Pain Support.org

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Ask the Experts on . . How Much Pain Medication Should I Give?

Question:

My patients seem to always want more pain medicine than I am comfortable giving them. I am concerned that if I give them more pain medication that this will lead to addiction. How can I prevent addiction, relieve patients' pain, and minimise drug-seeking compulsions?

Response:

The most common cause of escalating pain complaints is worsening disease, not tolerance to pain medications. Pseudo addiction (drug-seeking behaviour) is caused by inadequate analgesic medication prescribing. In pseudo addiction, the drug-seeking behaviour stops when adequate medication dosages are given. In comparison, in true addiction, drug-seeking behaviour continues to escalate.

The difference between tolerance, physical dependence, and addiction is frequently misunderstood. The belief that the use of opioids for pain relief causes addiction is a common clinical misconception that is a significant barrier to good pain management. It is useful to divide "addiction" concerns into 4 categories to improve clarity of understanding.

Tolerance. Tolerance is defined as a need for a larger dose of a medication to maintain the original effect. It is important to remember that a need for increased doses may also represent a change in the cause of pain (new aetiology, advancement of original process, etc.) requiring reassessment. This is often the reason for a need for increased doses in the terminally ill. When tolerance does occur, it is easily managed by increasing the dose -- tolerance to analgesic effect tends to parallel tolerance to toxic effects.

Physical dependence. Physical dependence is defined as development of withdrawal symptoms when opioids are discontinued abruptly or when opioid antagonists are administered. Like tolerance, this is a normal physiologic response (expected after 2-4 weeks of regular use). Opioids are not unique in this regard. Many other medications such as beta-blockers, alpha-2 agonists, and selective serotonin reuptake inhibitors (SSRIs) also cause withdrawal symptoms. In cases in which pain decreases in the course of an illness (as may happen after radiation to bone metastases or steroid treatment for increased intracranial pressure), most patients taper their narcotic use over a short period without difficulty.

Therefore, this is very seldom a clinical problem. I recommend that the opioid be reduced by 50% every 2 or 3 days.

Psychological dependence. Psychological dependence is defined as a pattern of compulsive drug use characterized by the use of an opioid for effects other than pain relief and continued use despite harm. Terminally ill patients virtually never become psychologically dependent in any negative sense to properly administered narcotics. Patients and their families should be counselled about the rarity of addiction when opioids are prescribed for management of pain
under medical supervision.

Pseudo addiction. The pseudo addiction syndrome is begins with inadequate pain management. Patients develop feelings of anger and isolation, which lead to acting-out behaviour. The clinician may initially experience frustration at not controlling the patient's complaint of pain, along with fears of inducing tolerance and dependence. Over time, clinicians may seek to avoid contact with the patient as a means of reducing the source of conflict. Both cycles continually interact until a crisis based on mistrust results. [1] When pseudo addiction is recognized as a true iatrogenic syndrome, the way in which patients receive pain treatment will hopefully improve.

Inadequate pain management leading to pseudo addiction has these features:

Preventing pseudo addiction includes trusting the patient's report of pain. Remember that pain is a subjective phenomenon; use opioids appropriately based on the patient's report of pain. Important components of appropriate opioid use include scheduled rather than dosing as needed and providing rescue medication for breakthrough pain.

Principles of Pain Management Dosing

In summary, the physician assistant must provide reassurance that aggressive treatment will be given to every type of pain that the patient is experiencing. Four general principles are used in prescribing and dosing analgesic medications: