What is Pain?

Pain is defined as any unpleasant sensory or emotional experience. What a pain specialist treats is mainly the physical or the sensory component of the pain. Without delving into the pathophysiology of the physical pain, we will simply define the pain as any unpleasant sensory experience arising from a physical injury.

Philosophy of pain management

The job of a physician is to help eradicate pain when possible and to help patients manage the pain the best they can when this is not possible. Pain management is not necessarily the elimination of pain. The main goal of pain management is to improve the quality of life and restore function to the best level possible.

Methods of pain control or elimination

The best arsenal in treating pain is the body's own natural healing process. Most injuries heal on their own. Body has an amazing restorative capability. Sometimes, a physician must educate the patient about the natural course of an injury and give time for this to take place. While healing is taking place, a physician can help the patient control the pain by various means. This is usually done in a step wise fashion, starting with the least aggressive or invasive means and adding stronger measures as needed. Pain control does not start with the use of strong opiate pain medications but often starts with over the counter (OTC) analgesics such as Tylenol (acetaminophen) and ibuprofen.

First tier in the treatment of pain is always with behavior modifications. Patient must be made to understand that they must heed the pain as a warning sign that their body is trying to tell them what to avoid. Rest is essential for any healing to take place. This does not mean bed rest but avoiding those activities that cause worsening of the pain. At the same time, modalities such as ice, heat, elevation, or splinting are crucial in helping decrease the pain.

In the second tier of pain management, the use of the OTC medications are used as mild analgesics. Tylenol as well as all non-steroidal anti-inflammatory drugs (NSAID) have analgesic properties. They are inexpensive and well tolerated for the most part. Often times, mild pain can be treated alone with these medications. Although for the most part these medications are safe (if used as directed), there are few things to know about them to prevent potentially serious side effects.

Tylenol (acetaminophen) can be hepatotoxic (meaning toxic to the liver) if ingested in large quantity. The upper limit of Tylenol that can be safely taken in a 24 hour period for a healthy adult is 4 grams. This is 8 extra strength Tylenols. Fatal dose of Tylenol for a healthy adult can be as low as 6 grams. This means that there is very little room for error. You must keep in mind that many of the OTC cold medications have Tylenol in them. So one must know what other medications that one is taking to prevent Tylenol overdose. For those patients with liver problem or for those who drink large quantities of alcohol, even the safe amount of Tylenol may be detrimental to their liver.

All NSAIDS (such as ibuprofen, Aleve, etc.) have potential nephrotoxic (meaning toxic to the kidney) side effects especially at high doses. Those patients with kidney problem should avoid NSAIDS until they have consulted their physician. More commonly, all NSAIDS (except for the COX2 NSAID, i.e. Celebrex) have potential GI side effects. Most of the time, the GI side effects are minor and include upset stomach, nausea, heartburn, and abdominal cramping. However, in small percentage of patient, these NSAIDS can cause an ulcer, even a potentially life threatening perforated ulcer.

There has been lot on the news about the potential harm from the COX2 NSAIDS such as Vioxx, Bextra, and Celebrex. They have been linked to increased risk of heart attacks and stroke when taken on a long term basis. What the FDA is now saying is that these COX2 NSAIDS are not any more inherently dangerous than the traditional NSAIDS. What the studies are showing is that all NSAIDS including the COX2s can increase the risk of heart attack and stroke when taken on a long term base, usually for 8 months or more. When taken for a short period of time, these medications pose no such danger. Here, other interventions such as physical therapy modalities such as electric stimulation, myofascial release, ultrasound as well as chiropractic manipulations, massage therapy, acupuncture, etc. may have a role.

Third tier of pain management involves the use of the opiate pain medications. All opiate pain medications belong to the same class as heroin. Heroin is derived from morphine. Once in the brain, heroin is converted back into morphine. All opiates have addiction potentials. Generally, the stronger the opiate the more likely one can become addicted. However, we have known that most patients that get exposed to opiate pain medications do not become addicted, but that a percentage of patients can and will become addicted. There are patients that seem to be genetically susceptible to getting addicted where as most do not.

The use of the opiate pain medications have revolutionized the treatment of both acute and chronic pain. It has enabled physicians to help our patient achieve a better quality of life and improve function when used appropriately. As a physician, I understand that some of my patient will get addicted to these medications. Although started with good intention, some of the patient may end up paying a huge price if not handled properly. Thus, it is a great responsibility to be diligent about how these medications are used, to look for possible signs of addiction, to help patients avoid getting themselves into trouble as well as offer them a way out if they happen to become addicted.

A great fallacy that most physicians were taught was that 'when opiates are used to treat pain, patients do not get addicted'. This couldn't be further from the truth. As some one who has been treating pain for more than 14 years, I will tell you that this myth has caused more people more harm than any other statement that I can think of when it comes to the use of opiate pain medications. There is a grain of truth in this statement. It should instead read that "when treated appropriately, the opiate pain medications are less likely to get patients addicted". Key to understanding the above statement is that when you do not over treat the pain, even those patients that are genetically predisposed to getting addicted are less likely to get addicted. In other words, when pain medications are taken up to the level of the pain, there doesn't seem to as a high risk of addiction. When these medications are used to completely mask the pain or go beyond the level of the pain, in those patients that are genetically predisposed, any extra medication in the brain will cause the euphoria and stimulate the brain which can lead to addiction. Along with opiate pain medications, there are other pharmacologic treatments such as use of anti-depressants and anti-seizure medications that can have a role in the treatment of pain.

The right and the wrong way to use the opiate pain medications

Patient must be made to understand that the pain is there for a reason. Pain is a message that the body sends to the brain that there is an injury, and it is designed to prevent further injury from happening by preventing the patient from doing things that can further harm themselves. The most important reason why a diabetic patient develops an infection/injury that goes unnoticed until it has wrecked havoc on the body is because diabetes often leads to neuropathy, which is a nerve damage that can lead to inability to feel pain.

Yes, most of the time, the pain can be brought under control with the use of the opiate pain medications. These medications can be of great help in improving the quality of life by helping manage the pain. However, the wrong way of using these medications is to use them to block the pain so the patient can continue doing those activities that cause harm to themselves. In other word, if you couldn't do something before you took the opiate pain medications, you shouldn't be doing them after you take them. The pain medications should be taken so that you can rest and recuperate rather than continuing in activities that are detrimental to you.

Opiate pain medications only mask the pain; it does not eliminate the cause of the pain. There are other medications such as the anti-inflammatory medications that actually decrease/eliminate the pain by getting to the source of the pain. When taking opiate pain medications, one must understand that the cause of the pain is still there. If the pain subsides with the use of anti-inflammatory medications, you are less likely to make the injury worse than if you were while taking opiate pain medications.

Side effects of opiate pain medications

All opiate pain medications have side effects. The most common of these side effects is constipation. As one increases the dosage or the potency of the medications, the greater is this side effect. Most other side effects such as grogginess and nausea and vomiting as well as respiratory suppression subside with prolonged use. However, constipation does not. Early preventative measures such as using stool softeners and increased fiber intake and good oral hydrations can eliminate or manage this side effect.


Any one taking opiate pain medications for an extended period of time will become physically dependent on them and will develop tolerance to them. Dependence and tolerance are not addiction. Dependence describes the physical state that happens once exposed to these opiates on a long term basis. This is manifested by physical withdrawal that happens when the opiates are taken away. Anyone who has been taking opiate pain medications on a long term basis will go through the physical withdrawal symptoms listed below. This does not mean that they were addicted.

Tolerance in our case is best described as the liver's ability to metabolize these substances better and faster once it has been exposed to them for a while. We all know that as a freshman in college, one or two beers got you drunk. By senior year, you were able to drink a six pack before it hit you. Patients taking oral opiate pain medication will notice that after a while, it loses some of its effectiveness. However, the liver will not keep metabolizing the medication faster and faster over time. There seem to be a break even point where a tolerance levels off and there isn't any further loss in effectiveness unless the medication dose or strength is increased. This is the reason why when treating chronic pain, it is important to make the patient understand that increasing the pain medications to achieve "no pain" eventually leads to same level of pain relief as when you first started out. Reverse is also true. That is, gradual decrease in the opiate pain medication can reverse this faster and faster metabolism. However, every time you decrease the medication, you may experience withdrawal symptoms. Slower the decrease the less withdrawal symptoms you will experience.

Withdrawal symptoms

Withdrawal symptoms will vary in intensity depending on how quickly you are reducing the medication or how high a dose you are coming off of. These symptoms can range from flu-like symptoms, agitation, feeling of doom, elevated blood pressure, quickened heart rate, dilated pupils, diarrhea, runny nose, goose bumps, and abdominal cramp. The physiologic withdrawal usually only lasts about a week. We will discuss the psychological withdrawal symptoms for an addicted person later in the addiction section.

As stated above, any one who has been on the opiate pain medication for a long period of time will go through withdrawal when coming off of it. This does not mean that he/she was addicted.



First and most important thing to understand about addiction is that it is a disease, an illness. Like any illness, it should be treated with empathy and understanding rather than being marginalized or criminalized. And like many illnesses, there is a genetic predisposition to addiction. Addiction is defined as 'continued behavior in spite of knowing that the continued course will harm oneself'. It is defined by 'the lack of self-control and feeling of helplessness in the face of such continued behavior'.

Why does anyone get addicted to anything? Because it makes them feel good, I mean really good. If something makes you feel bad or just put you to sleep, don't worry, you won't get hooked on it. What ever the 'drug of choice' is, it makes that person feel better than they should. It makes that person happy, excited, euphoric, and/or high. If something makes you feel that good, it is easy to understand why you would want more and more. Unfortunately, anything that makes you feel that good can't be good for you.

If you have ever seen the movie "When a Man loves a Woman" with Meg Ryan and Andy Garcia, there is a scene when Meg Ryan, an alcoholic at the end of her addiction, stands up in her first AA meeting that tells us a lot about why one becomes addicted to anything. She stands up and says "When I was 15, I had my first beer, and I liked it. So, I had another and another." Most of us do not remember our first drinking experience because it was not a very memorable experience. Alcohol, for most of us, is an acquired taste. However, for those that are susceptible to becoming addicted to alcohol, the first taste of alcohol produced such a highly euphoric and enjoyable feeling that they remember it vividly.

The reason why some people don't understand why others get addicted is because they do not have the same response/experience to these substances. They say, 'Gee, all it does for me is makes me groggy and nauseous'. They think that others must have the same experience as they do. 'Why can't Johnny just stop?' Of course, if Johnny had the same experience as they did, he wouldn't have gotten hooked. On the other hand, if they felt the way same that Johnny did, they would have probably gotten hooked as well.

We know that alcoholism runs in the family. We also believe that addiction to opiates have a genetic predisposition as well. We know that there are environmental and outside influences that affect addiction. For example, stress can often trigger a relapse in an alcoholic who may have been clean and sober for years. However, we have known that same stressors do not cause addiction in most. In 2004, a genetic marker for alcoholism was finally isolated. Argument between nature versus nurture can be (or should be) finally be put to rest.

Because addiction seems to have such huge genetic predisposition, we should treat addiction as a medical illness rather than a character flaw. It is not the weak of mind or lack of moral compass that lead some to fall victim to addiction, but rather a medical illness that brings about the behavior that we call addiction. About 10% of the populations is thought to be genetically predisposed to becoming an alcoholic. For those of us who treat chronic pain and addiction, we think that the genetic predisposition to opiate addiction is probably about the same. Addiction crosses all ages, races, sex, and socioeconomic levels. For those that are genetically predisposed, it is a life long condition; one does not become immune to it with age.

The common factor that predicts or explains why someone gets addicted to a substance is that, for those that are genetically susceptible, these substances act to make them highly euphoric or happy (at first). Alcohol for most people is a sedative. The first drink that they have sedates them. They may feel mild euphoria from it, but sedation is the predominant experience. It makes them feel groggy and calms them down. For those that are genetically predisposed to getting addicted to alcohol, it acts as a stimulant at a low dose. They become highly excited and extremely euphoric. They are the ones that are the "life of the party" when they start drinking. This is because for them alcohol triggers the brain in a different way. It makes them happy and excited. However, once they are hooked, these substances become a need rather than a way to make them "happy". After a while, alcohol becomes a necessity to just feel "normal" and to be able to function day to day. Opiate addiction behaves very similar to alcohol addiction. Most of the time, an addict is not trying to get 'high' but trying to survive by using the drug.

Most people don't like being "out of control". Once you are addicted to something, you are no longer in control of it; it is in control of you. What an addicted person wants the most is usually to get off the rollercoaster ride of "highs" and "lows" that addiction brings with it. However, they feel helpless and are often unable to stop the escalating pattern of addiction despite knowing what is happening.

Early on, before the patient becomes truly addicted and loses control, he/she does not want to stop because they feel "good". What I hear often early on from a patient that is getting addicted is "Why should I stop when it makes me feel good". Later on, after addiction has taken full control and patient feels powerless, what I hear is "I don't' want it anymore but give me more".

If something makes you feel that good, what's wrong with continuing it as long as you can get steady supply of it? Problem is when the brain is over stimulated, there seems to be increased dopamine receptors in the brain searching them out. This is thought to be the reason behind the cravings as well as the reason why normal things that used to give one pleasure no longer do. Addicted person no longer finds pleasure in simple things in life like eating or even sex. It changes the person. Family members often notice that their loved one is no longer him/herself.

Another thing that is totally different for those patients that become addicted is that the physical withdrawal is often followed by 2nd set of withdrawal symptoms, that of psychological withdrawal. Where as the first withdrawal caused agitation and restlessness, the 2nd withdrawal will often cause lethargy and somnolence. It's as if the brain needs that "kick" or stimulus that the drug gave.

Unlike some that may have gotten addicted to street drugs after experimenting with it, patients that get addicted to opiate pain medication got addicted inadvertently. Early on, patient may not realize that he/she is getting addicted. If one understands addiction and its early signs, one can avoid getting addicted by decreasing or stopping the opiate medication. If you take the pain medications below the level of the pain, the chance that you will get addicted is much less.

Can some patients actually become addicted, and not know it? Yes! There are great deal written/reported about this by former patients who became addicted, then somehow the medications were taken away from them (such as from incarceration), and after months of going through psychological withdrawal, their pain finally goes away. After their release, they have reported this to their former doctors. It seems that in some patients, the brain magnifies the pain to justify getting the medication it feels that it needs!

Common early signs that you may be at risk for opiate addiction:

Suboxone/Subutex (buprenorphine HCl)

So you are hooked? For those patients that are hooked on the opiates (whether to prescription medications or the street drugs), now we have an effective treatment option. Before Suboxone and Subutex came on the market, the only medication available to treat opiate addiction was methadone. However, methadone was a dismal failure. The reason was that when the patient stops the methadone, the craving usually came back.

With Suboxone and Subutex, we can finally treat the withdrawal symptoms as well as the craving. The therapeutic ingredient in both the Suboxone and Subutex is the buprenorphine. Buprenorphine is a partial opiate agonist, which means that it binds to the opiate receptors without triggering it. Thus, it eliminates the craving the brain has to be stimulated by opiates without triggering the release of chemicals that give rise to the feeling of euphoria and high. When treating withdrawal symptoms, patients can be weaned off the Suboxone/Subutex in matter of weeks. When treating addiction, patients maybe on them for a long time.

If you do decide to become 'clean/sober' with the help of Suboxone, you need to plan on being on it for at least 6 months. After 6 months, if the craving comes back as soon as you come off the Suboxone, you should plan on being on it for a full year.

If you have been off the opiates for more than 1 month, and you decide to go back to using it for whatever the reason, please do not go back to the same dose that you were using when you stopped. IT CAN KILL YOU! The tolerance that you have developed over time is now gone. That 80mg of OxyContin that you used to smoke on regular basis can now kill you. Unfortunately, one of my patients learned this the hard way.

Relapse Prevention

Why do some people relapse? If you have a monkey on your back that tells you that you must get high, it is not a choice. No matter how strong your will power, you may fail. All it takes is one dose to send you down the spiraling path of addiction. However, when you wake up and there is no craving, then whether you decide to get high or not is a choice, a bad choice, but still a choice. Suboxone gives patient a 2nd chance. It gets rid of the craving. Why then would anyone go back?

Reason why some people relapse is because they forgot. They forgot how bad it was when they were truly hooked. They remember how good it felt, but forgot the misery of being addicted. Memory is often faulty. If memory does not fade over time, no woman will have more than one child. We often remember our old relationships with fonder memory than we should. Those patients who attend NA (narcotics anonymous) or AA (alcoholics anonymous) seem to do better because the meetings remind them of how bad it truly was. You can find the local meetings by going on or

Suboxone assistance

If you can't afford to pay full price for Suboxone (it is about $5 to $9 a pill), there is a prescription assistance program through Washington State that you may qualify for. Go to to register.

By the way, now there is a FDA approved drug for alcoholism as well. It is called Vivitrol. It is a monthly injection of medication called naltrexone, which is similar to the opiate blocker found in the Suboxone. Alcohol also releases dopamine and by blocking this, the naltrexone seems to get the cravings for the alcohol under control.

Kyle Oh, MD

To learn more about Suboxone/Subutex visit:
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