Addiction

Although interrelated, pain medicine and addiction medicine are separate fields. However, on my acute pain rotation, I was introduced to some of the issues regarding opiate addiction. Addiction is an awful disease. We saw several patients, all young, all of whom became tolerant to and then dependent on pain medications. These are the patients who all the attendings know; they spend more time in the hospital than out of it and each time they are here, pain management gets consulted. Some patients have real pathology; one had an extensive surgery and has real pain, but over a prolonged hospital stay of several months, has required more and more pain medication. Even though now she is actively trying to decrease her use, it is a long road because she's been on opiates for so long. On the other hand, we have another patient who is on sky-high doses of IV pushes, probably because she likes the feeling she gets from it. Converting her to equivalent doses of long-acting medication or even to a patient-controlled machine don't achieve the same effect. She has no intention of changing her regimen and is incorrigible in her demands.

Sometimes physicians find these patients frustrating. Addiction makes patients belligerent, hostile, demanding. It decreases our threshold of safety for medications. It makes doctors wary and we undertreat pain and underprescribe medications on discharge because we don't want things to be abused. But it is also a very real disease. Patients with addiction have no free will at all. They are mentally, psychologically, and physically dependent. They have no choice in the matter, and it is not simply a question of willpower or strength of character. While patients can resolve to fight cancer or do physical therapy through pain, it is behavioral changes like overcoming addiction, exercising regularly, eating well that still proves to be the most challenging.

Image of opium poppy is in the public domain, from Wikipedia.