Tolerance, Dependence, and Addiction

Tolerance is a patient's need for an increasing quantity of medication in order to achieve the same effectiveness.

Physical dependence, by contrast, is a known effect of certain types of medication and is characterized by symptoms of withdrawal that differ among medicines...Medically speaking, physical dependence is not considered to be either postive or negative.

Addiction..is primary, chronic disease influenced by psychosocial and environmental facters.  It is also strongly genetic.  Addicts are not made from people who do not have the appropriate genetic makeup.  Exposure to pain medications..does not create addicts.  Psuedoaddiction is a syndrome in whcih patients who desperately seek relief from undertreated pain mimic the behavior of those seeking drugs for different reasons, and this merely clouds the picture.  People in genuine chronic pain suffer the more because these distinctions are not generally understood. 

Arthur Rosenfeld: The Truth About Chronic Pain

After reading the first part of Rosenfeld's book, I realized that S's struggles to get proper pain medication are not unique.  What is unique is the fact that he has bipolar disorder.  Bipolar individuals often self medicate with alcohol, narcotics and other illegal drugs.  They are much more susceptible to addiction in the true sense of the word. S was automatically classed with the drug addicts and drug seekers before he even explained what hurt.

After his second surgery, S wanted to get off the narcotics all together.  He was sick of the constipation, the fight with his doctor to get the proper dosages, and, above all, he was sick of being seen as a drug addict.  He was still in excruciating pain, but he was so humiliated by how he was treated that he felt the pain was better than fighting for proper pain management.  His psychiatrist actually asked him "Are you out looking for street drugs, yet?" When S responded with an emphatic "NO!" His doctor came back with "You will be."

His primary care physician told him flat out that he would no longer prescribe any pain medication and to either admit himself into a rehab program or experience withdrawal and all the wonderful things that come with it alone.
The neurosurgeon--who started him on the medications in the first place and later put him back on them--referred him to a pain management clinic.

The doctor at the pain management clinic told him that because of his bipolar disorder and the extent of the surgeries, S could not take the normal route of steroids and nerve oblation. The only option open to him was narcotics, but they could not prescribe narcotics because he was bipolar. "Go back to your family physician."

He tried to withdrawal at home. It was horrible. I had just had a baby less than a month before. We had been warned that because of the high dosage of medications he had been taking, he could end up with seizures and possibly die.  I just couldn't deal with that and a newborn, so he admitted himself into a rehab eight hours away from where we lived. It was the only one with an open bed.

He was not addicted to the medication. He was dependent on it. Just like I am dependent on my medication. If I am not properly stepped down from my medication, I go through severe withdrawal symptoms--dizziness, disorientation and possible suicidal thoughts. My doctor will step me down when it is time. The difference between me and S? My medication is a non-tricyclic antidepressant and his are narcotics.

The ironic part of this story? Within a month of returning from the rehab program, it was discovered that the second fusion had failed which explained the horrible pain he was experiencing and the need for additional pain management. His neurosurgeon prescribed an even higher dose of pain medication than he had been taking to get him through until the third surgery could be performed.  And, to add to the fun, we were told the third surgery was only to ensure that his spine was properly supported. The chances of actual pain relief were slim to none. We were looking at starting the medication game all over again.