Popular Painkillers That Can Cause Killer Pain
HEALTH, 11 Jul 2011
Penny S. seemed to have it all. She was young, pretty and active. Her husband was successful; her children healthy and happy. Then, out of nowhere, the pain began. It started as an aching fatigue in the afternoons and evenings. At night, “she looked like she’d hit a brick wall’” says her husband, Kent. “I…hurt…all…over,” is all Penny says, pausing between each drawn-out word for effect.
A doctor eventually diagnosed fibromyalgia—a syndrome that triggers pain throughout the body—and prescribed Vicodin, the top-selling opioid painkiller. “I liked the feeling of it, and it worked great,” Penny recalls. The Vicodin was a godsend: It enabled her to keep up with her responsibilities—kids, housework, social life—while continuing to work. Some days were better than others, of course, but the painkiller kept her head above water and she even started down the road to recovery from alcoholism.
Shawn F. is an addict of a very different stripe. At five-nine and 120 pounds, he’s a little guy, but he’s survived more than his share of addiction-induced mayhem, including motorcycle and car wrecks, bar fights and gunshots. “I kept a .45 in a shoulder holster, a 9mm in my belt and a derringer in my boot,” Shawn recalls. “I was a danger to the public. My drug was more.” Finally, Shawn’s multiple narcotics addictions landed him in a ward for the chemically psychotic. “I got sober strapped to a table,” Shawn says.
Shawn’s case is the kind that makes doctors cringe. His physician, Dr. Jonathan Tallman, says, “His body is a mess—arthritis everywhere, multiple failed back and neck surgeries.” Pain management requires a daily choice between lifelong suffering and life-threatening addiction.
One of the dangers of narcotics prescribed for chronic pain management is that they can reawaken the addict slumbering in the sober soul. Alert to this hazard, Shawn long ago worked out a regimen with his wife, older brother and sponsor. “They have a key to my med box. My wife checks it every couple of days,” he says. “I do not take drugs recreationally.”
Shawn had no way of knowing that he was about to be ambushed by a very different medical condition. One day, with virtually no warning, his pain meds stopped working—and the explosion of raw agony throughout his body and brain far exceeded what he recalled as his baseline level of pain. “When I stubbed my toe, it felt like someone slammed it with a hammer,” says Shawn, still shaken by the recollection.
At first he thought the problem was “all in his head” and he could “tough it out.” But after several days, when the pain had not diminished, he went to his doctor. The diagnosis—opioid-induced hyperalgesia— was so bizarre it might have been lifted from the plot of a horror movie. The painkillers had not merely lost their effect; they had triggered a syndrome of hypersensitivity to pain, even to stimuli that previously had not registered as painful.
Opiate-induced hyperalgesia is what doctors call a “paradoxical phenomenon,” a drug having the reverse effect than intended. After decades of heroin abuse topped off by a medical course of OxyContin and other prescription opiates for pain, the accumulated damage caused certain receptors in Shawn’s central nervous system leading to certain pathways in his brain to hit critical mass. His pain wiring went haywire.
The condition is actually not uncommon (albeit blessedly temporary) in non-addicts even on short-term high-dose prescription opiates. “Any individual can develop hyperalgesia after 30 days and maybe 75 to 100 morphine units a day,” says Dr. Michael Hooten, director of the Pain Rehabilitation Center at Mayo Clinic. But for addicts, the condition tends to be not only more prevalent but more acute, complex and long-lasting. According to Hooten, 20 to 30 percent of the general population struggles with chronic pain, but among addicts the proportion is 45 percent or more.
Hyperalgesia typically has a gradual onset, with pain increasing incrementally. The all-too-frequent response is for doctor and patient to assume the painkiller is losing its effect because of the swift development of tolerance and therefore to increase the dose. But as more narcotic floods the nervous system and brain, the hyperalgesia intensifies. The remedy has become the enemy. For that reason, all addicts on prescription opiates—and their doctors—should be vigilant from the start that hyperalgesia is as much of a risk as addiction.
Little about the condition is predictable, except for the pain. Hyperalgesia can hit abruptly, as it did Shawn; it can also strike after you stop taking pain meds, especially if you have gone cold turkey rather than tapering off. Equally variable is the kind and degree of the pain. Hyperalgesia patients have reported pain that is similar to the symptoms of withdrawal, such as uncontrollable shaking, twitching, even seizures caused by abnormal electrical activity in the brain. The pain may be localized in muscle tissue, in the bones, in the nerves, or in some combination of all three. Or your entire body may throb and ache.
“These are spectrum disorders,” says Dr. Dan Hall-Flavin, an addiction psychologist at the Mayo Clinic. “With the underlying biology of pain and the underlying biology of addiction, there is a lot of overlap.”
Once hyperalgesia is diagnosed, the best course of action is to taper off the Vicodin, OxyContin, Percocet or other opiate—stop feeding the beast. Certain medications, such as ketamine, methadone and even cough suppressants like NyQuil, may offer relief because they block a receptor in the central nervous system that is thought to play a key role in the syndrome.
With Dr. Tallman’s help, Shawn has begun tapering and looking for other solutions. “It’s not easy because the pain gets worse in the short-term,” Tallman says. With 15 years of sobriety, Shawn now wears a fentanyl patch (fentanyl, an opiate agonist, is 100 times more powerful than morphine). “There is no silver bullet,” Tallman says, but so far so good.
“My pain, the chronic pain, has not changed much, but day to day, with the little things, it is better,” Shawn says. He is also a regular at pain-management support groups. “Everyone that I know that this [opioid-induced hyperalgesia] has happened to are ex-addicts.”
Ironically, Penny only began abusing her pain medication after she got sober and her pain began to spiral ever higher. “At the end I was taking two pills at a time,” she says. “The drugs were not working.” Upping the dose fueled her undiagnosed hyperalgesia, creating a vicious cycle; her behavior became increasingly erratic as she chased relief. “I was an addict. Even being in recovery eight years, I was unable to admit I was hooked on painkillers,” she says. “I had it justified in my mind that it was a doctor’s prescription.”
“People who are coming in with both pain and addiction and which came first is a chicken and the egg,” Hall-Flavin says. “In the end it doesn’t matter—treat one and the other will often improve.” That’s the way it’s supposed to work—unless hyperalgesia turns treatment on its head.
As a result, some pain specialists choose to steer clear of the entire opiate category of painkillers. Dr. Matthew Monsein, a pain expert at the Courage Center and Abbot Northwestern in Minneapolis, has 30 years of experience with pain-wracked addicts like Penny and Shawn. “There are clearly patients who do better on opioids, but I believe it is a small percentage. Mostly the pain spirals up,” he says. In fact, some studies show that prescription opiates have, at best, only a modest and short-lived effect on pain and even less on functionality, while their risks—physical dependence, addiction and hyperalgesia—are daunting.
The Pain Rehabilitation Center at the Mayo Clinic boasts impressive results for the analgesic effects of not taking narcotics. At Mayo, doctors work to taper patients off narcotics and give them other tools. “Seventy percent of patients who complete the three-week program note a decrease in pain severity despite discontinuing pain medications during treatment,” Hooten says. The program focuses on so-called functional rehabilitation — managing the entire cluster of symptoms at the same time: depression and anxiety, addiction and pain. “The goal is resolving and improving management of the pain, not the pain itself,” Hooten says.
For addicts cursed with hyperalgesia, the stakes involved in finding a solution could not be higher. Shawn has had four support-group friends take their own lives when they could find no treatment to control the opiate-induced pain. “As a group, we have the highest rate of suicide,” says Shawn. “It’s like running through a marked minefield blindfolded. I’m going to try everything else, but suicide is my last option.”
Penny also traveled down that road. “My insurance company finally cut me off,” she says. “I wanted to die. Every single nerve ending in my body hurt.” She spent four days in the hospital, four months in recovery. “I was scared shitless,” she says. “I had no idea how I was going to get through the day.”
But with the support of her family and her community of fellow recovery folks, she was able to begin to turn the tables on her hyperalgesia. Now a 56-year-old grandmother, Penny says, “I decided I needed to do something different to be able to live again.” The drugs, she realized, “allowed me to be a crazed maniac—to push and not slow down.” So Penny changed her entire approach to living with pain: she meditates, eats healthy, does yoga, walks. Today she takes no narcotics and experiences less pain.
For the ex-addict in chronic pain, the onset of opioid-induced hyperalgesia can seem like the last turn of the screw. After wrestling your sobriety free from the stranglehold of addiction and leaving the junkie lifestyle behind, the medication prescribed by your doctor brings not relief from pain but a fresh new hell. Yet as both Shawn and Penny have proven, a separate peace can be made. There are many non-narcotic remedies for pain management, ranging from medications to meditation and mindfulness therapy to lifestyle improvements.
“For the person willing to make changes in their life, there absolutely is hope,” says Dr. Hooten. Dr. Hall-Flavin agrees. “Find a physician to work with who understands both addiction and pain,” he says. “Don’t give up hope. Believe in yourself.” Fortunately, ex-addicts have been schooled by the many challenges of recovery in believing in themselves and holding onto hope, even if only for today.
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Jeff Forester, a writer in Minnesota, is the author of “Forest for the Trees.”
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