What if I’m in Recovery and I Need Pain Medication???

A lot of people in recovery ask me about it: "I have to go for surgery and I'll need pain meds, what should I do? I don't want to relapse!" And they are right. The nature of addiction is such that even years into recovery most of us will end up right back where we were before if we take that first drug or drink. However, don't worry. If you need to take pain medications and want to preserve your recovery there are some precautions you can take to make sure everything goes OK.

My experience as a doc has been that opiates (codeine, oxycodone, morphine, hydrocodone, etc.) are way over-rated as pain medications. They only work for certain kinds of pain, and even then they often only take the edge off, at best. A perfect example is the pain that people get from shingles: it is intense. However, narcotics do almost nothing for it. However, certain non-narcotic medications (Gabapentin, pregabalin) provides great relief, sometimes completely taking the pain away.

Too, as a doc I have noticed that a lot of people have the impression that opiate medications are the first thing that one turns to when there is pain. Many come to see their doctor specifically asking for them. However, there are many alternatives, and some of them work better than opiates for certain types of pain.

However, if there comes a time when someone in recovery must take prescribed opiate medications, there is a way to do it safely and maintain recovery.

Narcotics are not the only option... and often not even the best option

Not all doctors are good with treating pain. Many don't do a proper assessment and just write a prescription. Some write a prescription for narcotics after a cursory assessment, or no assessment at all . At the other end of the spectrum, we have doctors who won't prescribe opiate medications to anyone, including people who absolutely need them. I have been sickened by seeing people suffering immeasurably as they die from cancer because their doctor refuses to prescribe them anything for pain. This is known as "the other narcotic crisis," where doctors over-react because of the narcotic addiction crisis and won't prescribe opiates to anyone in any circumstance.

However, to be fair to the doctors, they are under tremendous pressure legally, ethically, and professionally over their opiate prescribing, and it puts them in a tough spot (see my article "Prescribing Opiates From the Doctors' Perspective" click here)

However, doctors should assess your pain and explain to you your options rather than just write you a prescription. Some types of pain do not respond to opiate medications. For example, nerve-related ("neuropathic") pain, which is usually felt as electric-shock, lancinating, or burning pain, tends not to respond at all to narcotics.

According to pain treatment guidelines, your doctor should first identify the type of pain (see the above graphic). There are three general types of pain. "Nociceptive" pain is the most commonly seen pain type. This is where some kind of injury hurts. This would be the pain after a surgery, or if you got cut, or broke a bone, or had an infection in a tooth. The injury or illness stimulates the nerve endings, causing the sensation of pain.

Neuropathic pain is where something is affecting the nerves themselves. An example would be pain from shingles, where the virus infects the nerves and makes them inflamed and sick. Other diseases can affect the nerves, such as diabetes, pinched nerves in the neck or lower back, and alcoholism.

"Sensory hypersensitivity" pain is the kind that we can't quite explain, like the chronic fatigue syndrome/fibromyalgia pain, or the phantom pain that people experience after an amputation.

Pain treatment guidelines based on extensive research evidence and years of experience tell us that opioid pain medications have no role whatsoever in "sensory hypersensitivity" pain... they just don't work for that kind of pain. Yet, many people are on prescribed opiates for it. I did my doctoral thesis on fibromyalgia (a sensory hypersensitivity chronic pain syndrome, related to chronic fatigue syndrome), and I met many people with that illness who were on huge doses of opiates prescribed by their doctors (usually for years). When I asked them, many admitted that the opiates did little or nothing for their pain, and that they were still taking them because they were addicted to them.

How pain is best treated

We have A LOT of different medications and other methods of helping with pain, and all treatment guidelines advise using opiates only when all else is inadequate. Even when they are used, they should only be used in conjunction with other pain treatments, and never on their own.

The first-line medications for pain include such types of medications as anti-inflammatories (NSAIDs), corticosteroids, acetaminophen, disease-modifying drugs (DMARDs), biologics, antidepressants (SSRIs), anticonvulsants, and tri-cyclics. It all depends exactly what is the cause of the pain. Opiates are not on the list of first-line pain medications.

Opiates should only be used when these medications are not enough, and even then they should be used for the short-term, and at the lowest dose that is effective. As well, they should be used in conjunction with the first-line medications, as an add-on, rather than on their own.

As well, there are opiate preparations available that are designed to mitigate the abuse potential and risk of addiction, such as preparations that incorporate the medication narcan with oxycodone.

There's a lot more for pain than just medications

Too, sometimes people aren't aware of all the non-medication ways there are to control pain. Some of them will surprise you by how effective they are. Physical therapy (physiotherapy) is especially effective for muscular and tendon injuries, and neck or low-back pain. Massage therapy, acupuncture, relaxation techniques, meditation, yoga, biofeedback all help a lot of people who are willing to give them a try.

Other methods of helping pain that really work for some types of pain include rest (most people have difficulty taking it easy when they need to), TENS (trans-cutaneous electrical nerve stimulation), ice and/or heat.

I hate to use personal examples, but I get really bad low back pain once in a while, and I find that anti-inflammatories and opiates do nothing at all for it. However, a few trips to the physiotherapist usually works wonders. As well, I have my own TENS machine that I bought for $60, and I use that with great effect. I once had a really bad forearm injury and I had cortisone injections, took anti-inflammatories, and took really good care of it, but the pain continued for months. I ended up going for acupuncture, and it was completely gone after a couple of sessions. When I get a new injury, I find ice helps keep it from turning into an ongoing problem.

There is a lot of research evidence that supports many of the different non-medication approaches to pain relief. Your doctor should be well-versed in these and able to help you decide on what will work best for your specific situation.

Psychology of pain perception

It's well-known that negative psychology can cause people to feel physical pain, or make physical pain feel much worse. By addressing underlying psychological factors, a lot of people get significant release from pain. It's known as functional pain.

Physical pain, for example, is a common symptom of depression. May people who see their doctor for pain complaints turn out to be depressed, and their pain goes away once their depression is treated. Abdominal pain and pain in the muscles and joints are especially common.

What if you do need an opiate medication?

If you are in a situation where you do require a prescribed opiate medication, you can do so and still be in recovery. It's about being honest with your doctor, and your family/loved ones, and your sponsor (if you are a member of a recovery fellowship).

Letting these people know that you have a history of addiction, and that you want to make sure that the medication doesn't end up causing a relapse is key. As soon as you start keeping secrets from the people that matter, you are starting down that slippery slope to relapse.

You and your doctor can make arrangements so that the pharmacy only gives you small amounts of your opiate medication at a time. It is much better to do this than to have a large amount on hand and throw caution to the wind. Again, doing things that we know in our heart are a mistake (such as getting a large amount of the medication dispensed all at once) are the start of the slippery slope to relapse.

As well, making sure that YOU are not the person who controls the medication is key. Having your spouse, or even a friend (who is not an addict in recovery) as the guardian of your pill bottle, and giving you the medication that you need at the time that you are supposed to take it removes any temptation. Even with the best of intentions, if we start trusting ourselves when we really don't have to our addict's brain will start playing tricks with us. Best not to take any unnecessary chances. Recovery was way too hard to come by, so taking chances is just not worth it.

Again, honesty is key. If we find ourselves continuing to take the medication for the effect even though we really don't need it anymore for pain, we should tell our doctor, our family/friend, and our sponsor. It might be hard to do, but it always feels good after.

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