What Increases the Risk of Abuse?

According to rough estimates, between 3%-16% of people who suffer from chronic pain and are treated with long-term opioid narcotics have a prescription drug addiction, says Miotto. But what increases the risk?

According to Zacny, we still don't have a perfect way of knowing. "The studies just haven't been done," he says. However, most people agree that a recent history of any substance abuse may increase the danger.

Other possible risk factors for prescription drug addiction include any personal or family history of substance abuse, as well as recent emotional or psychiatric problems. "If you're in a high-risk group, if you or a family member has had a past history of addiction, or you're coping with a great deal of stress, you and your doctor may need to be especially vigilant," says Miotto.

Miotto says she worries less about people who are simply taking too much of the painkiller than those who use the painkiller along with other drugs, such as sleeping pills or muscle relaxants. "It's the people who are mixing drugs that I find are often at highest risk of problematic use and side effects," she tells WebMD.

There's also a widely held belief that people who are in pain are less likely to experience euphoric effects from a drug. The idea is that the medication is targeted -- it "goes to the pain" only and doesn't cause other euphoric effects, meaning that people with real pain are less likely to become addicted than people who don't.

"That's lore, sad to say," Zacny says. "It may very well be true, but it hasn't been really established. There's just a lot we don't know."

Although certain opioid drugs are often viewed as more addictive than others, there's very little evidence one way or another, Zacny says. Still, many think that the narcotics that don't last very long -- such as quick-release oxycodone or Vicodin -- may pose a somewhat higher risk of causing addiction. For opiods that last only a few hours, the pain will return. Over time, repeated medication can lead to a tolerance to these drugs. When tolerance develops, higher doses will be needed to get the same effective pain relief.

The risks of prescription drug addiction also depend on how you react to the drug. People who become addicted to prescription painkillers clearly experience a high, but most people find that the drug makes them feel unwell or nauseated. Other frequent side effects include mild dizziness, sedation, and confusion. According to some of Zacny's research, the majority of people who try the drug don't like the effects and would rather not take it again. So the risks of addiction may be higher in those who, for physiological reasons not understood, have a more positive reaction to the drug's effects.

The Effects of Addiction

For the relatively small number of people who do develop a prescription drug addiction, the effects can be devastating. Miotto says addiction often sneaks up on people.

"Often, you just start to call in prescriptions early, or take your spouse's medication, or take the medication when you're not really in pain, but when you're tired or depressed," says Miotto. "These behaviors can creep up on people slowly and then, all of a sudden, they have a physical dependency."

The problem is that the people who have a prescription drug addiction don't realize it. "Addiction is a disease of denial," Miotto says. It also pushes people to horrible extremes. Miotto knows one patient who eventually admitted that she pushed for surgery solely because she wanted the narcotic painkillers she knew she'd get afterward.

For many people, prescription drug addiction can cause a deep sense of shame that prevents them from getting help.

"Addiction is hard to talk about in normal terms," says Miotto. "People think of it as evil, as something that leads to lying and cheating and stealing. But we need to find a way of talking about addiction that isn't so shameful. We should treat it more like other chronic illnesses, like cancer or hypertension."

Doctor vs. Patient

In part because of the stigma of prescription drug addiction, chronic back pain can sour even the best doctor-patient relationships. Over time, the patient becomes increasingly frustrated by the doctor's inability to cure his or her pain. Meanwhile, the doctor may become suspicious of someone who always refills of powerful narcotics.

"Doctors can get afraid when dealing with patients with chronic pain, because they don't want to be the ones handing out hardcore painkillers all the time," says Khoo. "But that leads to a lot of undertreated patients with real back problems. These are people who are in so much pain that they're just not functional human beings."  

Khoo also says doctors may be too focused on trying to figure out the underlying source of pain while in the meantime ignoring the debilitating symptom.  

"The patient came to see the doctor because of pain," says Khoo, "and he doesn't really care about the underlying cause. He doesn't care whether it's a disc problem or a deformity. He just wants the pain to go away. So doctors need to concentrate on treating the symptom, too."

While this situation can be difficult for anyone with chronic back pain, people with a past history of addiction face the most skepticism from their doctors.

"I hate to say it, but when people walk in to the doctor and mention an addiction history, they may not be able to get these painkillers," says Miotto. "The doctor may just not trust them."

Working With Your Doctor

In order to get the treatment you need, you need to keep a good relationship with your doctor. This may require that you seek out a doctor with expertise in pain management. For a lot of understandable reasons, your regular doctor may not be comfortable handing out long-term prescriptions for narcotics.

For people who have a past history of substance abuse or are at higher risk of developing a prescription drug addiction for any reason, seeking out an expert -- or specialty center -- is especially important.

"Too often, addiction programs are completely divorced from pain management programs and vice versa," says Miotto. Khoo agrees and recommends programs that combine not only pain management and prescription drug addiction treatment, but also exercise, physical therapy, weight loss, and if necessary, therapy for depression.

One common way of using opioid narcotics safely is to use a pain agreement, a formal understanding between a doctor and patient about how the drugs will be used. The patient may promise to use the medication as instructed and, in some cases, agree to regular drug testing by urine analysis. In return, the doctor agrees to prescribe narcotic pain relievers as part of the treatment plan.

"Pain agreements or contracts are a way for a doctor to say to the patient, 'We're taking you seriously, so you need to take us seriously,'" says Khoo.

But these agreements may not be enough for people at high risk of addiction. "Some people decide that they just can't take pain medications responsibly," says Miotto. If that's the case, you may be able to get someone else to hold and dispense your medication for you. Another possibility is to use a transdermal patch -- these contain the medicine but deliver it slowly through the skin, preventing the high and reducing the risk of addiction.

For anyone with chronic pain, having a knowledgeable doctor and a trusting relationship is key. An expert won't have unfounded worries about the relatively small risk of prescription drug addiction. But he or she will also know how to help people at high risk of developing a problem.

"Doctors should not be afraid of treating pain," Miotto tells WebMD. "There are addicts out there who don't have pain but shop around and hustle for medication. But I think that there are very few compared to the number of people who have terrible pain and need help."

Originally published August 2004.
Medically updated April 2006.

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