How Not to Get Hooked on Pain Pills
Over the next six years, Crews Miller spiraled downward, dipping into heroin use and ultimately landing in a pool of vomit on the floor of a jail cell. She spent six months recovering in a Florida Department of Corrections program run by the Salvation Army. Now sober for nine years, she is a married, working mother of three daughters. In hindsight, she says, "I would rather deal with my postsurgical pain all day, every day" than go through the horrific ordeal of opioid addiction.
Crews Miller's story isn't as unusual as you might think. Many of those who overdose on opioids are people just like her. They're moms, grandpas, or high school students whose journey into hell involved a prescription from a doctor. Currently, more than 214 million prescriptions for opioids are written each year in the U.S. It's an inconvenient truth for physicians and health experts as they scramble to contain an epidemic that sends more than 1,000 people to emergency rooms every day and more than 16,000 to their grave each year. Prescription opioids block pain and flood us with feel-good chemicals, making them just as addictive as their illicit cousin heroin. The situation has become so dire that even the CDC has come out against them for some pain. Yet opioids remain a ready way to deal with physical suffering; despite warnings, many doctors still overprescribe them. Here's what you need to know to minimize your misery—and avoid a slide into misuse and addiction.
If you have significant yet likely temporary pain (for example, after surgery, an injury like a broken wrist, or a medical issue like a kidney stone)...
Reevaluate what's bearable
Many Americans expect that doctors—and drugs—should be able to eradicate discomfort. "That's inconsistent with attitudes elsewhere in the world, where patients and physicians recognize that a certain amount of pain is to be expected after trauma or surgery," says Bradley C. Martin, PhD, professor of pharmacy practice and founding head of the pharmaceutical evaluation and policy division at the University of Arkansas for Medical Sciences in Little Rock. This distaste for discomfort can be traced to the 1990s, when some experts became concerned that doctors weren't fully addressing the effect of pain on patients' well-being. Opioids, previously meted out to terminal cancer patients or following major surgery, became a key part of the new anti-pain strategy. Instead of being given in small amounts as a last resort, they were more likely to be prescribed generously and proactively for procedures as mundane as tooth extraction. While the pendulum is finally swinging back the other way, it's still true that "if you demand that your pain disappear immediately, you're likely to come away with drugs," says Beth Darnall, PhD, clinical professor at Stanford University School of Medicine and author of The Opioid-Free Pain Relief Kit.
That could be more harmful than helpful. Using opioids to get rid of all the hurt not only poses the risk of dependence, but it also interferes with the body's immune response and slows the healing process, says Anna Lembke, MD, medical director for addiction medicine at Stanford University School of Medicine and author of Drug Dealer, M.D.
Consider over-the-counter relief first
Don't underestimate the power of ibuprofen and acetaminophen (unless you have certain preexisting conditions—check with your doc). Taken together, these drugstore analgesics can provide relief comparable to opioids for pain due to broken bones and oral surgery, studies say.
Explore all the options
Ask your doctor about nonpharmaceutical ways—for instance, ice or heat—to find relief from acute pain. "Think about taking an opioid only after you've tried everything else," says Chris Johnson, MD, chair of the Minnesota Department of Human Services' Opioid Prescribing Work Group.
Illustration: Doug Chakya
Take less than what's prescribed
Unlike antibiotics, which you take in prescribed doses to kill bacteria, opioids are optional. And remember: "After just a few days, many people can become physiologically dependent," Martin says. While some may not notice any withdrawal symptoms when they stop their medication, others—perhaps due to their biological makeup—may shake with anxiety, feel achy all over, and become hypersensitive to pain. "Some people call it the opioid flu," says Martin, who adds that it can drive patients back to the pills, then back to their doctor—or another source—for a refill. Addiction (defined as compulsive use despite harmful repercussions) isn't inevitable, but while people with a history of depression, anxiety, or alcohol, tobacco, or drug abuse are at particular risk, it can happen to anyone. If you find yourself with a pill bottle in hand, "know that the fewer you take and the sooner you get off them, the better," says Johnson. (And don't save leftovers "just in case." Contact your pharmacist or local police department to find out how to dispose of them safely.)
If you have chronic pain (for example, backache, fibromyalgia, arthritis, migraines)...
Know the risks of taking these pills
Until the 1990s, treating chronic-pain conditions with opioids was practically unheard of because using them long-term seemed to guarantee addiction issues. But while doctors focused on fully treating pain, a massive campaign underwritten by drugmakers promised that, while patients would likely develop a physiological dependence on the drugs over time, the risk of addiction was relatively low. "They made it seem like opioid dependence was no big deal. Patients could stay on the drugs to ease their chronic pain, and if they eventually wanted to stop, they'd just need to taper off slowly," says Andrew Kolodny, MD, executive director of Physicians for Responsible Opioid Prescribing. That's not how it worked. Chronic-pain patients not only developed a tolerance to opioids over time, but many also became addicted—with sometimes-deadly consequences. As if that weren't bad enough, with chronic use, opioids can actually lower some patients' pain threshold, worsening their agony. In 2016, the CDC finally warned that opioids should never be the first or routine treatment for chronic pain. Lembke explains it to her patients this way: "I don't want to give you something that helps you in the short term and harms you in the long term. Opioids just aren't worth it."
See a healthcare provider who treats your whole body—
not just the part that hurts. Make an appointment with a primary care provider, a nurse practitioner, or an osteopath whose training emphasizes a holistic philosophy. "If she's pushing pills or doesn't recommend nonmedication treatments like physical therapy [PT] as your first line of defense, find another provider who will," says Lembke. Make sure your doctor stays involved in your care, even if he or she refers you to another expert.
Be picky about specialists
An array of providers can subspecialize in pain medicine. "Anesthesiologists sometimes do nothing but injections; a physiatrist may focus on rehabilitation; a family practitioner might rely on medication," says Jim Lincer, MD, president of the American Board of Pain Medicine (ABPM). Your goal: a pain specialist whose expertise meets your needs and preferences (for example, if you'd rather try PT than take pills) and who is certified by the ABPM or the board of their specialty.
While fewer opioid prescriptions are being written, doctors continue to dole them out for reasons ranging from compassion to convenience. "Physicians are trained to relieve suffering, and they loathe telling patients they don't have anything that can make their pain go away," says Lembke. And for chronic-pain patients in low-income and rural areas who lack adequate insurance coverage or access to treatment alternatives, prescription opioids can seem to make some sense—it's more practical to recommend a pill than ask a patient to take off from work and drive an hour to acupuncture twice a week. Practitioners also worry about online reviews and satisfaction surveys: Failing to provide complete relief can anger patients and result in negative feedback, says Lembke. But just because a doctor prescribes a drug doesn't mean you have to take it, according to Deborah Dowell, MD, who coauthored the 2016 opioid guidelines for chronic pain for the CDC. Better to ask: What are the alternatives? What are the risks? What are the benefits? How long do you anticipate that I'll be taking this? What do we hope to accomplish, and how will you know when we've done that?
Become the boss of your pain
Learn what you can about your issue, including best practices for treatment; for example, opioids are not generally recommended for migraine headaches, fibromyalgia, and lower-back pain. Use the right lingo when talking to experts: "Ask about your options for ‘comprehensive pain management,' " says Darnall. This type of mind-body treatment (practiced by ABPM certificate holders) integrates approaches like PT, pain psychology, gentle yoga, and acupuncture. Also express your interest in "chronic-pain self-management," which means you'd like information and skills to treat symptoms on your own (for example, relaxation advice and sleep hacks that have been shown to help with discomfort). This shows that you're serious about becoming more independent of doctors and clinicians—and pills—over time, says Darnall, and charges them with empowering you to do so.