The latest example making news is war veterans suffering from pain and co-occurring post-traumatic stress disorder who are being prescribed potent opiate painkillers. Even though it’s widely known that veterans with PTSD are at high risk for drug and alcohol abuse, a recent study in the Journal of the American Medical Association shows they’re twice as likely to get prescriptions for addictive painkillers as veterans with only physical pain.
Even more concerning, vets with active substance abuse problems were four times more likely to get addictive drugs than those without mental health issues.
Vets with PTSD who are prescribed these drugs are more likely to suffer drug overdoses, self-inflicted injuries and suicides, according to the study. In addition to their addictive potential, opiate drugs can actually exacerbate certain emotional problems and only slightly reduce or even worsen pain.
Side effects, tolerance and withdrawal symptoms can compromise the drugs’ pain-relieving effects. In a 2009 study of 1,843 workers with back injuries, researchers found that only 26 percent of the patients on opioid painkillers experienced pain relief, and only 16 percent experienced improvement in physical function.
This is not to say that people should not be treated for their debilitating emotional and physical pain. Opiate painkillers can be highly effective for managing pain and studies by the American Pain Society and National Institute on Drug Abuse suggest that the majority of patients can take these medications without developing an addiction. But veterans (as well as other high-risk populations, such as chronic pain patients with a personal or family history of addiction or a co-occurring mental health disorder) need specialized care that goes beyond opiate-based drug therapy.
Unfortunately, many doctors are unprepared to help patients in pain. Surveys by the National Center on Addiction and Substance Abuse at Columbia University suggest that only 40 percent of doctors received training to identify drug abuse and addiction, and less than half received instruction in pain management. And though there are efforts underway to prevent excessive prescribing of narcotic painkillers, including additional training for medical professionals, further research about chronic pain and addiction, and enhanced tracking and record-keeping to prevent doctor-shopping, it has yet to be determined how effective any of these measures will be.
In the meantime, doctors working with patients in extreme emotional and physical pain must strike the ideal balance with treatments that will reduce pain without doing additional damage. Here are a few of the alternatives that should be considered before an opiate-based pain management regimen is put in place:
Many types of pain respond to non-opioid pain relievers, such as anti-epileptic drugs, antidepressants and anti-arrhythmic drugs, and anti-inflammatory drugs, such as aspirin, ibuprofen and acetaminophen. While all drugs carry some risk, when used as directed these medications can deliver pain relief without putting the patient at risk for addiction or serious side effects.
Pain relief is among the most popular uses of acupuncture. By correcting imbalances in the body and releasing endorphins and other pain-blocking neurotransmitters, acupuncture has been used as a complementary treatment for various pain conditions.
Stress, depression, anxiety and other issues can increase the body’s sensitivity to pain. Massage therapy, along with other stress management techniques, such as meditation, guided imagery, progressive muscle relaxation and deep breathing exercises, can help ease tension and reduce pain. Massage has proven particularly effective in treating back and neck pain.
A well-balanced diet can aid in digestion, reduce the risk of certain diseases and help the body function optimally. Exercise releases natural mood-boosters like endorphins and strengthens the muscles, which can help to prevent injury and pain. Yoga may be particularly effective in reducing tension and connecting mind, body and spirit. All diets and types of exercise are not right for everyone, which is why a health care provider should be involved in establishing each patient’s diet and fitness routine.
Biofeedback trains patients to tune into various body functions, such as heart rate, muscle tension and body temperature, and control them to achieve a desired state of balance.
The stretching and strengthening exercises used in physical therapy may help restore function and ease various types of pain.
Therapy can aid those struggling with pain as well as co-occurring disorders such as depression, anxiety, PTSD and substance abuse in developing the skills to cope with their condition and improve their outlook on life.
Emotional support can come from family and friends, as well as support groups made up of people living with chronic pain and other conditions. In addition to feeling less alone, participants may discover pain reduction techniques that have worked for others.
Other alternative approaches that have been used to treat pain and related conditions are energy-based techniques, such as therapeutic touch and reiki, chiropractic care, hypnosis, dietary supplements and herbal remedies.
In some cases, opioids may still be required to control the patient’s pain. To reduce the risk of addiction, the patient must work closely with their physician and other treatment providers to follow a structured plan that sets clear boundaries and requires careful monitoring.
No patient benefits from undertreated pain. In fact, studies show that prolonged, untreated pain can lead to reduced function, depression, psychological problems and substance abuse. As doctors, we are called upon to find the delicate balance that allows us to prevent prescription drug abuse while ensuring adequate access to painkillers for patients in need. This is no easy task, but we can more closely strike this balance by learning about the signs and risk factors for addiction, communicating with our patients, and utilizing drug alternatives.
David Sack, M.D. is board certified in addiction medicine and addiction psychiatry. As CEO of Elements Behavioral Health he oversees drug rehab and addiction treatment programs throughout the United States.
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Last reviewed: 2 May 2012