WHEN PAIN RELIEF BECOMES ADDICTION

When it comes to chronic pain, sometimes the treatment becomes a burden of
its own.

Lady Ann Lofton-Ertenberg of Winter Haven reached that point last year,
deciding she would prefer her long-term back pain to the hazy unreality of
a medicated life.

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

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

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

The recent announcement by radio talk-show host Rush Limbaugh of plans to
enter a rehabilitation program has brought new attention to the issue of
addiction to prescription drugs. 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 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.

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 be
appropriate for treating acute pain but are generally ineffective for
chronic pain because they don't target nerves but merely mask the symptoms
rather than addressing the cause.

"We treat in a holistic manner," Latif says, speaking for his own practice
and for the field in general. "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."

Latif's 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.

Defining Addiction

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

Neither increased tolerance nor withdrawal problems alone indicate an
addiction, 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, 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.

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, 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, 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," Jacobs 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 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," Latif says.

Patient Goes Cold Turkey

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, LoftonErtenberg leaned
forward and felt a burst of pain in her lower back.

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

She was diagnosed with damage to the L4 and L5 vertebrae, and her condition
deteriorated to the point she began using a wheelchair. She went from
taking no prescription drugs to being on several medications for pain and
sleeping problems.

A spinal operation in March 2002 brought little relief, and the drugs were
taking their toll on Lofton-Ertenberg. She suffered from nausea and blurred
vision and felt mentally sluggish.

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

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

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

It was only after her cold-turkey session that LoftonErtenberg did research
on the Internet and realized she would have been wiser to taper off the
painkillers gradually.

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

Lofton-Ertenberg is not a listener to Limbaugh's radio show, and she says
she never experienced the sort of high from OxyContin that could have led
to psychological addiction. She does, though, understand how others might
not be as successful in breaking away from 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."