Pain management is one of medicine's more challenging aspects. Patients with acute and chronic pain and their doctors face complex considerations, ranging from the subjectivity of pain and legal issues surrounding narcotics prescriptions to addiction and overdose. Narcotic pain medications (opiates like Oxycontin, Percocet and Vicodin) carry a great risk; according to the National Institute on Drug Abuse, opioid addiction and overdose deaths have increased 400 percent in the past 15 years.
"[In this decade], people got reintroduced to opiates because of medicine and pain treatment," says Dr. Howard Wetsman, chief medical officer at Townsend Addiction Treatment Center. "[The problem is that] opiates are not good pain medicine."
Wetsman is part of an increasingly vocal group of critics who are standing up against opiates as a preferred treat- ment for pain. According to psycho-therapist Paula Norris of Springfield Wellness Center in Springfield, Louisiana, hospitals aren't always good at handling this issue. In her work with patients who have become dependent on narcotic pain medication, she finds that hospital-established standards of care aren't designed to reduce addiction risk.
"There's some evidence that the standard of care has become: If you operate on somebody, you give them a narcotic for their pain," she says. "[If] the doctor does not prescribe, they aren't using the standard."
Doctors rely on standards to ensure conformity of care among physicians, but standardized use of narcotics for pain is interfering with case-by-case judgment calls. When opiate prescriptions are encouraged after certain procedures, doctors are reluctant to rely on non-narcotic medicine like acetaminophen or alternative therapies like acupuncture or massage.
In the long term, Norris says, narcotic medications actually interfere with the body's ability to stave off pain.
"What ultimately happens with prolonged use of pain meds [is] your body stops making endorphins and your pain threshold decreases, so the slightest amount of pain is very excruciating for you," she says.
Dr. Richard Mestayer, director of the Springfield Wellness Center, says opiates are most effective when used short-term (less than six weeks). He advises against their use for chronic pain issues and says they should not be used by patients who are predisposed to addiction.
Mestayer says it's not always possible to know about these factors in advance.
"[There are] a lot of reasons people get addicted," Mestayer says. "Maybe they have an injury and get on pain meds, and maybe for them for some reason — genetic or otherwise — a perfect storm occurs. In a year or two you're really taking a lot, and your doctors are getting nervous ... and you start taking something cheaper like heroin."
Wetsman says some of this pre-existing vulnerability has to do with naturally low levels of the neurotransmitter dopamine in the mid-brain. Dopamine affects the way the brain interprets rewards and can be lowered by genetic patterns and chronic stress. His treatment program uses both medical and social intervention to elevate dopamine to normal levels, which discourages relapses.
At Townsend, Wetsman offers ongoing chronic disease management as well as treatment for addiction to pain medication. The program centers around brain science as well as therapies like 12-step programs, cognitive behavioral therapy and dialectical behavior therapy. "We look at the biological component that most people ignore," he says.
For patients who are concerned about using pain medications, Wetsman suggests assessing quality-of-life factors to determine risk.
"For chronic pain treatments, you should see the person getting better functionally," he says. "If functioning isn't improving, there's something wrong with the care."
Most doctors agree that the best way to avoid dependence on pain medication is to avoid using it entirely. For conditions like lower back pain, which affects 80 percent of adults at some point in their lives, the National Institute of Neurological Disorders and Stroke (NINDS) reports, there are many non-narcotic treatments available, including hot and cold packs, bed rest, physical therapy and over-the-counter medications.
Be aware that hospitals may have pre-existing protocols that default to prescribing narcotics. Ask your doctor about alternative ways to manage pain, such as breathing techniques or non-addictive, non-steroidal anti-inflammatory medications like Aleve or Advil.
And if you do become dependent on a drug, seek formal treatment as soon as you can.