Regent University's School of Psychology and Counseling
Faith and Therapy Magazine

Dr. Scott Wykes

Abstract

The use of prescription medications for pain management is on the rise. Along with the increase of legitimate use comes the rise in abuse and dependence.  Clinicians and pastoral staff may be in contact with patients and parishioners who may be caught in the dangerous cycle of opiate dependence.  Gaining awareness of the criteria associated with opiate intoxication, abuse and dependence can assist professionals in making the appropriate treatment recommendations and, if necessary, referrals for specific dependency treatment.

As she sits across from me, I notice her dilated pupils as wide as tea cup saucers.  There is no change in their diameter in spite of the fluctuating light shining into the room from lighter to darker with each movement of the clouds.  She comments that the room is too hot.  I notice the hair on her arms, standing, as if to reach for whatever wisp of wind available to release the heat that her body so readily produces.  She cannot explain her nausea, aches and pains or drowsiness, except to assume that she is experiencing post-partum depression or post-op blues from her emergency C-section that produced her first child 4 months ago.  A trained clinician who is adept at empathy and willing to step into her world, might begin the process to build rapport in order to validate her feelings for the trauma that she has experienced.  A post-modern, Solution-Focused therapist might begin to deconstruct the problem and look for the exception-- when the problem of nausea, aching and depression were not happening.  Thus the building of solutions to alleviate the symptoms could begin.  However; another therapist might begin reviewing or discussing her use of analgesic prescriptions—pain medications.  Opiates like Vicodin and OxyContin were most likely prescribed for the client after the operation and though initially taken according to the prescription, they may have now become “needed” to get through the day.  She might not understand the reasons behind her doctor discontinuing her painkillers; and is now searching for a way to cope.

This client is surely not alone.  In a decade and a half, the number of new young adult abusers of prescription painkillers has grown five-fold-from 400,000 in the mid-eighties to over 2 million in 2000 (CSAP, 2003).  This increase has also been noted in the emergency room statistics.  In a short time span, 1998-2000, the number of people entering an emergency room because of the misuse of hydrocodone (Vicodin) rose 48%, Oxcycodone (OxyContin) rose 108% and methadone 63% (CSAP, 2003). With such dramatic increases in misuse, one might begin to wonder where all these opiates are coming from.  Apparently, not all physicians are trained in the area of recognizing addictions and the power that they have as a prescriber in enabling patients in their misuse and dependence.  Unfortunately, addiction and addiction medicine is an area in which physicians receive little formal training (Bobbit, Kepling, and Althari, 2008).  This trend points to a larger number of prescriptions becoming available for abuse by the younger generations, including school age adolescents.

As easy as π

Prescription drug abuse is on the rise in school age children (Sowinski, 2009).  Chris* was just 14 when he started using prescription drugs.  He had heard from his friends about these pills that would make him feel “really good” and could even help with improving his grades.  For a youth whose high anxiety would correlate to dropping grades it was a no brainer that he would get hooked as his grades began to improve after each daily dosing.  It wasn’t long before he started attending parties where “pharming” was the norm.  Pharming is the dangerous practice wherein party-goers grab a few or a handful of unknown pills out of a bowl filled by the contributions of other party-goers and ingest one or many of them.  The source of these contributions usually come from teens cleaning out medicine cabinets or other unmonitored pill storage areas.  The ease of abusing prescription medications facilitates their lure. Getting high only takes one swallow as opposed to multiple drinks of alcohol.  Pills can be ingested anywhere without arousing suspicion unlike alcohol breath or undeniable stench of marijuana.  Pills are smokeless and no “works” are required; taking pills doesn’t produce external damage to the body like the nasal passages of a cocaine addict, the tracks of an intravenous user, or the scab marks of a methamphetamine user.  This is not to say that Chris and other abusers won’t eventually smoke, snort, or shoot up their opiates, but in the early stages, ingestion is enough to satisfy the need. However, as the cost increases and availability decreases, some prescription medicine abusers begin to turn to heroin (Carlisle, 2009).

Chris presented to therapy due to his parents’ belief that he had untreated Attention Deficit Disorder because of the tremendous level of impairment in his attention and memory. His complaint was that he just could not sleep through the night.  Abusing opiates since he was 14, and now experiencing the effects of physiological dependence at 25, Chris cannot seem to shake his opiate habit. As equally puzzling is his lack of ability to connect his symptoms to the damage done to his brain due to his long-term drug abuse. The goal of prescribing opiates is to dampen the brain stem in order to block pain receptors.  Along with that it affects the other autonomic functions, like breathing, hearing and temperature regulation. It is hard for him to stay focused when he is sweating, vomiting and dealing with diarrhea every few days as he tries to quit taking the pills on his own but continues the cycle of dosing and withdrawal. Chris’s generation is not the only one affected by the recent trend. Misuse and abuse of legal and illegal drugs constitute a growing problem among older adults (Simoni-Wastila and Yang 2006).

Despite a wealth of information on the epidemiology and treatment of alcohol abuse in older adults, few comparable data are available on drug abuse in this population.  The evidence suggests that although illegal drug use is relatively rare among older adults compared with younger adults and adolescents, there is a growing concern of the misuse of prescription drugs with potential for abuse.  It is estimated that up to 11% of older women misuse prescription drugs and that nonmedical use of prescription drugs among all adults aged greater than 50 years will increase to 2.7 million by the year 2020 (Simoni-Wastila, L., and Yang, H., 2006).  Factors associated with drug abuse in older adults include female sex, social isolation, history of a substance-use or mental health disorder, and medical exposure to prescription drugs with abuse potential.  As the population that we encounter continues to age, it is important to recognize these factors in the clients that we serve and in the congregants who fill the pews and volunteer in our places of worship.

Counselors not Physicians

As Counselor Educators, therapists, psychologists, and pastoral counselors, surely we are not expected to be experts in the area of the use of medications.  However; we do have the responsibility to be knowledgeable of some of the benefits and side effects of some of the more widely used pharmaceuticals.  The use of analgesics will likely continue as a necessary component of pain management prescribed by qualified medical professionals.  Psychoactive medications are used by approximately 1 in 4 older adults, with a likely increase as the population ages (Simoni-Wastila, L., and Yang, H., 2006).  The prescribing of these medications has the potential for abuse and dependency and as providers and confidants we are on the front lines to provide advocacy and referral when we encounter addiction in our clients.

What Can We Do?

The co-occurring nature of a substance abuse problem and a mental health problem is fairly common.  Asking whether your client has recently or is currently prescribed pain medication is an integral start.  A therapist, psychologist, lay counselor or pastoral care team can be highly involved with clients and congregants by providing crucial emotional and spiritual support whether enduring pain or managing off of the medication if it has become a problem.  As treatment providers, we can also maintain active contact with the prescribers by reporting observations through informed consent.  Overall we can be open to the possibility that prescription drug abuse can be found in our clients’ complaints—depression and anxiety may not be the only presentation of what is in front of you.

It is likely that on any given Sunday, there may be clients and congregants who are taking prescription pain medication appropriately. However, others may not be and these are some signs to be aware of:

Opioid Intoxication:

1. Drowsiness (or coma if overdosed)
2. Slurred speech
3. Impairment in attention or memory

Opioid withdrawal:  These symptoms can be observed between dosages as the medication is slowing being detoxed from the body.

1. Dysphoric mood (feeling hopeless)
2. Nausea or vomiting
3. Muscle aches
4. Lacrimation (excessive tears) or rhinorrhea (excessive runny nose)
5. Pupillary dilation, pilo-erection (hair standing on end), or sweating
6. Diarrhea
7. Yawning
8. Fever
9. Insomnia

These are signs that are observable by the clinician/pastor and may be reported by the client.  However, listening to the language of the client is important also. Hearing the client talk of “needing” the medication; planning life activities around dosages; disclosures of taking more than prescribed or needing more because the current dose wasn’t helping anymore; switching doctors because there was no longer a willing prescriber; or new or mysterious pains and injuries to justify continuing the medication are all signs that should alert us to the potential for problem use.

The purpose of the information in this article is not to say that all problems encountered in a therapy session are drug related, but to bring about awareness of a silent epidemic that is found between the youth and the aged of our population.  Because these types of medication, designed to be helpful, are so easily abused and readily lead to dependence, it will take all of us to build awareness for the people with whom we have relationships. If you suspect that you or someone you know is abusing pain medication, seek the assistance of your care provider and call the involved physician.

Note: September was national Recovery Month. The following link offers helpful information for individuals and families struggling with addictions of any type www.recoverymonth.gov/. The step before recovery is awareness that a potential problem exists.

References

American Psychiatric Association, (2000).  The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.  Washington, DC, American Psychiatric Association.

Bobbtit, K., Kepling, M. and Althari, H., (2008).  Understanding Addiction: The orthopedic surgical perspective to a significant problem.

Carlisle, N., (2009 07/20).  Heroin on the Rise in St. George: Police: Prescription pain medicines often a segue to the cheaper opiate. http://www.bhcjournal.com/default.aspx?tabid=182&ArticleId=33895 The Salt Lake Tribune.

Center for Substance Abuse Prevention, (2003).  Trouble in the Medicine Chest [1] Rx Drug Abuse Growing.  Prevention Alert, Volume 6, Number 4.

Simoni-Wastila, L., and Yang, H. (2006).  Psychoactive drug abuse in older adults.  The American Journal of Geriatric Pharmacotherapy, Volume 4, Issue 4, December pp 380-394.

Sowinski, G (2009 07/20).  Prescription abuse on the rise locally.  Retrieved from http://www.bhcjournal.com/default.aspx?tabid=182&ArticleId=33894. The Lima News, Ohio.