Addiction to opiates is very common and occurs easily.
Many people think that addiction is common because they
mistakenly believe that persons who go through withdrawal if their drug
is stopped are addicted. In fact, a person who experiences withdrawal is
physically dependent; physical dependence is a normal response to
sustained opiate therapy and is not important to a patient as long as the
drug is not stopped suddenly.
Addiction is a disease, which is defined by craving,
loss of control over the drug, compulsive use of the drug, and continued
use of the drug despite harm to the user or others. Opiates are among
the drugs that can become problems for people with the disease of
addiction; others include nicotine, alcohol, cocaine, and stimulants.
Fortunately, the capacity to develop addiction does not appear to be
very common; for example, most people drink alcohol but only a small
minority develop problems.
Most patients with pain severe enough to need an opioid
have no history of addiction to any drug; their risk of developing
addiction to the opioid is very, very small. If a person has a history
of drug abuse, however, the risk is probably higher. These persons
should still receive an opioid if it is clinically indicated, but
treatment must be watched carefully. All patients should understand that
the risk of addiction can never be said to be zero, but in most cases,
the risk is small and careful monitoring of drug treatment by a doctor
makes it very unlikely.
Pain medication can and should only be prescribed to a
patient when pain occurs.
A patient with continuous or frequently recurring pain
should be given pain medication around the clock, preferably a
long-acting drug. It is far easier to prevent pain than to deal with it
after it occurs. "As needed" dosing should only be considered
in some patients. For example, patients with repeated episodes of acute
pain may be given a drug to take just when the pain occurs and some
patients who are given a pain medication around the clock are also given
a short acting drug that can be taken when an acute pain (a so-called
"breakthrough pain") occurs.
Uncontrolled pain is an unavoidable part of many
serious illnesses like cancer.
Pain does not need to be an inevitable part of most
serious illnesses. Cancer pain and pain associated with other serious
illnesses usually can be controlled with medications and other
The side effects of opiates prevent a person from
functioning and can cause more suffering than the pain.
The truth is that if the dose of the medication is
carefully adjusted, and the side effects are treated, most patients have
a much better quality of life. The overall effect of treatment with
these drugs is very favorable in most cases.
As a patient's pain increases, the illness must be
getting worse and death must be near.
Although it is true that pain can be a signal of
disease, and the doctor should assess new pains or pains that are
worsening, it is also true that pain comes and goes for different
reasons. Worsening pain doesn't necessarily mean advancing disease.
If end of life is near, morphine or other opiates can't
be increased without causing death.
Many people make an unfortunate connection between the
use of morphine and imminent death. Remember, physicians use morphine
and other opiates to relieve pain. These drugs can be used safely when a
patient has a serious medical illness, and even at the very end of life.
It is a myth that the only way to stop the pain associated with cancer
or other serious illness is to give the patient a lethal dose of these
medicines. Almost always, doses can be increased with little risk of
serious harm. The reason to increase the dose is to relieve worsening
pain; pain relief is often the most important concern at the end of
Enduring pain builds strength and character.
Many patients think that if they "tough it out”
this time it won't be as bad next time. That doesn't work. The opposite
is true. Pain weakens a person. It weakens the immune system. It does
not build character. Pain should be treated immediately and effectively.
Doctors face a choice between treating a disease and
treating the pain.
Some people believe there is a choice between treating a
disease and treating the pain caused by the disease. This is not true.
Pain should be treated at all times, whether or not the disease can be
treated. Some people mistakenly believe that if they're given a lot of
pain medication, their doctors have "given up on them." The
better way of thinking about it is this: If you treat the pain, the body
doesn't have to concentrate on battling it. There is some evidence that
treating pain relieves stress on the body, so the body heals faster.
Patients need ever increasing doses of opiates because
tolerance develops rapidly to these drugs.
Tolerance means the loss of drug effect over time.
Tolerance to opioid medications is a complex phenomenon. It usually does
occur to side effects, such as nausea and sleepiness, and is a favorable
occurrence. Tolerance to pain relief might become a problem, but does
not appear to be an inevitable consequence of chronic opioid therapy. In
fact, most patients stabilize on a dose for a long time. If more pain
medication is needed, it usually is because the painful problem has
worsened. In this case, pain control usually can be regained, the dose
of drug can be increased or a patient can be switched to another opioid.
Edited by Russell Portenoy, M.D.,
Chairman, Department of Pain Medicine and Palliative Care, Beth Israel
Medical Center, and June L. Dahl, Ph.D., Professor of Pharmacology at
the University of Wisconsin-Madison, and Director of the Resource Center
for the State Cancer Pain Initiatives. The myths document was prepared
and edited on behalf of The Mayday Fund, a New York-based family
foundation dedicated to alleviating the incidence, degree and
consequence of human physical pain.