The instructions on the bottle read, Take 1 tablet every 4-6 hours as needed for breakthrough pain.

Exactly what does that mean? Some may interpret these instructions as permission to use a medication round-the-clock every four hours. Some may interpret that phrase as the bottle should only be opened come "hell or high water." And what exactly is "breakthrough pain?"

For those whose pain never ceases, it is hard to know when pain is "breaking through." Doctors write these instructions as if there is supposed to be some magical ceiling that pain burst through before the medication should be used. The problem with this confusion is that many people ultimately do take the pain medication on a routine schedule. So, if the instructions allow for four pills per day, a person locked into a routine might take Vicodin, Percocet, Dilaudid, or Norco at morning, noon, late afternoon and bedtime, everyday. With this type of schedule, the body becomes conditioned to "salivate" for pills.

Years ago, a famous scientist named Ivan Pavlov, studied physical conditioning in dogs. (Note: Conditioning is a learning process in which an organism's behavior becomes dependent on the occurrence of a stimulus in its environment) The infamous Pavlov's dogs where fed at certain times of day and the food was associated with some specific stimuli like bells. Every time a bell rung, or every day at five o'clock, a dog was fed. Soon the dog began to salivate with anticipation upon the sound of the bell or at a certain time of day. The dog was conditioned to the routine of the reward. Conditioned learning has since become one of the most powerful ways to train any animal, even humans.

Knowing this science, is it possible to understand that once someone is taking a pain pill on a routine schedule that the brain may start to trigger a pain signal in anticipation of the pill, in order to get the reward? Instead of salivating, pain becomes the physical anticipatory behavior. At morning, noon, late afternoon and bedtime, pain levels might rise in order to signal that it is time for a pill. Why else would the pain increase? Without a change in activity, sudden incident, or sudden worsening of the painful condition, "breakthrough pain" may just be a conditioned "salivation" response for a pill in some people, especially those who take breakthrough pain medications routinely, round-the-clock.

If the instructions on a bottle read, Take one pill every 4-6 hours as needed for breakthrough pain, one should interpret those instructions as meaning that the pill should only be taken in the event that the pain is beyond tolerable levels. One operative phrase in this interpretation is "in the event." Something needs to happen like a trip to the grocery store, playing with the grandchildren, or a long car ride. The other operative phrase is "beyond tolerance levels." The pain may always be there; the question is how much can one tolerate? Everyone is different. What one can tolerate, another cannot. But, if one finds that the pain is intolerable all the time and has to take pills every four hours, then that trap can doom the person to an endless cycle of conditioned pain signals. In such a case, increasing or starting a more stable long-acting (sustained release) medication may a more appropriate pain solution in order to avoid salivating for pills.