Five years ago, I found myself seated on an examining table in a Bridgeport hospital, enjoying for the first time in what seemed an eternity the absence of pain. I’d been introduced that day to the gut-ripping terror of my first attack of kidney stones. And though I was grateful to learn I wasn’t about to die, I felt even better when the emergency room doctor administered a dose of morphine. In seconds I went from rending my garments to relaxing beside a placid lake.
Before she sent me home with a prescription for painkillers and the name of a good urologist, I asked the doctor what folks did for such an occurrence long ago. How were they treated? How did they ever get through such an ordeal without modern drugs? “Lots of pain” was all she said.
Suppression of pain is one of medicine’s greatest achievements. Anyone who has had a bone repaired, a kidney stone quelled or even cosmetic surgery will agree that life without pain medication would often be tortuous. So it’s the cruelest of ironies that many of those medications that deliver us from physical agony can also be the unraveling of a person.
Mother’s Little Helpers
Addiction to prescription pain relievers is rife in the United States, and the consequences are staggering. In 2010 1.9 million people were said to be dependent on or abusing their pain medication, up from 1.5 million the year before, according to the National Survey on Drug Use and Health. Although prescription pain medicine addiction makes headlines when it sends celebrities spinning out of control, it also plagues many people out of the spotlight who grapple with it behind closed doors.
With 116 million Americans suffering from chronic pain according to the Institute of Medicine, the problem of painkiller addiction isn’t going away anytime soon. “It absolutely is getting bigger and it absolutely is a national crisis,” says Dr. Sigurd Ackerman, president and medical director of Silver Hill Hospital, the New Canaan–based psychiatric and substance abuse treatment center that has designed a new residential program to treat addiction to pain medication.
That is certainly the message that the Obama administration is sending as it seeks to curb what officials are calling a “prescription drug abuse epidemic.” Included in its efforts, the administration’s Office of National Drug Control Policy wants physicians to undergo mandatory training to prescribe potent pain medications like Oxycotin, hydromorphone and others. It is also calling for prescription-drug monitoring programs, stepped-up law enforcement and public education about the dangers of prescription narcotics as well as proper disposal of such drugs.
The Centers for Disease Control and Prevention has sounded the alarm as well. In a report last fall, CDC linked the number of overdose deaths in 2008 (14,800) from opioid painkillers with a sixfold jump in prescriptions for the drugs between 1999 and 2009. Opioids are the most common treatment for long-term pain and include such frequently prescribed drugs as Vicodin and Percocet.
Though not everyone agrees that those statistics are necessarily related, no one denies the enormity of the problem. Trips to the emergency room because of misuse and abuse of pain relievers almost doubled from 2004 to 2009, says CDC. And those taking the drugs for nonmedical purposes—without a prescription or for the feeling it induces—topped 12 million in 2010.
Connecticut residents, for their part, are among the least-frequent offenders for nonmedical use of pain relievers, according to the Substance Abuse and Mental Health Services Administration. In 2009, the most recent year for which data is available, 3.79 percent of the Nutmeg State’s residents age twelve and older had used a pain reliever nonmedically in the previous year, as opposed to 4.84 percent nationally. Still, the state was close to the national average of 2.8 percent for overall illicit drug dependency or abuse.
Road to Recovery
It’s against this backdrop that Silver Hill Hospital will start accepting patients this month for its new program. The need, says Ackerman, is there. The focus will be on people suffering from chronic pain who are addicted to opioids. Pain is considered chronic when it lasts at least twelve weeks. Typically, patients receiving painkillers for acute pain usually take them for just a few days and tend not to become addicted.
The program will have several components, starting with a thorough assessment and then, depending on individual condition, moving through withdrawing the patient from the addicting medication, establishing a new low-dose regimen if need be, and teaching the individual more effective approaches to dealing with pain. Treatment will also include some form of relaxation therapy, such as yoga or mindfulness training, and physical therapy. “We’re not after pain control per se,” says Ackerman. “We’re after an improvement in their functioning and a sense of greater tolerance for whatever pain they’re left with.”
Family involvement is critical to beating addiction and will be an integral part of Silver Hill’s program. Often a spouse or other loved one unwittingly facilitates or enables addiction. “It’s not malevolent,” Ackerman says. “You feel sorry for the person, so you don’t want to push them to get off the couch, you accept the fact that they need a lot of medication and you don’t interrupt the process. Enabling is complicated. It depends how guilty you feel as a family member. That’s why they have to be part of the change that we’re after.”
Treatment programs for chronic-pain patients who abuse their pain medication are relatively rare, despite the tremendous need. Those that do exist tend to require abstinence from all opioids regardless of the severity of the pain, says Ackerman. But Silver Hill leaves open the possibility of continuing the painkillers to some degree, based on patients’ individual needs.
Silver Hill is uniquely positioned to launch the program, which requires a minimum of four weeks’ residential treatment. The 115-bed hospital already has five well-established residential programs and considerable experience treating dual-disorder patients. Depression, anxiety or any number of conditions that might accompany pain-pill addiction are issues that the staff faces virtually every day. Patient follow-up is also part and parcel of its daily work.
Opioids, which attach to receptors in the brain and elsewhere, change how one perceives pain. In the process the drugs can also produce a sense of well-being or euphoria. A patient’s pain management might be well under control, but when the narcotic’s good feeling wanes, he or she might start taking more of the drugs than necessary, trying to maintain the high, Ackerman says. That can lead to addiction. And because opioids are a sedative and slow respiration, too much can be deadly.
Addiction is not about physiological dependence, Dr. Ackerman is quick to point out. Everyone who takes opioid painkillers develops a tolerance to them, requiring higher doses to achieve the same effect, and has withdrawal symptoms when they stop.
“Addiction is a behavioral diagnosis,” he explains. “The addicted person becomes preoccupied with maintaining an adequate supply of the medication. They might doctor shop. They may do things that are illegal. They may forge prescriptions, for example. They may buy the drugs off the Internet or the street. They might get arrested for possession if they can’t document that it’s based on a prescription. But that doesn’t stop them.”
Not everyone who uses painkillers becomes addicted. Genetics plays a part, as do personality, cultural background and upbringing. Those who have other addictions—to alcohol, for example, or even cigarettes—are also at risk of becoming addicted to opioids, Ackerman says.
New Approach to Pain Management
Much of the problem can be blamed on the medical profession itself. Over the years there’s been a pendulum swing in doctors’ attitudes toward painkillers, from being overly fearful that patients will become addicted to a more permissive outlook. Today many professionals are questioning the ease with which doctors and other health care professionals prescribe painkillers to some patients.
Robert Twillman, director of policy and advocacy for the American Academy of Pain Management and a psychologist by training, tells of having surgery on his elbow a couple of years ago and coming away with nearly 125 extra painkillers. “Part of how we’ve gotten where we are today is that for the last twenty years we’ve been out there teaching doctors and others how to make use of opioids,” says Twillman, who also does advocacy work on behalf of the American Pain Foundation. “But we haven’t taught them how to use all the other tools that help relieve pain. What they know is, ‘Oh, here’s somebody who says they have pain; I’m going to write them a prescription for Vicodin.’ And that’s not always the right solution.”
That’s why one of the key goals of Silver Hill’s prescription drug addiction program is changing patients’ overall outlook in regard to pain, bringing in other answers besides medication, such as counseling, relaxation techniques, physical therapy and more. “One of the things we work toward is to have the patient accept the level of pain that they can never get rid of,” says Ackerman. “The tradeoff for that is the patient can once again have the kind of life he would like to lead. He can get up off the couch, go back to some gainful activity, and also relate to his children and his spouse better.”