POTENTIAL ABUSEIn the past decade, the number of prescriptions written in the USA for narcotic painkillers has risen an average of nearly 500% per drug.
On one hand, that's good news for the millions of Americans thought to suffer from inadequately treated pain. But the dramatic rise in prescriptions also means that there are more pills than ever available to people likely to abuse them, rather than use them for medical purposes.
Unfortunately, it's nearly impossible to predict who will end up abusing or even becoming addicted to narcotic painkillers. Radio talk-show host Rush Limbaugh -- back on the job Monday after more than a month in rehab -- and rock singer Courtney Love would appear to have little in common except their celebrity and their recently reported problems with the prescription painkiller OxyContin.
Addiction is difficult for many doctors, let alone patients, to understand. It's not the same as physical dependence, which can occur as soon as anyone begins taking a narcotic painkiller, or opioid.
''Whenever you have opioid therapy, dependence is associated with that, whether you like it or not,'' says Jianren Mao, a physician who directs the Pain Research Group at the Massachusetts General Hospital.
''That's the property of this medication. But dependence usually is not a significant issue.''
Forget about what you've seen in the movies. Most people going through withdrawal from a narcotic painkiller aren't writhing in agony. They may feel discomfort, which can be minimized by tapering off the drug instead of stopping it abruptly.
''Addiction is totally different,'' Mao says. ''Addiction is characterized as a psychiatric disorder. Addiction only becomes obvious when patients can't get medication. The moment they can't get their medication, that's the moment of truth.''
Desperate for the euphoric feeling they get from narcotics, addicts will go to great lengths to obtain the drugs, no matter the consequences. Limbaugh, for example, reportedly bought drugs through his housekeeper.
Mao and other experts say uninformed doctors are at least partly to blame when their patients become addicted to prescription painkillers. Commonly, the groundwork is laid when patients come seeking relief from acute pain, such as that resulting from knee surgery or a back injury.
Instead of trying non-narcotic painkillers first, some doctors might go right to opioids. Eventually, patients develop tolerance to the drugs -- another characteristic of opioid therapy -- driving them to seek higher and higher doses to relieve their pain. Their doctors fail to realize that opioids don't effectively treat all pain conditions.
''Before you know it, the surgeons and the primary care physicians are prescribing a very high dose of opioids,'' Mao says. ''Now the pain becomes chronic, and the opioid dose becomes high.''
Uncomfortable writing prescriptions for such large doses of narcotics, the doctors finally refer patients to pain specialists.
''Doctors are woefully undereducated about addiction,'' says Susan Foster, vice president and director of policy research and analysis at Columbia University's National Center on Addiction and Substance Abuse. ''Consequently, physicians may unintentionally set up a patient for abuse or addiction or not treat the disease (addiction) when it occurs.''
A few years ago, Foster's center surveyed a nationally representative sample of primary care physicians to assess their knowledge about addiction. Researchers gave the doctors a description of a hypothetical patient who was addicted to drugs and asked them to pick from five possible diagnoses. Only about 6% correctly diagnosed the patient as being addicted.
Foster has some advice for patients taking narcotic painkillers that they might not hear from their doctor: ''If you get to the point where you're beginning to feel some euphoria as well as pain relief, that's a sign that the drug needs to be stepped down. The more you take a drug for its euphoric effects, the greater your risk of having problems with it.''
Researchers aren't sure why some people become addicted while most don't. Possible explanations include a genetic predisposition to addiction, growing up with addicted parents or siblings, or having friends or peers who abuse alcohol or drugs, Foster says.
''We're used to taking pills for our ills, and we generally don't view drugs prescribed by our doctor as dangerous.''
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