People receiving the top treatment for pain—prescription painkillers—can rapidly transition from pain relief to painkiller addiction. And yet, your doctor may be the unwitting instigator of this misery, if you don’t ask the right questions from the start. The risk for addiction after receiving an opioid painkiller prescription, including generics of hydrocodone and oxycodone and common brand names like Vicodin, Percocet or OxyContin, is not something your doctor will necessarily tell you. What else isn’t he/she telling you during your brief medical consultation?
1. Opioid painkillers can be addictive, so a short course at a low dose is best.
Opioid medications affect your central nervous system and activate your brain’s opioid receptors—a process that inhibits pain signals. This same process also increases the brain’s reward signals, flooding its pleasure circuits with dopamine, a “feel-good” neurotransmitter. If the dose of your opioid medication is high (above a daily dose of 20 to 30 MME), or if you take more pain pills than prescribed, the dopamine surge in your brain may give you a sense of euphoria. This euphoria makes these painkillers powerfully addictive. The duration of the opioid pain treatment also factors into your addiction risk. Research shows that the risk for long-term opioid dependency spikes around four to five days; the Centers for Disease Control and Prevention (CDC) recommends that clinicians limit painkiller prescriptions to seven days or less and at the lowest dose that will bring relief.
How to take action:
The initial opioid prescription you receive from your doctor impacts your likelihood of becoming addicted to the medication, so make it a point to request a low-dose, short-course prescription. You should also ask about non-addictive alternative medications, like non-steroidal anti-inflammatory medications (NSAIDs) and other therapies.
2. You are more likely to get hooked on your painkillers if you have a mood disorder.
According to a 2017 study, people who suffer from chronic pain and have a co-occurring mood disorder (e.g. depression) are two times more likely to become addicted to opiate painkillers. An earlier study determined that pain patients who have co-occurring mood disorders derive less benefit from opioid painkillers, requiring a higher dose to produce the same level of pain relief other patients experience at a lower dose. Higher dose levels raise the risk of opioid addiction. An additional risk is posed by mixing opioids with any benzodiazepines you may take to manage depression or anxiety. Mixing benzos(e.g. alprazolam, diazepam or lorazepam, under brand names Xanax, Valium and Ativan) with opioids is very dangerous and can be life-threatening, especially if you drink alcohol with these medications still in your system.
How to take action:
Tell your pain management doctor if you have a co-occurring mood disorder and be sure to mention any other medications you are taking. Ask about non-medication therapies to avoid medication toxicity or overdose.
3. There are non-addictive alternatives for pain management, but insurance may not cover them.
Opioid painkillers are inexpensive and usually covered by health insurance companies or Medicare. However, safer and less addictive pain management therapies are more expensive and often not covered by insurance. For example, pain-reducing skin patches (like lidocaine or Butrans which uses a less addictive opioid called buprenorphine) are not typically covered by insurance or require special approval from a doctor. Even if you ask your doctor to write you a prescription for a less risky alternative, your insurance company may deny the request.
How to take action:
You will likely need to solicit your doctor’s help in appealing denials by your insurance company to cover the less addictive, more expensive alternatives. Your efforts may be aided by recent policies adopted by large pharmacies, (e.g. CVS and Express Scripts) to limit opioid painkiller prescriptions to seven days or less. If you require long-term treatment for chronic pain, you may get approval for an alternative.
4. Don’t hang onto leftover painkillers.
Prescription opioids, such as hydrocodone, oxycodone and fentanyl, were responsible for 53,000 drug-related deaths in the U.S. during 2016. Most alarming is that more than 50% of opioid users obtained the medication from friends and family, not from a doctor. Many opioid users report that they got the pills from a friend or relative’s medicine cabinet and a significant number of those users are teens. With more than 3 million people in the U.S. addicted to opioid painkillers, it’s important that everyone does what they can to limit access to those pills.
How to take action:
Limiting your own consumption of addictive painkillers is important, but you also want to take measures to prevent others from getting hooked on them. Those who are especially vulnerable are young people; they may assume that pills from the medicine cabinet that were prescribed by a doctor can’t be bad for you. Take measures to dispose of any leftover painkiller prescriptions properly and/or keep them out of the house. Your prescribing doctor (or dentist) may not have the time or foresight to mention that opioid painkillers are not only highly addictive, but they also are not always the best choice for pain management. Some experts argue that a holistic approach to pain management is more effective. This may involve using a combination of non-addictive medication, relaxation techniques, physical or exercise therapy, as well as alternative modality (e.g. acupuncture). The burden may be on the patient to get proactive about asking questions and finding the combination of therapies that works best. Some options you might ask your doctor about include analgesics, NSAIDs, anticonvulsant medications, certain antidepressants, local anesthetics, cognitive behavioral therapy (CBT) and hypnotherapy. Sources: “5 Must-Ask Questions When Your Doctor Prescribes Painkillers” – Dr. David Sack, MD. Psychology Today https://www.psychologytoday.com/blog/where-science-meets-the-steps/201503/5-must-ask-questions-when-your-doctor-prescribes “The dose makes the poison: Opioid overdose study supports call for caution in prescription levels” – University of Michigan Health System https://ihpi.umich.edu/news/dose-makes-poison-opioid-overdose-study-supports-call-caution-prescription-levels “Long-term use of opioids may depend on the doctor who prescribes them” – Scott Weiner, MD. Harvard Health Blog https://www.health.harvard.edu/blog/long-term-use-of-opioids-may-depend-on-the-doctor-who-prescribes-them-2017032711459?utm_source=mc&utm_medium=btc&utm_campaign=100417 “Study: Doctors from lower-ranked med schools prescribe more opioids” – Jacqueline Howard. CNN https://www.cnn.com/2017/08/08/health/opioid-prescribing-med-school-study/index.html “Chronic pain among patients with opioid use disorder: Results from electronic health records data” -NBCI PubMed.gov https://www.ncbi.nlm.nih.gov/pubmed/28476267 “The association between negative affect and opioid analgesia in patients with discogenic low back pain” – NBCI PubMed.gov https://www.ncbi.nlm.nih.gov/pubmed/16154274 “Benzodiazepines in Combination with Opioid Pain Relievers or Alcohol: Greater Risk of More Serious ED Visit Outcome” – Substance Abuse and Mental Health Services Administration (SAMHSA) https://www.samhsa.gov/data/sites/default/files/DAWN-SR192-BenzoCombos-2014/DAWN-SR192-BenzoCombos-2014.pdf “Amid Opioid Crisis, Insurers Restrict Pricey, Less Addictive Painkillers” – NY Times https://www.nytimes.com/2017/09/17/health/opioid-painkillers-insurance-companies.html “Prescription Opioid Analgesics Commonly Unused After Surgery” – JAMA Network https://jamanetwork.com/journals/jamasurgery/article-abstract/2644905