Excerpts from Chapter Two of Pain Recovery by Dr. Mel Pohl

According to a 2006 study, 90 percent of all people in the US receiving treatment for pain management receive prescriptions for opioid medication. These medications carry with them a risk of dependency and addiction. For those with chronic pain who become addicted when they take opioids for pain relief, the two conditions exacerbate each other, making both worse than they would be alone. Many professionals believe the benefits of opioid treatment far outweigh the risk of developing addiction, but those who do become addicted find themselves in a conundrum: They need opioids to treat pain, but when they take them, they experience horrible consequences.

With addiction, the problem exists not so much with the drug itself, but with the way that drug works in the brain and nervous system. Some of you are destined to develop addiction because of how “well” the drug works—both physically and emotionally. You were probably wired differently from birth, and with continued exposure to a drug, particularly an opioid (whether you started taking it for pain or not), you eventually became addicted.

Some people develop tolerance and physical dependence. These phenomena occur with continued exposure to certain substances over time. With increased use of certain drugs (e.g., an opioid), the body reacts by decreasing the effect of the drug, in this case pain relief. This is tolerance. Consequently, in order to achieve pain relief, you increase the dose of the drug. This adjustment works temporarily, but eventually the need for still-increased doses will occur. Eventually, the drug seems not to work any longer, which results in using stronger, more potent drugs in an escalating upward spiral.

If you become tolerant to the drug, this indicates that your body is “normalized” in the presence of the drug. In fact, you may become so used to the drug that you need the drug to feel normal. Without it, you feel terrible. This is physical dependence. When the drug is discontinued abruptly, you will feel withdrawal—in effect, the opposite feelings that the drug caused. So if opioids cause decreased pain and some amount of calmness and well-being, then withdrawal consists of increased pain and anxiety, body aches, stomach and muscle cramps, diarrhea, nausea, vomiting, insomnia, and agitation. This outcome is one of the main reasons some of you will feel the need to continue the opioid, since, when you try to stop or even reduce the dose, you feel terrible.

So what is the solution to this awful problem? You feel that you have to take the drug to feel any level of pain relief, even though it barely works. In fact, as you’ll learn, it actually may be making the pain worse due to a phenomenon known as opioid-induced hyperalgesia. You might consider cutting down the dose of the opioid; however, that presents the immediate problem of withdrawal. In the short run, cutting down or stopping will make you feel much worse. This is because the withdrawal of the opioid from your system inevitably causes a temporary increase in symptoms, including pain. This effect makes the process of coming off opioids challenging but not impossible. You may be tempted to substitute one opioid for another, which may temporarily put off the process.

We have treated hundreds of people with pain who are tolerant to and dependent on opioids. The withdrawal process is best done under medical supervision and temporarily, you are likely to feel worse. But on the other side, when the opioids have left your system for a week or two, your pain will diminish and you will start to feel better. The discomfort of withdrawal may continue for a while, even for several months in some, but eventually your nervous system will readjust to the absence of opioids and you will return to a state of well-being that has escaped many of you for years.

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