Controlling pain and guarding against addiction

Pain arrived for another too-long visit recently, so I called on my palliative care doctor to get relief. Pain has been an exhausting, debilitating aspect of my cancer, affecting me primarily in my ribcage, on the right side. This is the site where my stage 4 lung cancer first was diagnosed. If it weren’t for the pain I felt in my ribs I never would have known I had cancer, and it’s still my only symptom.  

I went to see Dr. Eytan Szmuilowicz, the director of Palliative Medicine at Northwestern Memorial Hospital in Chicago. He specializes in managing pain for seriously ill patients, a specialty called palliative care which is one of the fastest-growing areas in medicine. I told him I couldn’t put up with the pain and asked for more, stronger, drugs.

It is so comforting to have a doctor who is focused on me and my pain, and not have to deal with doctors worried about drawing scrutiny for being perceived as over-prescribing powerful narcotics. 

It’s not that I don’t understand doctors’ predicament. Indeed, the government is watching them closely. The U.S. Centers for Disease Control and Prevention (CDC) has warned about the rising incidence of overdoses from prescription drugs and declared that health care providers “follow science-based guidelines for safe and effective prescribing of painkillers.” 

Overdoses from prescription painkillers killed more than 15,500 people in the United States in 2009 (the latest year for which data are available), and deaths have more than tripled over the past two decades, according the CDC’s website. Nearly one-third of those overdoses were due to methadone, one of the painkillers I’m taking. And my doctor just boosted my dose.

The increase in overdose deaths parallels a sharp rise in sales of prescription painkillers, the CDC says. The agency says it is “tracking trends in prescribing rates and daily doses, studying differences from state to state, and identifying patterns of improper prescribing behaviors. Identifying health care providers who prescribe painkillers inappropriately could reduce overdoses and misuse.”

When I ask him about it, Dr. Szmuilowicz says without hesitation that he has no concerns that I will abuse or become addicted to the drugs he is prescribing me. Instead, he is immediately sympathetic to my plight and works diligently to adjust my regimen.

I was a bit surprised by how readily he agreed to prescribe more drugs for me. My previous experience before I was a cancer patient was that doctors were unwilling to prescribe highly addictive drugs — but they weren’t palliative care doctors.

My main problem with the painkillers I’m taking is that they make me sleepy. I can fall asleep in the middle of a conversation, or a movie, especially if I’m at all bored. The doctor suggests weaning me off of the long-acting morphine and increase the dose of methadone and increase the dose of short-acting morphine, and add acetaminophen (Tylenol). If this doesn’t work, we’ll adjust, he says.

I agree to this latest plan. I admit that I’m not really worried about becoming addicted to painkillers; I’m far more afraid of unremitting pain. I realize that these are two bad choices and that addiction wouldn’t be any fun either. But at least I’d be zonked enough to not know I was addicted, or care. I also confess to Dr. Szmuilowicz that I mostly want to talk with him about this subject for a blog post. He smiles.

So maybe you’re not worried about me becoming addicted, I say, but don’t you see at least some of your patients abusing these drugs? And do your patients ever ask you about the risks of getting addicted when you suggest a new or stronger painkiller? 

He nods, telling me that more than half of his patients have expressed concerns about becoming addicted. Yet only a small percentage — somewhere in the low single digits — ever have any real problems, he says.

“It’s important that patients be open with their doctors,” he says, confirming for me once again the importance of a close patient-physician relationship. Then he adds, “I would hate for somebody not to get the treatment they need because of these concerns.”

Palliative care has managed to shed some of the stigmas attached to it: that doctors drug patients to ignore them, and patients just want to load up on pain prescriptions.   

Though it is rare for cancer patients to become addicted to pain medication, Dr. Szmuilowicz says he looks out for signs. This is especially true if the patient has a history of drug addiction, or has family members with addiction issues. But, he adds, addiction is not always easy to spot.

Dr. Steven Passik, Director of Clinical Addiction Research and Education at Millennium Laboratories, a pharmacogenetics company that analyzes how a person’s genetic makeup affects their reaction to drugs, notes that 85 percent of all addiction cases are apparent by age 35. 

“Drug exposure alone is not sufficient to create addiction, especially in people over 35,” Passik says, noting that cancer tends to strike people older than 50.

He says it is important to understand what addiction really is, and how it differs from physical dependence. 

Passik listed what he terms the four “C’s” of addiction:

A drug is being used Compulsively, the person has Cravings or is out of Control and the person Continues to use the drug despite its obvious harm. By contrast, physical dependence is apparent if a person gets sick after missing a dose or if higher doses are needed over time to control pain. 

Frankly, I’m completely indifferent to which category I might be put into.  I’m probably not an addict given my age. I don’t think any of the four C’s apply to me. However, I do feel I have a physical dependence on the drugs I’m taking. I haven’t been sick after missing a dose because I rarely miss a dose — not with round-the-clock pain! And I do need more of the drugs to control the pain because I’ve developed a tolerance to them.

Given that I keep taking more painkillers, the number of accidental overdoses does frighten me. Because I don’t want to end up in that category.

This post originally ran in "Cancer In Context" and has been run with permission from Thompson Reuters.

Image by Purple Penning via Flickr