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Pain and addiction

Baltimore Sun
Thanks for joining us April 20 for a discussion with Dr. Paul Christo of Johns Hopkins about pain treatments and addiction. Many patients have expressed concerns during our previous live chats about the possibility of becoming addicted to their prescribed medication.

Christo is director of the Multidisciplinary Pain Fellowship Training Program at Johns Hopkins University School of Medicine. He also has a radio talk show Saturday nights on WBAL.

Read the transcript of the chat below.

Note: Comments made here are for informational purposes only and do not represent or substitute as medical advice. Patients are advised to consult their own physician or pharmacist for advice, diagnosis and treatment.

Learn about other pain topics in Pain: Time to Take Charge.

 Health chat: Pain and addiction(04/20/2011) 
11:31
Baltimore Sun Health: 
Hi, Dr. Paul Christo will be joining us at noon, but feel free to add your questions and comments to the queue now and we'll start addressing them in about a half hour.
Wednesday April 20, 2011 11:31 Baltimore Sun Health
12:00
Baltimore Sun Health: 
Welcome to our live chat on pain and prescription drug addiction. Dr. Paul Christo, pain specialist from Johns Hopkins is back with us to take your questions. We'll get to as many as we can. So don't be shy and ask away.
Wednesday April 20, 2011 12:00 Baltimore Sun Health
12:00
dr.christo: 
Hello,
I look forward to your questions.
Wednesday April 20, 2011 12:00 dr.christo
12:00
Baltimore Sun Health: 
It's a timely topic now given that the Maryland General Assembly has passed a bill establishing a prescription drug monitoring program for the state. Also on Tuesday, the Obama administration has launched a campaign to reduce prescription drug abuse. You can read about these iniatives http://www.baltimoresun.com/health/bs-hs-prescription-drugs-20110330,0,1122265.story and http://www.voanews.com/english/news/usa/Obama-Administration-Says-Prescription-Drug-Abuse-Fastest-Growing-Drug-120270059.html
Wednesday April 20, 2011 12:00 Baltimore Sun Health
12:01
Baltimore Sun Health: 
Dr. Christo, we've gotten some comments during our previous pain chats from patients concerned about the addictive nature of some of the medications prescribed to help alleviate their pain. In your practice, do a lot your patients express some of these concerns as well?
Wednesday April 20, 2011 12:01 Baltimore Sun Health
12:07
dr.christo: 
Most of the concern centers on the risk of using opioids. We have two competing forces right now. One is the major undertreatment of pain, and the other is a rise in non-medical use of prescription medications (opioids mainly). Patients do express a concern over the risk of addiction and I tell them that the risk ranges from 3-40% or so and depends on their age, previous history of addiction, and family history of addiction among other things. We trial the medication (opioid) to determine if it's right for that person. We also do things like urine monitoring, opioid agreements, and pill counts to do our best to ensure that patients are taking the medications safely and properly.
Wednesday April 20, 2011 12:07 dr.christo
12:09
Baltimore Sun Health: 
What do you tell them? How can they manage their medications in a way to avoid addiction?
Wednesday April 20, 2011 12:09 Baltimore Sun Health
12:14
dr.christo: 
I ask all of my patients to be honest with me. The physician-patient relationship needs to be one of trust, so that the patient using opioids feels comfortable approaching me with signs of trouble. I tell them to let me know if they want to stop using the medication because of side effects or lack of benefit. If they feel that they're loosing control over use, they should let me know or have family or friends let them know and me. The goal from my perspective is not to discharge the patient if problems arise; rather, I may discontinue use of the opioid and try other medications, nerve blocks, mind/body therapies. Sometimes, patients don't want to try other things, so they tend to look for the medication elsewhere.
Wednesday April 20, 2011 12:14 dr.christo
12:14
[Comment From go yardgo yard: ] 
for chronic pain, how long can someone stay on an opiod? can people stay on percocet for years?
Wednesday April 20, 2011 12:14 go yard
12:17
dr.christo: 
Go Yard,
The idea is to remain of the opioid as long as the patient and doctor feel that goals of therapy are being met, side effects are minimal, and that signs of misuse, abuse, addiction don't appear. There are emerging side effects to consider for long term use: increased pain, breathing changes at night, and decreased levels of testosterone and estrogen. We're more aware of these potential problems now and ask patients if they occur. It may be necessary to reduce the opioid dose, or even stop use.
Wednesday April 20, 2011 12:17 dr.christo
12:18
[Comment From go yardgo yard: ] 
what comprises an opioid agreement?
Wednesday April 20, 2011 12:18 go yard
12:24
dr.christo: 
Go Yard,
It consists of understanding the risks of therapy (addiction, constipation, nausea, vomiting, fatigue, endocrine changes, etc), goals of therapy (continued employment, part time employment, etc), things that may prompt the prescriber to discontinue use-also known as consequences (showing up early for refills, forging prescriptions, reports of lost or stolen prescriptions, etc). Got to the American Academy of Pain Medicine website (www.aapainmanage.org) for an example.
Wednesday April 20, 2011 12:24 dr.christo
12:25
Baltimore Sun Health: 
For further reading, here is a paper from the American Academy of Pain Management on the subject of opiod agreements. http://www.aapainmanage.org/literature/Articles/OpioidAgreements.pdf
Wednesday April 20, 2011 12:25 Baltimore Sun Health
12:25
[Comment From LaurenLauren: ] 
Do people with a history of narcotic addiction have a risk of relapse after having a surgery that uses narcotics in the anesthesia? What should recovering addicts that need surgery do to prevent this from causing a relapse?
Wednesday April 20, 2011 12:25 Lauren
12:28
dr.christo: 
Lauren,
To my knowledge, the risk of relapse from opioids (narcotics) that are used during surgery is very low. Just let the surgeon know of the history of addiction because there will be risk associated with the use of opioids for pain after the surgery (percocet, lortab, etc). Get a sponsor involved and be honest with the doctors involved to help prevent any relapse from using opioids after the surgery.
Wednesday April 20, 2011 12:28 dr.christo
12:30
[Comment From JazzJazz: ] 
what type of treatments are effective in helping people who've been using lose doses of pain med? Is it a detox process cold or is there an offboarding process?
Wednesday April 20, 2011 12:30 Jazz
12:33
dr.christo: 
Jazz,
Low doses generally don't require detoxification. Patients may have minor withdrawal symptoms that don't last very long from stopping low doses. Otherwise, the dose is gradually reduced over a couple or more weeks to help reduce withdrawal symptoms, and a clonidine patch can be used to reduce certain specific withdrawal side effects.
Wednesday April 20, 2011 12:33 dr.christo
12:34
[Comment From spinalsurgeryx2spinalsurgeryx2: ] 
Medical Marijuana is legal in some states. (legal here in MI) I am allergic to codeine so most strong painkiller are out for me. What is your opinion on medical Marijuana for pain. (I'm considering trying this alternative for chronic arthritis in my spine.)
Wednesday April 20, 2011 12:34 spinalsurgeryx2
12:47
dr.christo: 
Spinal Surgeryx2,
This is a controversial area. It's illegal at the Federal level, but legal for medical purposes in certain states.

For pain treatment, there have been a large number of recent studies showing that THC/CBD (active components in marijuana) in an oral spray are effective in treating neuropathic pain, especially in patients suffering from multiple sclerosis. Arthritis isn't considered neuropathic, though. Some other recent studies have shown that smoked marijuana is effective for pain of HIV and neuropathic pain. Other studies on chronic pain have shown that THC is effective for pain in patients with musculoskeletal disorders (?arthritis), fibromyalgia, spinal cord injury and other pain conditions. There is growing interest in the use of marijuana for suppressing pain conditions. The key is the development of forms that are really effective in alleviating pain while having the fewest side effects. I would be aware of potential side effects of long term use: impaired thinking, shortened memory, confusion, altered perception of time. Make sure you follow up with the physician recommending it.
Wednesday April 20, 2011 12:47 dr.christo
12:47
[Comment From wonderingwondering: ] 
I take 15 milligrams of percocet daily for over three years,I see my same doctor every two months ,having no side effects ,am I an addict? She says that compared to the amount of over the counter drug I would have to take it could destroy my liver .I don't drink and have never felt the need to increase dosage.
Wednesday April 20, 2011 12:47 wondering
12:53
dr.christo: 
Wondering,
Make sure you understand the term addiction because it is often misunderstood.

Definition of addiction: primary, chronic, neurobiological disorder with genetic, psychosocial, environmental factors influencing the development and manifestations. It is characterized by behaviors that include one or more of the following:Impaired control over drug use, compulsive use, continued use despite harm, and craving.

It doesn't sound like you're describing these behaviors at all. The opioid in percocet (oxycodone) should not cause liver damage. The other part of percocet (acetaminophen) can cause liver damage if taken in large quantities (greater than 4,000 mg per day). Just be ware of the dose you're taking.
Wednesday April 20, 2011 12:53 dr.christo
12:54
[Comment From mikemike: ] 
what about tremadol is it addictive. and will itstop you from getting your wife pregnant cause i take those and we are trying to have a kid?
Wednesday April 20, 2011 12:54 mike
12:56
[Comment From go yardgo yard: ] 
thank you for the definition of addiction! that is so helpful to keep in mind.
Wednesday April 20, 2011 12:56 go yard
1:00
dr.christo: 
Mike,
Tramadol has pretty low risk of abuse or addiction. This is why it's not a controlled substance (monitored by the DEA) like oxycodone, morphine, methadone, for example. I'm not aware of male fertility problems with tramadol, but we typically ask pregnant woman to avoid using it, if possible because it's categorized as Category C (animal studies show adverse fetal effects, but no controlled human studies are available). It often comes down to weighing risks versus benefits in those who really need the medication for pain control.
Wednesday April 20, 2011 1:00 dr.christo
1:01
[Comment From BernieBernie: ] 
I was perscribed roxicodone after my first back surgery ( triple lamonectomy and discectomy) and now awaiting my second surgery ( 3 level fusion). Though this medication is takin helping me I am wondering how rough it is going to be to get me off of this leter?
Wednesday April 20, 2011 1:01 Bernie
1:04
dr.christo: 
Bernie,
Getting off of it just relates to reducing the dose gradually to avoid significant withdrawal symptoms. The higher the dose, the longer it will take. A drug called clonidine can be used to reduce symptoms of withdrawal as well.
Wednesday April 20, 2011 1:04 dr.christo
1:04
Baltimore Sun Health: 
Thanks for all of your great questions today. That's all the time we have. We also have a collection of articles from health journalists on a variety of pain topics here: http://www.baltimoresun.com/health/hk-pain-gallery,0,7737765.storygallery
Wednesday April 20, 2011 1:04 Baltimore Sun Health
1:04
dr.christo: 
Thank you for your questions. I hope it was helpful.
Wednesday April 20, 2011 1:04 dr.christo
1:04
 

 
 
 

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