NOT RELIEF

Looking For Immediate Solutions Can Cause Addiction To Painkillers

When it comes to chronic pain, sometimes the treatment becomes a burden of
its own. Lady Ann Lofton-Ertenberg of Winter Haven, Fla., reached that
point last year, deciding she would prefer her long-term back pain to the
hazy unreality of a medicated life.

Doctors had Ms. Lofton-Ertenberg on a regimen of the pain medications
OxyContin and Vicodin, and the anti-anxiety drug Xanax, following back
surgery last March. Feeling herself slipping toward dependence, the
middle-school guidance counselor went "cold turkey" and abruptly stopped
taking all the medications.

Ms. Lofton-Ertenberg made it through a rough two weeks. She eventually
found relief through laser surgery performed by Dr. Osman Latif, an
interventional pain-management specialist at Watson Clinic in Lakeland,
Fla., and she is now free of prescription drugs.

"I don't see how I could have lived my life on pain medication," says Ms.
Lofton-Ertenberg, 45. "And so for me I had to find a way not to be on it."

Radio talk-show host Rush Limbaugh's recent treatment at a rehabilitation
program brought new attention to the issue of prescription-drug addiction.
Mr. Limbaugh told listeners he became addicted to painkillers following
back surgery several years ago.

People with chronic pain present a dilemma for doctors: How to relieve the
symptoms without risking dependence on powerful narcotics?

Pain management is a relatively new medical specialty, and Dr. Latif says
the processes involved in pain transmission have proved much more complex
than doctors expected when the field came into existence in the 1970s.

Dr. Latif stresses the distinction between acute pain, which might last for
a month after an injury or an operation, and chronic pain, which can last
for months or years beyond any obvious cause.

He says narcotic painkillers such as OxyContin and Vicodin can treat acute
pain but are generally ineffective for chronic pain because they don't
target nerves. They merely mask symptoms rather than addressing the cause.

"Basically, in chronic pain it's a situation where there's abnormal
processing of the nervous system, so the nervous system sort of
misinterprets signals that it usually perceives as innocuous or not
painful," Dr. Latif says.

His approach involves four main weapons: anticonvulsant drugs, which "cool
off" the nervous system; antidepressants, which help block the processing
of pain impulses; injections of anti-inflammatories directly into the
affected area; and physical therapy. He doesn't absolutely rule out the use
of narcotics but prescribes them sparingly. When none of those approaches
succeed in alleviating the pain, he will sometimes opt for surgery.

Defining addiction Dr. William S. Jacobs, an assistant professor of
addiction medicine at the University of Florida, cites studies that found
addiction rates of about 10 percent among Americans (excluding alcohol and
tobacco). He says the same proportion probably holds true for people on
prescription painkillers.

Neither increased tolerance nor withdrawal problems alone indicate an
addiction, Dr. Jacobs says. He follows the definition of the American
Society of Addiction Medicine, which ties addiction to three factors:
continued use of a drug despite adverse effects, a narrowing of interests
aside from the drug and relapses or failed attempts to discontinue use.

While cautioning that patients often believe themselves to be addicted when
they really aren't, Dr. Jacobs says addiction to prescription drugs seems
to be on the rise, probably because of increased acceptance in the past 15
years of prescribing narcotics for non-cancer patients. Despite the risks,
he says patients in chronic, life-affecting pain who haven't responded to
alternative treatments deserve to be prescribed powerful opiate drugs.

Dr. Jacobs is a rarity - a pain management specialist also trained in
addiction treatment. When he realizes a patient has become addicted, he
tries to manage both the chronic pain and the addiction. He says other
pain-management doctors shouldn't discharge addicted patients but should
refer them to addiction specialists, just as an endocrinologist would
continue treating diabetes and send the patient to a cardiologist upon
discovering high blood pressure.

One strategy for blocking addiction is to avoid fast-acting drugs such as
Lortab and Percocet.

Among the newer class of timed-release painkillers, Dr. Jacobs says
OxyContin can be risky because it delivers 30 percent of its daily dosage
in the first hour.

For patients who benefit from opiates yet show signs of addiction, Dr.
Jacobs suggests such strategies as prescribing only a week's supply at a
time or giving a family member control over the pills.

"It's a difficult problem," he says. "People need to understand that
addiction is an equal-opportunity disease. Normally people think of an
opiate addict as a heroin addict living on the street. In reality in this
country, 70 percent of the people who are addicts actually have jobs."

Patients sometimes arrive at Dr. Latif's office having been on prescription
painkillers for months or years. In such cases, he might taper the patient
off the medication, perhaps halving the dose each week. The doctor is
careful to distinguish between physical dependence and psychological addiction.

"In the case of psychological dependence, that is much harder to treat and
the relapse rate is very high," Dr. Latif says.

Patient goes cold turkey Ms. Lofton-Ertenberg doesn't think she was ever
addicted to painkillers, but weaning herself from medication was far from
easy. The woman's travails began in October 2001, when she and her husband,
Richard, were hanging light fixtures in their home. Standing on a ladder,
Ms. LoftonErtenberg leaned forward and felt a burst of pain in her lower back.

Within a week, the previously active woman couldn't lift her purse.

She was diagnosed with damage to the L4 and L5 vertebrae, and as her
condition deteriorated she began using a wheelchair. She went from taking
no prescription drugs to several, for pain and sleeping problems. A spinal
operation in March 2002 brought little relief, and the drugs were taking
their toll. She suffered from nausea and blurred vision and felt mentally
sluggish.

Without consulting her doctor, she decided to stop taking the medications.
She underwent withdrawal symptoms, including severe depression, that nearly
caused her to resume the drugs, but her husband helped her make it through
the acute period of the first two weeks.

M.s Lofton-Ertenberg became a patient of Dr. Latif, who performed laser
surgery on her last December.

She says she now feels fine and takes only two Aleve pills a day.

Only after quitting cold-turkey did Ms. Lofton-Ertenberg search the
Internet and realize she could have tapered off the painkillers.

"I know my happy ending is not common," she says.

She does not listen to Mr. Limbaugh's radio show, and says she never
experienced the sort of high from OxyContin that could have led to
psychological addiction. But she does understand how others might be less
successful breaking the grip of prescription drugs.

Had her attempt failed, she says, "I would have fallen in a deep hole, and
I don't think it would have been hard to fall into it. I can see where
someone else could have . stayed in that spot in their life."

Gary White writes for The Ledger in Lakeland, Fla.

[SIDEBAR]

Addiction defined

A maladaptive pattern of substance use, leading to clinically significant
impairment or distress, as manifested by three (or more) of the following,
occurring at any time within a 12-month period:

1. Tolerance, as defined by either:

a. A need for markedly increased amounts of the substance to achieve
intoxication or effect.

b. Markedly diminished effect with continued use of the same amount of the
substance.

2. Withdrawal, as manifested by either of the following:

a. The characteristic withdrawal syndrome for the substance.

b. The same (or a closely related) substance is taken to relieve or avoid
withdrawal symptoms.

3. The substance is often taken in larger amounts or over a longer period
than was intended (loss of control).

4. There is a persistent desire or unsuccessful effort to cut downor
control substance use (loss of control).

5. A great deal of time is spent in activities necessary to obtain the
substance, use the substance, or recover from its effects (preoccupation).

6. Important social, occupational, or recreational activities are given up
or reduced because of substance use (continuation despite adverse
consequences).

7. The substance use is continued despite knowledge of having a persistent
or recurrent physical or psychological problem that is likely to have been
caused or exacerbated by the substance (adverse consequences).

Source: DSM-IV