Chronic Pain and Addiction

The interface between chronic pain and addiction is very complex.  Pain becomes worse the harder one looks at it, and taking narcotics tends to draw attention to the pain… so as a broad generalization patients don’t do as well on pain meds as off.  At the same time, patients will claim that is not true, even as they suffer depression, become overweight, lose friendships…    Again, things are already complex, but if you throw in a bit of denial things really get complicated.
An interchange on the pain topic:
Question:
Dear Sir,
What happens when a chronic back pain ( 2 surgeries ) woman attempts to detox off oxycontin to methadone, gets addicted, detoxes to suboxone, and then can not get anyone to listen to her as she struggles to detox off suboxone?  My sister would like to get off all opiates and they want her to detox over months and she is not receiving any psychological support from her psychiatrist. In addition, at 10 mgs there is little pain relief.
Suggestions?

Answer:
Thanks for writing. Such a tough situation—and unfortunately a very common situation as well.
My first thought is to make sure that everyone understands what she is dealing with.  You mention ‘detoxing’ off oxy to methadone–  methadone is an opiate ‘agonist’ just like oxycodone, meaning that then both do the same thing in the brain—they both mimic endorphins and activate the ‘mu’ receptor for opiates.  Some people use methadone, some use oxycodone, but they are interchangeable for the most part.  Yes, oxy may have a bit more rapid onset and so it is a bit  more addictive, although they both are so additive that the difference doesn’t matter much.
You may find other opinions—maybe not—but I would say that if she has been addicted to those medications, she will always have problems with opiates.  Like everyone else I hate to assign a lifetime diagnosis to people, but I just NEVER see a person who has been addicted to opiates walk away from them without a major change in life that includes going to 12 step meetings regularly.  Even then, staying clean is very difficult for most people, and their opiate addiction tends to relapse repeatedly.  In science lingo (I notice your PhD), attending meetings and taking other steps in recovery are necessary, but not sufficient, to stay clean.
Pain makes addiction much more difficult to treat.  The pain will change along with opiate cravings.  Patients get offended when I say this, but they shouldn’t—to them the pain is the same whether it is coming ‘purely’ from damaged tissue vs coming from deeper brain centers involved in addiction.  I have watched many times as pain patients ‘talk themselves’ into needing opiates for a pain that  they never used to need opiates for.  Because of that interaction, people with chronic pain generally do WORSE on opiates than those who take nothing!  The people on nothing will automatically suppress the pain—try to ignore it—whereas people on opiates will focus in on the pain and exaggerate it.  Functionally the same thing happens.  Patients will ask for opiates, saying that they need them to work, but if you did a blind observation you would see a clear difference in the other direction—that the people on opiates are less functional.  They are also less happy, have less energy, and have worse sleep patterns.

Suboxone has a ceiling effect, so that the dose/response curve isn’t a straight line but rather levels off at about 2 mg of Suboxone per day.  Increasing Suboxone beyond that amount reduces cravings but does not reduce pain.  I recommend 8-16 mg for most people as the ideal dose to get the maximum suppression of cravings.  Patients always claim that more Suboxone will help, and they can abuse Suboxone as well—but double blind studies show that it is all in their heads as a placebo effect, and taking Suboxone , 8 mg once per day in the morning, will work as well as any greater or more frequent amount.
I recommend that she try to understand the nature of her situation—the dead end offered by opiates, and the life long nature of addiction—and consider staying on a stable dose of Suboxone long term.
A very tough situation–  I wish you the best.
SD