Timothy C. Hain, MD, Chicago IL.• Page last modified: July 7, 2020
One is physically addicted when one takes a medication daily, and suffers withdrawal symptoms unrelated to the primary purpose of the drug, when one attempts to stop. Certain common patterns of drug use are generally considered addictive. For example, daily use of narcotics or use of sedative medications during the day usually indicates a physical addiction.
Narcotic drugs are often abused. In a study of migraine treatment in which daily narcotics were prescribed, there was evidence for dose violations (taking more than prescribed), multisourcing, lost prescriptions in about 50% of persons on narcotics (Saper et al, 2004). Diversion of drugs is also a significant concern.
While few people want to be addicted to drugs, from time to time, these agents are needed to keep patients comfortable and productive. In this situation, there should be regular physician supervision and consideration of other approaches than the addictive medication. Recently, it is recommended that there is a "pain contract" for patients being prescribed regular narcotic medications. We think this is a very good idea.
If one wishes to stop an addictive medication, one must usually "wean" off. In general, this means cutting down the dose by a significant amount (say by 1/2), every week, until it is entirely stopped. Going "cold turkey" with addictive medications is usually a bad idea.
Narcotics include Tylenol #3, anything with codeine or hydrocodone, Darvocet, Darvon, Demerol, Vicodin, Percodan, Roxanal, Stadol, and many others. Drug dependence is characterized by repetitive use of a substance that results in problems in three or more areas of life such as : 1). Development of tolerance 2). Development of withdrawal 3). use of substance in larger amounts or for longer periods than intended 4). unsuccessful efforts to cut down on use of substance 5). spending a great deal of time in activities necessary to obtain substance 6). giving up social, occupational or recreational activities because of drug use 7) continuing to use substance despite physical or psychological problems associated with use.
In recent years (this is 2017), it has been recognized that addiction to opiates can occur very quickly, and it is best to greatly limit the # of pills prescribed to a "naive" patient.
Sedatives or drugs containing sedatives (Fiorinal, Fioricet, Valium, Ativan, Xanax, klonopin, Equinil). Addiction consists of either daily excessive use (e.g. 4 Fiorinals/day), or significant withdrawal symptoms unrelated to the primary indication for the drug -- for example, unable to sleep after stopping Ativan, Valium or Xanax. Barbituate overuse can be treated with phenobarbital which allows a slow taper. Barbituates are sometimes associated with chronic daily headache (see section below on rebound) in women.
While not generally used for headache, amphetamines such as Dexadrine and Ritalin, and of course alcohol are also addictive.
Ergot drugs and Triptan drugs(DHE, ergotamine, any drug with "ergot" in the name, and anything with "triptan" in the name). The main problem here is "rebound" headaches (see below). Recommendations for MAXIMUM use of medications follow.
|Medication||Maximum Recommended Use|
|Codeine||2 treatment days/week|
|Oxycodone (i.e. Percocet)||2 treatment days/week|
|Butlbital (i.e. Fiorinal)||2 treatment days/week|
|Proproxyphene (i.e. Darvon)||2 treatment days/week|
|Butorphanol (i.e. Stadol)||2 treatment days/week|
|Ergotamine tartrate||8 treatment days/month. Maintain 4 day gap between treatment days|
|Sumatriptan||6 treatment days/month or 2 treatment days/week|
Adapted from table 6 in: Solomon G, Cady R, Klapper J, Ryan R. National Headache Foundation: Standards of care for treating headache in primary care practice. Cleveland Clin. J. Med 64/7, 1997, 373-383