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Sickle Cell and Drug Addiction: Definitions

Sickle Cell and Drug Addiction: Definitions

 Addiction is very easy to stumble into and very hard to get out of, especially when you have a chronic medical condition that requires some form of pain management therapy.

We do give medical professionals alot of flack for treating us all like drug addicts; but those negative attitudes had to have come from somewhere. Several people have come to me expressing thoughts of narcotic addiction in the past, so I know that this topic weighs heavily on our minds.  

The next few entries will talk about addiction, and I hope that this will spark a conversation in the forum and with yourself to see if you might be at risk for addiction. I’m researching this topic for all of us; those battling addiction, those dealing with chronic pain management therapies, and  those constantly aware and nervous about getting addicted.

Many health practitioners do not understand addiction and use the term ‘addiction’ very liberally. Sickle cell patients have often been mislabelled as drug abusers, and this has resulted in a breakdown of the therapeutic relationship. Nurses and doctors should be careful when using the word addiction, and make sure they apply the correct word to the right scenario.

The definitions for addiction are so varied that the American Society of Addiction Medicine, the American Pain Society and the Academy of Pain Medicine came together to issue proper definitions and parameters for all the facets of substance abuse and use.

The first three definitions: Physical dependence, tolerance and pseudo-addiction, I know many of us can relate to. I have experienced all three, and usually, with every hospital admission, I go through a cycle of dealing with each of these.

Physical dependence is a state of adaptation manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.

For example, when you have been in the hospital for a week, on the PCA, or regularly administered IV narcotics, and the doctors stop or rapidly decrease your dose, you might experience symptoms of withdrawal. This is because your body has grown accustomed to that medication, and you have become physically dependent on the drug. You may have night sweats, hallucinations, feelings of nervous anxiety, mood swings or feel like bugs are crawling on you. Fortunately, these effects fade in a couple of days as your brain readjusts to it’s biophysical state.

It is always recommended to gradually wean yourself off the dosage. So instead of getting 2mg of Dilaudid every 2 hours, you take 2mg every 3 hours, then 1 mg every 2 hours, then 0.5mg every 2 hours, until you are completely off it. Stopping the narcotic with no weaning period will lead to symptoms of acute withdrawal and may be quite destabilizing for many patients.

 Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one of more of the drug’s effects over time. For example, when you first started taking Dilaudid, perhaps 1mg was enough to control your pain. As time progresses, the 1mg will become less and less effective, and your doctor might increase you to 2mg. This will work great for a while until your body gets used to it, and then you will have to be increased again or switched to a different drug. This is a natural adaptive response, and it does not mean you are getting addicted to the drug.

Pseudoaddiction has been used to describe behaviors that may occur when pain is
undertreated (Savage et al., 2003; Weissman & Haddox, 1989). Patients with unmanaged pain may become focused on pursuit of medications, often are labeled “clock watchers” or described as “on the call bell,” and may seem otherwise to be “drug seeking.”

Pseudo addiction is one thing that many sickle cell patients can relate to, and are often guilty of.

For example, when I’m in the hospital, I know that once I ring the call bell, it will take 5-10 minutes for someone to come to my room, another 5 minutes to tell the nurse that I’m in pain, another 10-15 minutes for her to look up the orders and bring me my next dose of pain medicine. It might even be longer if the nurse is at lunch or busy with another patient. So even though my pain meds aren’t due until 4pm, I might ring the bell at 315 just to get a headstart on the process.

When you are in a full blown crisis, having the pain reach a 10 is the worse thing ever. I am so afraid of getting to that threshold, because once my pain is 10/10, it is very hard to get it back down. This fear might lead me to exhibit pseudoaddictive behaviors, asking repeatedly for pain meds, asking for an extra dose, clock watching etc. A 10 is the worst pain of my life, and I do not want to go there at all!

Based on previous experiences, I know that if I rank my pain less than a 3, the nurse might half the dose, or not even give me pain meds at all. So even if my pain is a 4, I might rank it higher than what I feel it is. Once again, this is not addiction…this is another example of pseudoaddictive behaviors.

What if your doctor doesn’t believe you are in so much pain, and he refuses to give you a prescription? What do you do when you are in an actual pain crisis, and noone wants to help you? Well, deception can ensue in the patient’s efforts to obtain relief; sometimes you might ask your friend for some pills to tide you over, or raid your parents’ medicine cabinet. Sometimes the individual may even resort to the purchase of illicit drugs, or resort to using marijuana.

This behaviors, to the uneducated, might be characterized as drugseeking, but you have to remember that the sickle cell patient is in actual physical pain. The patient is described more appropriately as “relief seeking” rather than “drug seeking.”

Pseudoaddictive behavior can be distinguished from addiction by the fact that achievement of adequate analgesia allows the patient to demonstrate improved function and use the medication as prescribed, and not use drugs in a manner that persistently causes sedation or euphoria (Savage & Horvath, 2009). This means that once the sickle cell patient has their pain under control, they aren’t trying to get more drugs.  We don’t ask for pain meds to get the rush or to get high…we do it because we are in real pain.

Oops! Looks like I’m over my word limit! Stay tuned for the next installment in the series: Sickle Cell and Addiction

References:

Savage, S.R., & Horvath, R. ( 2009).Opioid therapy of pain. In R.K. Ries, D. A. Fiellin, S. C. Miller, & R. Saitz (Eds.),

Principles of addiction medicine (4th ed.) (pp. 1329- 1351). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.Savage, S.R., Joranson, D., Covington, E.C., Heit, H.A., Hunt, J., & Schnoll, S. H. ( 2003). Definitions related to the medical use of opioids: Evolution towards universal agreement.

Weissman, D.E., & Haddox, J. D. ( 1989). Opioid pseuodaddiction-an iatrogenic syndrome. Pain, 36 , 363-366.

Journal of Pain and Symptom Management, 26 (10), 655-667.

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Sickle Cell Warrior

Sickle Cell Warrior

Tosin is dedicated to perpetuating healthy and positive messages about sickle cell. Although sickle cell is a subject often taboo in the communities this condition is most prevalent, Tosin's message is that sickle cell is not something to be ashamed of and you can live a rich and fulfilling life with sickle cell. Sickle cell warriors are the most amazing people in the world, with a great fortitude for compassion, willpower and strength.

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4 Comments

  1. Tywanda Mines
    Tywanda Mines May 05, 06:45

    Thanks for educating us all on drug addiction in sickle cell patients. This has been very informative. I am sharing this with everyone I know and on facebook and twitter. Because I want all possible to be educated on this subject. This effects all sickle cell patients in a MAJOR way. Stereotypes and prejudices hit us smack in the face everytime we seek medical attention of any matter. No one treats cancer patients as drug addicts when they’re in pain, but they do when you say you have sickle cell and you’re in pain and need more meds. It can be very frustrating. It is my hope that one day we will all be better educated when it comes to this painful disease. Thanks for all the time you put into your blogs and fellow scwarriors.

  2. suz
    suz May 08, 15:46

    Very interesting. I always wonder how to rank the pain, because the level of interest the nurses give you and pain meds is dependent on that number you tell them, and no matter what you tell them you have that feeling that mentally they dial it down by 2-3 notches.

    Very interesting article. I am on to article 2 now..thanks for putting this info together for us.

  3. Brandi, RN
    Brandi, RN May 11, 01:40

    Pseudo-addiction and pseudo-seeking are very sad behaviors. These behaviors are, of course, born of the people who are not having adequate pain relief. I went into it on another post, but I see it here again and find myself compelled to reply!

    Not everyone responds to pain the same. The pain scale faces are the most discouraging to people who do not respond to pain in the way that the nurse or doctor are expecting. Happy face, sad face, crying face). Do they show passed out from pain face? Do they show trying to distract myself by talking on the phone face? No. So people in pain are forced to “put on a show” for their nurse or doctor, so that they are believed. The patient has to roll around wailing loud enough that the nurse can no longer ignore their pleas for help.

    There is another pain scale that I really like to use as an RN. This is found, in my hospital, right underneath the dreaded faces. There are descriptive words attached to each number. This is helpful for me especially to those people that are grossly underrating their pain. I can’t remember them all but: 0=no pain, 1= minimal, 6= distracting, 7= distressing, 8= intense, 9= immobilizing, 10= excruciating.

    A lot of people will rate their pain at a 2 or 3 so if their distracted by their pain. I can clearly tell that this person is AT LEAST distracted by their pain because they can’t concentrate on finishing a sentence! A lot of people don’t realize that if you’re currently distracted by your pain, by the time I can get the medication from the lock box, draw it up, get back to the room and give it to the them, it’ll be between 5 and 10 minutes. Quite possibly it may be longer, if I’m stopped 16 times by other people, the medication has run out in the lock box and I have to wait from pharmacy, there’s no order for more and I have to wait for the doctor to call back.
    There is a short step between distracted and distressing. If your pain is rated at distracting, on a good day, by the time the medication hits your blood stream, you may already be distressed or further.
    I fear though, that even if you’re rating your pain very carefully, as SCW points out, you may be left to suffer longer. Thus, the pseudo-seeking/pseudo-addiction. The seeking and addiction part are the misconception from the healthcare provider, the pseudo part being that they’re WRONG! If I wake up with a headache, do I not seek some tylenol? Just sayin!

  4. Cat
    Cat October 15, 09:40

    I just found this website scw, because my 21 yr old daughter suffers from SB and she has been hospitalized every month this year except June:(. She is currently in the hospital now, going on day12..this is the longest hospitalization yet.. I don’t know what to do to help her?? They recently started tramadol, and Celebrex??

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