A couple of weeks ago, when I learned that I would have the opportunity to interview Mark L. Kraus, M.D., FASAM*, one of the nation’s top thought leaders on addiction, I asked you to tell me what questions you wanted me to ask. I tried to incorporate most of your questions into our discussion.
Dr. Kraus is an addiction medicine specialist and a diplomat of the American Board of Addiction Medicine. He is also an internist in private practice and Assistant Clinical Professor of Medicine at Yale University School of Medicine.
Dependence or Addiction?
I began our discussion by asking Dr. Kraus if he differentiated between dependence and addiction. He responded, “Yes, I think that physiological dependence and addiction are different.” He went on to explain that opioids work by binding to a mu receptor site, causing a biophysical and biochemical reaction. The receptor sites become so sensitive, or up-regulated, to the opioid that they must continue to be bathed in the chemical or they will scream, “Give me more!” If they don't get enough, they will crash. This same physiological reaction occurs whether a person is taking opioids to relieve pain or is abusing them.
“Where addiction goes further,” Dr. Kraus said, “is when it causes dysfunction in the person's life – financial, personal, legal problems. When it starts to interfere with their very being, I think we're starting to talk about an addiction.” He described addiction as a chronic brain disorder whereby someone becomes so up-regulated that tapering them off or withdrawing them from the medication becomes a really big problem. It can be done, but it is very difficult.
On the other hand, the pain medicine patient who is taking the medication properly, as prescribed, can usually be tapered down and off with much fewer problems. He concluded, “So I think the difference is the behavioral aspect.”
Tolerance or Addiction?
Some of you asked how to tell if you've just built a tolerance to the medication or the dosage of the opioid you're taking, or if it has turned into an addiction problem.
Dr. Kraus began by saying that when a patient is being treated by a licensed professional, who is prescribing opioids for pain management, they have a relationship. Then he went on to explain, “We've learned that opioids cause a thing called tolerance. You need more of the drug to continue to get the effect you're seeking. That's something, unfortunately, that's inherent in that class of drugs. It may very well be that they'll need to go up on their dose when it's not doing what the doctor and the patient want it to do.
“Drug seeking, drug behavior, misusing and abusing the script is not happening with the pain management patient, who is responsible and taking what the doctor said. The problem with the addict is they start misusing, abusing and diverting in an effort to buy more. That becomes an issue. Then the issues with their financial, legal and personal life become very much out of control and there's a big change in their behavior.
“That then becomes a very different situation. The only way the addicted person can behave is to get more drugs. They're spending their time seeking drugs. That's what they have to do in order to function. That's different that the person who has been taking their medication responsibly, the way the doctor prescribed it.”
Reducing Pain Medication
One person asked if it's ever smart to reduce your dosage of pain medication without a doctor monitoring your reactions.
Dr. Kraus responded, “I think it goes back to what I said before. There has to be a significant relationship between the doctor and the patient so there's communication going back and forth. I think that if the patient feels they need to reduce their medication, it should be with the doctor's knowledge and they need to discuss that. When they start doing things on their own, whether it's reducing the medication or taking more of the medication, that's misuse. In the pain patient's case, I think having that dialogue is extraordinarily important.
“I know that in my own practice, with patients I take care of who have pain, we have that dialogue. And it's a dialogue that is critical to their care because, after all, they're the ones that know their body. They may feel that at that point they can reduce their medication. Fine, let's do that. Or, you can't really do that the way you want to. We have to do it in a way that you're not affected adversely. So I think the back and forth is critical.”
Stigma on Patients Taking Opioids
A question I've heard from chronic pain patients more times than I can count is why, even though they have been ideal patients for many years, always taking their pain medications exactly as prescribed, do doctors still treat them as potential addicts? I asked Dr. Kraus if there was anything we, as patients, can do in communicating with our doctors that will help that relationship.
“Be open and honest and straightforward,” said Dr. Kraus. “One of the things I think about a lot is education. Not only do the professionals who prescribe have to be educated for responsible prescribing and really understanding what's going on, but also the lay population has to understand that misuse, abuse and diversion is something that just creates problems and keeps this stigma going. Having said that, I think that patients have to have that discussion with their physician...
"We've got to have physicians understand about pain. Pain medicine has come on to itself. There's even a pain specialty. So doctors who are treating patient in their primary care offices need to know that in their community there are doctors who are specialists. So I get a consult for you for heart disease because I'm at the point where I think I need help. It's likewise the same for pain. If I'm treating you and it seems to be going beyond what I know, I'll go to a pain specialist for help. I think we need to support the pain specialty in America, which is coming on to itself, because they're there for doing that. They consult and can take that rough case, get it squared away and put it back in the doctor's office... They need to establish that working team so that the patient is being properly treated."
I told Dr. Kraus that I couldn't agree more, but that from what I hear from patients, that kind of relationship and teamwork is more of a rarity than it is commonplace.
He responded, “Unfortunately, that's right. I think that as pain medicine grows and we realize its importance and the family of medicine promotes them, which is what's happening, I think that we'll see it treated as a regular part of medicine, a consultative part of medicine, so that people can be sent there for getting straightened out and doctors can learn from them about how to do it in their offices better.”
Helping Loved Ones Who May Be Addicted
I sometimes receive questions from people who are concerned about a loved one who they feel may have an addiction problem. I asked Dr. Kraus, “How can family members tell if their loved one is addicted or just has a physiological dependence on opioids due to their chronic pain and how can the family member help them?”
“It's a complex question,” said Dr. Kraus. First of all, if a family member starts seeing changes in behavior – isolating, problems that the person is having legally, financially, missing family functions, changing friends – that might be a tip off that something's going on. Or acting bizarre, acting in ways that they hadn't acted before, changing their personal hygiene – things like that would be big flags.
“The other thing is, it's got to be that the person we're talking about has a real strong relationship with this patient and can ask, 'Can I go to the doctor with you because I want to tell him my concerns? We need to work that out because something's not right.' And they would have to allow it.
“I think that going to the doctor and expressing it to the doctor with the patient, their loved one, spouse, partner, or significant other, would be very, very helpful. Letting the doctor know what they have seen as an observer would be very helpful. So again, it's that relationship the person have to have and the person with the problem has to have with their doctor. I think that would be the way to handle that.”
Dr. Kraus also noted that TurnToHelp.com has a very simple screening tool they could try to get the patient to answer. TurnToHelp.com is a Web site that offers patient case studies, a questionnaire to determine if you might be dependent on a prescription painkiller and a physician finder to locate a doctor certified to prescribe treatment.
I also talked with Dr. Kraus about treatment options for opioid addiction or dependence other than rehab facilities. You can read that portion of the interview here: Dr. Mark Kraus Discusses Treatment Options for Opioid Addiction and Dependence
* MORE ABOUT MARK L. KRAUS, MD:
Mark L. Kraus, M.D., FASAM is a General Internist in private practice at Westside Medical Group, Waterbury, CT. Dr. Kraus is a fellow of the American Society of Addiction Medicine (ASAM) and a Diplomat of the American Board of Addiction Medicine. Dr. Kraus is an Assistant Clinical Professor of Medicine at Yale University School of Medicine. He does clinical research in the field of Addiction Medicine, and teaches Addiction Medicine and General Internal Medicine to the Yale General Internal Medicine Residents. Dr. Kraus has written numerous articles and chapters on the subject of Addiction Medicine, and has lectured internationally, nationally and locally in the field of Addiction Medicine.
Published On: November 30, 2011