Twelve-steppers and others on the road back from drug addiction and alcoholism often refuse pain meds—even opiates after major surgery—for fear of relapsing. And some of their best friends in recovery only encourage them in this line of reasoning. But for PWAs suffering severe pain, such refusals can be destructive and lead to needless suffering (see “Ouch! Make It Stop,” p. 94). Not only does pain slow healing, but studies show that untreated pain is more likely to lead to relapse than properly treated pain. Even if your drug of choice was heroin or prescription opiates, experts say, you should take appropriate, doctor-prescribed pain killers.

True, if you have severe, chronic pain and take opiates for more than a month, you are likely to become physically dependent and undergo withdrawal when medication is stopped abruptly. But tapering off can control this problem, and going through withdrawal, however unpleasant, is not, by definition, a relapse.

We often confuse physical dependence with addiction, but the two conditions are not equivalent. Addiction is the compulsive use of a drug despite negative consequences; dependence is the need for a drug to avoid symptoms. There is no addiction if the consequences of dependence are improved health, decreased pain and improved quality of life. Most patients who become dependent on painkillers are not addicted. QED: Using doctor-prescribed medication properly is not a relapse.

Some tips if you are in pain:

1. Tell your doctors about your addiction history. This will alert them to use caution when prescribing. If nonopiate medications aren’t effective, don’t be afraid to speak up. If a doctor treats this as “drug seeking,” find another doctor. If you’re in the hospital and feel that your pain medication is inadequate, speak with the patient advocate or ombudsman.

2. Explore alternative approaches to pain control. Some people find relief with acupuncture, massage, electrical nerve stimulation and other nondrug techniques. But don’t let a stiff upper lip get in the way of admitting you need additional relief.

3. See a pain specialist. These folks know how to distinguish between addiction and dependence, recognize the severity of unalleviated pain and are up on the latest research, techniques and drugs.

4. If you need opiates, try to maintain a steady level of pain relief. Studies show, interestingly, that people given opiates on demand are less likely to develop addiction than those who have to wait for medication to be given at a specific time: If you must wait in pain for medication, you develop a psychological association between the pill and the relief. This “up and down” feeling is reminiscent of active addiction. But if you stay at a steady, well-medicated level, this pain-and-relief pattern will be absent or lessened. Physicians call this type of prescribing PRN (an acronym for the Latin words as needed). However counterintuitive, keeping yourself comfortable is less likely to get you in trouble than drugging only when you can’t stand the pain anymore.

5. If on methadone, you may need higher doses of opiates. Some people assume that if you are on methadone, you feel no pain. This is false, but because of their tolerance, methadone patients may need extremely high doses (which could kill others) to get relief. Again, don’t be afraid to demand the relief you require.

6. Be sure that your doctors know about all your medications. Pain meds can interact with HIV drugs, particularly protease inhibitors. Some meds make painkillers stronger; others, weaker. Don’t take chances: If you feel overmedicated or as though your breathing is slower than normal, get help—these are signs of overdose.

7. Tell your sponsor or other recovery-support people about your use of pain meds. If you’re afraid that you will not take the meds as prescribed, have a friend give them to you as needed, bearing in mind that you should try to maintain a steady level. Ask yourself, “Am I in physical pain? Or do I just want distraction?” An honest answer will tell you whether you are drug seeking. If you attend support-group meetings, express your feelings about the situation. Just talking about pain can help relieve it because fear and loneliness make pain worse.

8. Don’t let others’ judgments keep you from relief. If someone in recovery says, “You’ve relapsed” because you take pain medication, ask to see his or her medical license!

Adapted by permission from an article in Notes From the Underground, Winter 1998–99, published by the PWA Health Group (212.255.0520). Other resources include “The AA Member and Other Medications” from Alcoholics Anonymous (212.870.3400).