Opinion | Pain Management Tests the Limits of Drug Addiction Recovery


Last summer, I learned that I needed major oral surgery, including having some teeth removed, bone grafts and implants. I’d dreaded the prospect for years, but it could no longer be postponed. Beyond fear of pain and temporary disfigurement from missing teeth, I had another major concern: I was addicted to heroin in my 20s. If the pain after the two scheduled procedures was severe enough, I might need to take opioids.

During my active addiction, although I used plenty of cocaine, heroin was my true love. It made me feel safe, warm, nurtured — the opposite of the undeserving person that I feared I truly was. Neuroscience research now shows that the brain’s natural opioids are an essential part of the system that bonds us to one another, which is why for people like me who have had difficulty feeling lovable, these drugs can taste like paradise. As an expert on addiction, I knew that a return to compulsive drug use wasn’t inevitable with medical opioid exposure. But I also knew that it was wise to be cautious about reopening a door that could lead me back to my past.

There’s a common belief that people with past addictions should never take any potentially addictive substances for medical reasons — period. As a result, some languish in extreme pain because they believe that drug exposure will cause them to lose control and immediately return to active addiction. But the truth is, “While euphoria associated with drugs may be a trigger, the stress of profound pain also puts someone at risk of relapse,” said Dr. Sarah Wakeman, an associate professor at Harvard Medical School.

Fortunately, my primary dentist, Dr. Dennis Bohlin, is himself in recovery, and was able to help me navigate these risks. But others aren’t so lucky. There is much misinformation about how opioid pain treatment affects people in recovery and those at high risk of addiction. Understanding how psychoactive drugs and addictions really work is crucial for better managing medical opioid use — and ending policies that interfere with both prevention and recovery.

“There’s not a single right answer” about how to treat people in recovery with opioids, said Dr. Wakeman, who is also the senior medical director for substance use disorder at Mass General Brigham Hospital. Physicians often undertreat pain in people with addiction, but some also unfairly disregard fears about triggering craving, she said, adding that the best approach centers on the patient’s concerns.

Still, there is a strong belief in the medical community that pain drugs are a greater risk to people in recovery than not treating their pain. Some of this thinking relates to the idea, memorialized in the Alcoholics Anonymous slogan: “It’s the first drink that gets you drunk.” It’s indisputably true that if you never take a first dose, you are in not in danger of becoming disinhibited and continuing uncontrolled drug use.

However, it’s also the case that loss of control is not absolute or completely determined by pharmacology. A series of ingenious studies devised by the addiction research giant Alan Marlatt of the University of Washington shows why. For these experiments, Dr. Marlatt worked with people with alcohol use disorders who had rejected treatment. In a bar-like setting, they were asked to taste test various beverages. Some of the drinks were vodka tonics, while others contained no alcohol but were disguised as cocktails.

If it is true that the first drink creates uncontrollable craving in the brain, the heavy drinkers who participated in these studies should have subsequently consumed more drinks after taking the first sips of real alcohol, than when they were given mocktails. But in fact, when participants were told that their drinks contained alcohol — even if it was actually placebo — they drank more. The reverse was also true: When they were given placebo drinks labeled as alcohol, they escalated their drinking.

In other words, it was belief in the idea that alcohol exposure leads to loss of control that increased consumption — not the alcohol itself.

These findings do not mean that people with severe alcohol use disorder can simply moderate their drinking by changing their beliefs, nor do they change the fact that abstinence is often safer. But they do show that exposure by itself doesn’t automatically trigger a loss of control, even for those with addictions.

This helps to explain why medications like buprenorphine and methadone — which are opioids — can be used to treat people with opioid addiction. When given a regular, appropriately individualized dose, patients on these medications can function as well as anyone else, even though they take an opioid daily. The bias that frames addicted people as self-centered hedonists further compounds the idea that opioids should be withheld, even for pain levels that would be seen as intolerable in others. In reality, people with addiction are much more likely to report mental health problems, which can lead them to seek chemical relief.

In my own case, depression and an undiagnosed autism spectrum disorder led me to my addiction. I desperately wanted to connect with others, but felt unworthy — so much so that I decided that the only way people would even pretend to like me was if I had something they wanted, like drugs. Living with that much self-loathing required anesthesia. My recovery has been about defusing it with cognitive techniques, antidepressants and critically, genuine social bonds.

And so, when I had the two surgeries, I took steps to bolster my recovery support and minimize risks.

One way to maximize safety is to know what to expect. Anxiety can increase pain, while having a sense of predictability and control reduces it. Dr. Bohlin, whom I have seen for more than 20 years, is expert at making patients feel safe and maximizing a sense of autonomy.

Another key is the role of social connection. For his own recovery, Dr. Bohlin says: “The secret is that I fell more in love with my recovery than with my drug.” In 12 step groups, he said, “I felt safe and loved and wanted. And that’s what I really wanted more than the drug.” The brain’s natural opioids — including endorphins — are critical to the physiology of stress relief. Typically, these neurotransmitters are released when we are soothed by loved ones, producing a sense of calm and contentment. This is why social connection can relieve both physical and emotional pain — and why its absence is a risk factor both for becoming addicted and for relapse.

So, I told my friends that I was having the surgery, and I had my husband pick me up after the procedures. He also picked up my prescription — only a few days’ supply, which is another useful precaution. If I’d had cravings, I would have asked him to hold them for me, as experts recommend. For those in 12-step recovery, more support from a sponsor is also suggested.

I felt both less anxiety and less pain because I knew relief was available if needed. I took six opioid pills during the course of two separate surgeries. But I didn’t experience craving. I had one moment where I felt as though my body was in perfect ease, and a vague memory of having loved this experience earlier. However, it wasn’t overwhelming or seductive — let alone worth risking the life I have now. A life worth living — where you feel deeply connected to others, have the tools you need to manage distress and have a strong sense of purpose — is the best defense against addiction.

It may be that for some people, pain itself makes opioids less euphoric, for reasons that aren’t fully understood. This may also be part of why I didn’t crave more.

With the support and precautions mentioned above, people with addiction who need pain care can be treated humanely and effectively, by controlling drug access and surrounding the person with support. Some may still choose to avoid exposure — but no one should be left in agony because of false beliefs that this protects them from addiction.

Maia Szalavitz (@maiasz) is a contributing Opinion writer and the author, most recently, of “Undoing Drugs: How Harm Reduction Is Changing the Future of Drugs and Addiction.”

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