I’ve written on this blog a few times about hyperesthesia, one of the many possible symptoms of opiate withdrawal. In this condition, a patient’s sensitivity is drastically increased. It can be sensitivity to light, touch, sound, or a combination of the three, but it is most often experienced as a heightened sensitivity to pain and discomfort. In a state of hyperesthesia, patients feel agonized and tormented by mild discomfort that might not bother them if they weren’t in a state of withdrawal.
As you might imagine, this condition can be subjective and hard to quantify. It is also often masked by, or combined with, extreme anxiety. Patients with long-term addictions react extremely strong to mild discomfort, partly because feeling any discomfort is associated with the beginning of the brutal sickness of withdrawal. Even when they are on medication that protects them from the full brunt of withdrawal, they still read small discomforts as warning signs, and the feeling of impending doom can make life difficult for them, their loved ones, and their physicians. The demands of anxious and hyperesthetic patients are one large reason why many physicians will refuse to treat people with addictions.
I’m coming back to this topic today because of a recent conversation I had with a patient. He wanted to get off Suboxone, but needed it to decrease his anxiety so he could leave the house and take classes. He found every option stressful, and started to panic while contemplating even the smallest amount of stress. He had never been prone to anxiety before addiction rewired the way he looked at the world. It was the unfair but unavoidable truth that every path open to this patient would involve introducing some element of stress into his life, and his panic at the prospect was threatening his ability to function. I had a long talk with him about how it was impossible for me to medicate him into a state of perpetual calm, free of fatigue, stress, or discomfort; the desire for that feeling had driven him to narcotics in the first place, and he could probably only get it by going back to them.
This is not the story of an individual patient with anxiety problems. This is a problem that I see in all my patients to varying degrees. On top of the problems caused by their addiction, they have gained a fear of discomfort that is sometimes devastating. When they were caught in the cycle of addiction, this fear functioned as a survival mechanism to protect them from falling into withdrawal; now, it gets in their way.
One vital part of recovering from addiction involves a sort of retraining the patient’s expectations to the discomforts and stresses of the world. This is something that 12-step programs often recognize and do well, and halfway houses are often designed specifically for people who are in the midst of this retraining. It’s an aspect of care that I think medication-based addiction therapy needs to adopt and strengthen. We often talk about it in terms of “hedonic tone”, or a patient’s “happiness level” and their ability to tolerate changes to it, but I feel it’s not something that is consistently addressed. It is, however, a vital part of patient care, and the sooner we can systematically incorporate it into medication-based recovering programs, the better off we will all be.