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 an addiction…this is another example of pseudo-addictive 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 no one 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 drug-seeking, 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.