Welcome to the current newsletter issue of Advances in Medicine
(AIM) - Take AIM against pain, brought to you by Dr. Tim Sams
and My Pain Relief Doc - www.mypainreliefdoc.com
Feel free to send me an e-mail with your own thoughts and
experiences. Email: timsams@mypainreliefdoc.com.
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ADDICTION vs. TOLERANCE
"I don't want to take that medication, doc, cuz I don't
want to get addicted."
"My wife says I'm getting addicted to this medication."
These are among the most common concerns I hear on a daily
basis. The issues of medication addiction, tolerance, and abuse
are inescapable with pain treatment and rife with
misunderstanding and ignorance.
Developing a tolerance to medication for pain is almost
inevitable, and has both positive and negative consequences. The
overarching principle involved in tolerance is referred to as
homeostasis. Living organisms require a certain internal
consistency to sustain life. Living organisms, especially
humans, can adapt to changing environmental stimuli including
ingested chemicals. Within certain parameters, the body of the
organism comes to expect chemicals that are ingested daily and
over time. For our purposes, the primary "culprits" in
tolerance development are: caffeine; nicotine; benzodiazepines,
e.g., Valium, Librium, and Xanax; muscle relaxants, e.g.,
Zanaflex and Flexeril; and the opioids, e.g, Vicodin, Norco,
Oxycontin, MS Contin, and Methodone.
Positive effects of tolerance include a gradual reduction in
unpleasant side effects, such as lethargy, fatigue, or even
headache. Serum levels in the bloodstream stabilize as much as
they can, so there is less variability in dosing or pain relief.
The major negative consequences of tolerance are related to
withdrawal and decreased pain relief. As the body gets used to a
medication, it becomes less effective, i.e., it provides less
muscle relaxation, less reduction in anxiety, or less pain
relief. Unfortunately, this can happen in a matter of weeks.
As your body develops a tolerance to medication, you essentially
become dependent on the medication. You may experience a negative
reaction to abrupt cessation of the medication. Withdrawal is a
syndrome stemming from abrupt cessation of a medication for
which tolerance and chemical dependence had developed.
Withdrawal symptoms vary from mild to severe. They can be
characterized by anxiety, muscle tension, increased autonomic
arousal, including blood pressure and heart rate, headache,
fever, chills, sweating, nausea, vomiting, violent convulsions,
and death, usually from dehydration or electrolyte imbalance.
The purely physical consequences of tolerance, chemical
dependence, and withdrawal are distinguished from the combined
physical and psychological syndrome referred to as addiction.
In terms of ingested chemicals, addiction presumes tolerance,
chemical dependency, and likely withdrawal symptoms upon abrupt
cessation of a chemical. However, the DSM IV and other addiction
measures require that the addict also have distress, threatened
health, physical problems, and/or marked impairment in
interpersonal, occupational, mental, or emotional functioning
because of their use of the drug.
Someone who resorts to theft to support a cocaine habit, or
loses a job because of alcohol dependency may reasonably be
considered addicted because of distress and marked impairment in
one or more areas of life function.
If a patient taking MS Contin is too sedated and impaired to be
able to drive, spends much of their day falling asleep,
routinely takes more than is prescribed, routinely runs out
early each month, and constantly tries to talk the doctor into
upping the dose, we might consider that patient addicted and
would probably recommend detox and opioid abstinence. For this
patient, use of opioids is making him/her less functional, not
more, and independent of their self-report of pain relief.
Most patients take their medications, including opioids, as
prescribed in doses that make them more functional, not less.
These patients do not fulfill the DSM IV criteria for addiction
of functional impairment or distress even though they may have
tolerance and chemical dependency and would experience
withdrawal upon abrupt cessation of the drug. This is an
absolutely critical distinction and one that escapes spouses,
patients, and doctors alike.
If a medication makes you more functional, does not impair your
function in significant ways, and you take it as prescribed, you
are not addicted. On the other hand, if it impairs your function,
you take it other than prescribed, and it has become an issue for
those around you, you are certainly abusing the medication and
may very well be addicted. At a minimum, you need to be taking
either less medication or a different medication; you may need
to be detoxed from that class of medications.
I would not hesitate to take dependency-producing medication
including opioids if I had moderate to severe chronic pain. I
would not hesitate to recommend them to family members.
Don't let people who don't have chronic pain determine
what's best for you. On the other hand, everyone taking
medications for chronic pain should take a long and hard look at
their function from time to time. If you have a history of
chemical dependency of alcoholism, you should take a long hard
look on a regular basis.
Good light,
Dr. Tim
My Pain Relief Doc
www.mypainreliefdoc.com
Copyright 2007. Dr. Tim Sams and My Pain Relief Doc.
All rights reserved. www.mypainreliefdoc.com
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Thanks, Dr. Tim
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