TREAT THE ADDICTION FIRST; THEN TACKLE CHRONIC PAIN

In an article that appeared in The Star on Aug. 19, I described a
fairly common situation for family doctors.

The patient on the other side of the desk claims that he is in
excruciating pain that can only be relieved by narcotics. He says
OxyCocet works but the last prescription, 100 tablets, were stolen
from his car.

In the past he has not followed instructions on the pill bottle and a
local pharmacist says he is seeing other doctors for narcotics. There
is no doubt that we are dealing with an addict here and if he is after
drugs, you can tell if he's trying to deceive you because his lips are
moving.

You can also be pretty sure that there is a trail of destruction
behind the patient. Lost jobs, failed and abandoned relationships,
estranged relatives, possibly even a criminal record. He will have a
long and woeful story about all the failed treatment for whatever is
the cause of the intolerable pain.

Normally doctors and their patients can readily agree on the kind of
treatment that is needed. Unfortunately this is not the case with
addicts and this, combined with the amount of deceit that they use
while defending their habit, can lead to tense and uncomfortable situations.

But giving in to the patient's demands will only fuel the disease he
suffers from, provide very unpleasant withdrawal symptoms, or provide
him with more narcotics to sell to his friends on the street. The pain
he complains of may be real, you just can't tell, but in any event he
would be much better off without high doses of narcotics which are
neither good nor safe for him and those around him.

He needs help, but where to start? Should the pain or the addiction be
treated first? Could they be the same thing?

Non-reveRsible chemical change

We now know that chronic pain and addiction have a lot in common.
Research shows that the brains of chronic pain sufferers and addicts
undergo the same non-reversible chemical change. Behaviour patterns
are similar too.

For example, they blame others for everything including the stress and
anguish they impose on themselves and are intolerant of anyone but
co-dependents who sympathize with their plight and are prepared to
become "enablers."

These traits conspire to obstruct the patient gaining the insight and
motivation they need to overcome their predicament.

I prefer to start by treating the addiction because then one can
obtain the stability needed to set realistic goals and begin treating
the pain.

While it is unusual to be able to eliminate chronic pain completely
with either drugs or surgery it is usually possible to employ other
professionals, psychologists, physiotherapists and occupational
therapists in a multi-disciplinary approach aimed at also achieving
greater level of daily function.

Constant preoccupation with drugs, their acquisition and the pain they
believe can be cured by chemicals only undermines progress on the
journey to recovery.

So, my advice for addicts with chronic pain is to get help for the
addiction first.

Co-dependents and those who have to live with addicts can actually
help them by not tolerating any self-destructive and sympathy of
drug-seeking behaviour. They should not hesitate to contact
organizations such as Al-Anon because they can provide the information
and support.

Until addicts decide to embark on the journey toward recovery those
around them are cast in the role of distressed spectators, so they
need help too.

There is no doubt that it would help if my medical colleagues used
more vigilance when prescribing narcotics for chronic pain. At the
first hint of drug abuse or diversion they need to be prepared to
confront the patient and change from a nurturing supportive role to
being more directive. It is normal to feel angry towards someone you
discover has been deceiving you, and doctors tend to dismiss addicts.

It would be better for the doctor if he or she became familiar with
the safeguard and constraints that can be introduced to the
prescribing and treatment for pain and addiction.

Examples of this include requiring the patient to sign a contract,
having the pharmacist dispense the drugs daily and urine drug
screening to ensure compliance. In fact, pharmacists are often our
best allies in detecting and responding to drug abuse.