more likely to be tempted to take them, Grinspoon says. The best way to get rid of them safely is through local “take back” programs, which are usually found in police stations, DEA collection sites, or pharmacies.

The good news is that if you have a history of addiction, there are ways to manage your pain safely — even if you need to take opioids. “I was very reassured that I didn’t run into any issues when I had to take oxycodone for my pain,” Grinspoon says. “I didn’t experience any cravings or feel high. Taking two pills is very different from snorting 10, which is what I used to do when I was addicted.

“Recovery and pain control don’t have to be mutually exclusive.”

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