As the CDC gets ready to issue its 2016 guidelines for prescribing opioids for chronic pain, a comprehensive overview of the scientific literature, Prescription Opioid Misuse, Abuse, and Treatment in the United States: An Update, was released to little fanfare just last month in the American Journal of Psychiatry.
The authors, headed up by the renowned Kathleen Brady, MD, PhD, both a Distinguished Professor and an Associate Provost on the addiction sciences faculty at the Medical University of South Carolina, paid particular attention to the fact that we have little research to guide treatment of people addicted to prescription opioids including hydrocodone (Vicodin), oxycodone (OxyContin and Percocet), and morphine.
How Can This Be?
With all the talk about the opioid “epidemic”, how could this be? Because until 5 to 10 years ago, treatment research on opioid use disorders was largely focused on intravenous heroin use.
Reviewing the scientific literature from 2006 to the present, Dr. Brady and several colleagues took a look at the scope of opioid abuse and overdose problems in the U.S., as well as practices having to do with prescription practices, treatment, and prevention of opioid misuse and addiction.
Their review addressed some important questions about which many in the public and the field hold misconceptions, as well as some important points seldom addressed by the media in all the hysteria about the opioid “epidemic.” This article will focus on those aspects of the Brady review.
What’s the difference between physical dependence and addiction?
As the review points out, if a person is taking the medication(s) as prescribed, being physically dependent on them does not necessarily mean that an individual has an opioid use disorder or what’s commonly referred to as “addiction.”
When opioids are used regularly (say, daily for more than two to three weeks) even as prescribed, individuals tend to become physically dependent on them. This means that tolerance is developed, more of the drugs are needed to get the same intensity of effect, and some withdrawal may occur if the person goes off the opioid abruptly.
To avoid withdrawal symptoms, which are very uncomfortable but not life threatening, those who become physically dependent on opioids prescribed for pain can generally be managed by tapering the opioid gradually when their pain subsides.
The authors use the term “misuse” of opioids as a broad one that captures any use outside of prescription parameters, including misunderstanding of instructions, self-medication of sleep, mood, or anxiety symptoms, and compulsive use driven by an opioid use disorder (or what most of us know as addiction.)
How bad is the prescription opioid addiction problem?
It’s hard to watch or read the news without hearing about the opioid “epidemic.” And, as the Brady review points out, since the late 1990s, the prevalence of opioid misuse has escalated rapidly in this country, with opioids second only to marijuana as one of the most commonly initiated drugs.
Before 1990, physicians were criticized for undertreating pain, and then the pendulum shifted the other way. Now, some are concerned that hysteria and hyper vigilance about opioids will lead to inadequate pain management for many who really need help. (One of my physicians recently shared with me that he thinks physicians who regularly prescribe opioids are seen as having a “black mark” on their backs.)
Before 1990, physicians were criticized for undertreating pain… Now some are concerned that hysteria and hyper vigilance about opioids will lead to inadequate pain management for many who really need help.-Anne FletcherThe article notes that rates of unintentional overdose on prescription opioids almost quadrupled from 2000 to 2010, accounting for more than half of all overdose deaths and exceeding overdose deaths attributed to all other illicit drug categories combined.
Yet, Brady and co-authors strongly reinforced the case Kenneth Anderson made in a recent Pro Talk column titled, How the Media is Fueling the Overdose Epidemic when they state, “Concomitant use of multiple prescribed and illicit substances is implicated in the majority of overdose deaths.”
In other words, the culprit in most of these cases is a deadly mix of drugs, not the opioid itself. Brady’s group stresses that use of benzodiazepines combined with opioids is the most common factor in prescription opioid-related overdose deaths.
Anderson adds that it is relatively difficult to overdose on opioids alone and that alcohol and cocaine can be deadly mixes with opioids as well. He stressed,
“The reason drug mixing is so common is that the current crop of new opioid users simply does not know how dangerous it is… If today’s opioid users were equally well-informed of the dangers of drug mixing, most would avoid it and countless lives could be saved.”
Time and Energy
As important as concerns are about opioid use and abuse, I also take issue with the amount of time and energy placed on the issue when nearly 88,000 people (approximately 62,000 men and 26,000 women) die from alcohol-related causes annually, making it the third leading preventable cause of death in the United States.
In 2013, the most current year for which figures are available, prescription opioids were involved in 16,235 drug poisoning deaths and heroin in 8,260 deaths. (Anderson reiterates that most of these deaths involve drug mixing.)
With all the attention on opioids, I am concerned that the harmful effects of alcohol misuse may be getting lost in the shuffle. (I’ve heard clients at the dual diagnosis clinic at which I work say, “I ‘just’ have a problem with alcohol,” as if that just doesn’t compare with a “real” drug problem.)
How Should Pain Be Treated in People With Addictions?
I’ve known people both personally and professionally with an active or past addiction to be in severe pain yet denied prescription painkillers or “violated” by their probation officers because they took a prescribed painkiller for such problems as an agonizing toothache. Yet Brady and colleagues boldly state:
“The treatment of pain in individuals with addiction disorders does not differ significantly from the treatment of pain in non-addicted individuals… In the management of moderate to severe acute pain, opioids are generally the mainstay of treatment in addicted or non-addicted individuals.”
They make the important point that people with substance use disorders are at greater risk than others in the general public for accidents and injuries associated with pain and that untreated pain can be a major trigger for relapse.
In such cases, scheduled – as opposed to “as needed” – administration is preferred for a variety of important reasons detailed in the article. Multiple alternative approaches, including the use of non addictive medications, TENS units, nerve blocks, trigger point injections, relaxation training, and biofeedback are suggested as well.
What do we know about treating prescription opioid use disorders?
Research specifically pertaining to prescription opioid use disorders is limited, even though heroin use disorders are about four times less prevalent. Thus, treatments shown to be effective for opioid use disorders more broadly tend to be used. As such, the treatment protocol for opioid use disorders typically involves medically supervised detoxification followed by maintenance with opioid substitution therapies, such as methadone and buprenorphine (usually in the form of Suboxone). These longer acting opioids are prescribed in controlled amounts to reduce cravings and prevent withdrawal symptoms with less euphoric effects. As the authors note, “Opioid substitution therapy often involves long-term, or even lifetime, use of [such] medication.”
…the treatment protocol for opioid use disorders typically involves medically supervised detoxification followed by maintenance with opioid substitution therapies, such as methadone and buprenorphine (usually in the form of Suboxone).-Anne FletcherNaltrexone is a different kind of medication that can be given orally or by injection to block the euphoria induced by opioids. Studies are on going about its effectiveness. One concern is that because naltrexone decreases opioid tolerance, it can increase the risk of overdose in people who return to illicit drug use. (Brady and co-authors point out that overdose deaths associated with oral naltrexone are three to seven times higher than those associated with methadone maintenance therapy.)
The article goes on to review the limited number of studies specific to treating prescription opioid use disorders, most notably the Prescription Opioid Addiction Treatment Study. This is to date the largest existing randomized controlled study of treatment for prescription opioid use disorders. It examined varying durations of Suboxone treatment and different intensities of counseling for patients with prescription painkiller addiction. Treatment outcomes have now been reported for a subset of the original group of patients after 42 months. Overall, use of Suboxone was associated a greater likelihood of illicit opioid abstinence.
Although such experts recognize such medications as the treatment of choice for opioid use disorders, I’ve noted in a previous column, Opioid Addiction: Why Don’t More Rehabs Use Suboxone?, that numerous treatment facilities are resistant to using these medications, increasing their clients’ chances for relapse and even death due to overdose.
It’s also a problem that some Alcoholics Anonymous and Narcotics Anonymous don’t view Suboxone and methadone users as being in recovery, even though the academic and most of the medical world does.
In the end, as Brady and co-authors suggest, we just don’t know if we can extrapolate effectiveness of existing treatment options beyond those drawn from research with broader opioid use disorder samples of people (for instance, heroin users) to “patients presenting with a primary prescription opioid use disorder, particularly those with a chronic pain condition that led to initial use of opioids” because research in this area is sparse.
Also, questions have been raised by recent research about the benefit of counseling when added to medical maintenance treatment (for instance, with Suboxone) for people with prescription opioid use disorders. Brady and colleagues conclude,
“At present, the data are insufficient to provide guidance on the type (or inclusion) of psychosocial treatment – contingency management, relapse prevention, support groups like Narcotics Anonymous – that might be most effectively partnered with opioid substitution therapy. Identification of treatment combinations that work best for specific patient subgroups is an important area for future research.”
As I – and others – have long said, it’s important to recognize that one size doesn’t fit all, just as with any other area of medicine or behavioral health.
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