Avoiding Conditioned Responses to Medication
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.
Care must be taken in order to avoid unwanted conditioned responses. No one wants to train the body to want pills. No one wants pain as an automatic, reflex signal when it is time to take a pill because that can lead to an endless cycle of pain. The onset of a pain reflex may be one way that chemical dependency on pain medications grows into a nasty monster that chokes the life out of a person. And Pavlovian conditioning may be the force creating that life-squeezing grip on people’s lives.
Even though someone is hoping that these same pain relieving medications will give life back by taking the pain away, in some people, the pain pills may have the potential of taking life away by causing more pain, reflex pain, depending on how the medication is used. But in particular, the habitual routine of taking pills every four to six hours could create an endless cycle of pain behaviors that are dependent on an internal clock or other conditioned stimuli. At five o’clock, the pain alarm goes off and it is time to take a pill. The same thing happens at 11 o’clock and three o’clock. At this point when pain becomes a conditioned, physical anticipatory reflex, the purpose of pain pills seems to be defeated.
To avoid this problem in the future, maybe doctors should change the instructions on the bottle to read: “Open bottle and take one pill, only in the event of an emergency.” These instructions would leave less up for interpretation and less chance for patients to become Pavlov’s patients, salivating for pills.
Christina Lasich, M.D., wrote about chronic pain and osteoarthritis for HealthCentral. She is physiatrist in Grass Valley, California. She specializes in pain management and spine rehabilitation.