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Feeding Addiction: Overprescription in America

 

Opioid addiction and overdoses in the United States has increased dramatically in recent years, and in order to combat the problem, drastic measures need to be taken, according to Dr. Kenneth Thompson, Medical Director at Caron Treatment Centers, “The whole system for combating substance abuse has to change to alleviate the current epidemic. Communities have to alter their stance on what’s acceptable and parents and educators need to play a larger role as well. Doctors have to manage pain more prudently and recognize and address signs suggesting their patient is developing a problem with opioids. Pharmaceutical companies need to change their marketing of addictive substances such that there is more honest and ethical representation of the addictive substances they manufacture.There are groups of concerned physicians, community members and educators who are taking action at the grassroots level, but there’s more work to be done.”

Runwell had the opportunity to interview Dr. Thompson about the complexities of opioid addiction, and the difficult road of recovery for not only an individual, but a community.

The CDC reports a threefold increase in the number of prescriptions issued for opiate-based painkillers. Have you seen a drastic increase in opiate and heroin addiction over the last 20 years?

We’ve been talking about the abuse of opiate-based painkillers as an epidemic for the last two or three years. Most of us who’ve worked in the addiction and recovery field have known about this for many years. 15 or 20 years ago, we began viewing pain as the fifth vital sign, in addition to respiratory rate, blood pressure, pulse, and temperature. There was a push in the medical field to make sure we were alleviating patients’ pain effectively and pain specialists and doctors began more aggressively treating pain to ease people’s discomfort as well as meet the standard of care that was being established.  

As a result, the use of prescription medications is increasing. Current studies estimate 30-40 percent of patients on opioids long enough will become addicted to them and the number of unintentional overdose deaths from prescription opioids has quadrupled since 1999. Additionally, the demographics have changed; opiate and heroin abuse has reached the suburban middle-class, and it’s hitting younger adults and adolescents particularly hard. Caron just released an infographic on the heroin epidemic around teens and young adults.

A common trajectory we’ve seen at Caron is a young person prescribed a painkiller for an injury and becomes addicted. This can quickly progress to the use of IV heroin, often a cheaper alternative, which is profoundly more lethal because of its route of access. The availability of prescription opioids is unbelievable. There are few towns where you would have difficulty buying an opioid on the street. It is stories like this that have raised an increased awareness in communities in general.

We hear/read a lot of stories about how a sports injury (or other injury) led to prescription opiate addiction, which led to heroin use - how common is that in your practice?

I think it’s a common story. I can’t comment on the incidence of a sports injury resulting in heroin use, but the majority of the young adults, ages 19 to 25 admitted to Caron are addicted to opiates, whether oral opiates or injectables like IV heroin. This is a larger percentage than years ago.

As an example, if someone breaks a leg, opiates might be a legitimate remedy for a couple of days or even a few weeks, but the standard has been to prescribe six weeks of pain medication, often followed by a refill. This does two things: One, it places more opioids in prescription cabinets, which has been a source for adolescents and young adults to get their drugs. Secondly, the patient is exposed to an opiate for a long period, and in some cases, such as when a person is genetically predisposed to addiction, the opiate lights up their brain and the manifestations of addiction occur. Opioids are highly addictive for some people. Those particularly at risk for addiction are people who might describe an energizing effect from the drug or a euphoric feeling. They like the way it makes them feel beyond how it relieves their pain. The desire for a drug can be so intense that when the oral opioids are not available or become too expensive, people might switch to heroin.

Do most individuals that get hooked on opiates have addiction in their family?

Family history is definitely a risk factor for the development of addiction. It is estimated that about 60 percent of addiction has a genetic basis. If there’s a family history of alcohol, opiate, or other drug addiction, then there’s an increased chance that a sibling, child, or other blood relative will become addicted.

If a person has no history of addiction in their family, is it less likely they will become addicted to prescription opiates such as Vicodin or Oxycodone?

The risk of becoming addicted is still present, especially if a person is exposed to the drug for longer periods of time. The absence of a history of addiction in the family is not a safeguard. Addiction frequently skips generations, but exposure to the drug itself may transform an otherwise non-vulnerable person into one who becomes vulnerable to addiction. One person may try an opiate and say, “That’s the best feeling I’ve had in my entire life.” That is the group that is likely to lose control if they keep taking that drug. Another person might be using it for pain management and not initially feel that instant attraction, but persistent use may transform gene expression and result in brain changes that create the addiction and loss of control.

Why are opiates so addictive?

Some people like them. It’s a biological process. Many of my patients describe that initial intense fondness for the drug, which drives them to use more and more. Opioids can create a tremendous surge in dopamine, the pleasure chemical, in the brain. Because of this, there are a larger percentage of people who immediately like opiates than people who use other drugs. Drugs, other than cocaine, are less likely to result in such a high level of dopamine. Opiates light up the brain in many people. The appeal is immediate; they produce euphoria and increase energy.

Why is recovering from an opiate addiction so difficult?

For the same reason—opiates are such likable drugs. But once someone becomes addicted, it’s hard to give something up that seems to quell their stresses and makes them feel so good. Unfortunately, over time, the good feeling diminishes and it takes a larger quantity and more frequent use to achieve the same effect. In addition, as time goes on, opiates result in a miserable withdrawal experience, so that many people use the drug just to alleviate the discomfort of withdrawal and to feel as normal as they can.

Cracking down on prescription medication correlates with a reported spike in heroin use and overdoses. Do you think prescription drug monitoring programs are a realistic way to combat overprescription?

One of the unintended consequences of the increased restrictions is that doctors become more vigilant about prescribing so that opiates become less available, which in turn, results in people switching to the even more dangerous drug, heroin. A monitoring program can be particularly effective for doctors treating addiction. It may help in assessing a patient if doctors can access a database and learn what that person has been taking, and of course it’s helpful for practitioners to know if a patient is getting opiates from another doctor. Then, the new doctor would be less likely to supplement that medication or be co-opted into being a “dealer,” in a sense, who continues to prescribe for that patient. Finally, in reducing the number of opiates available, a monitoring program may also help to lessen the number of people becoming addicted. However, those who are already addicted are still more likely to move to heroin if they can’t get prescription opiates.

Are there effective treatments for pain that can be used as an alternative opiates? If so, why do you think opiate prescription and addiction is still on the rise?

Yes. At Caron, we have a Chronic Pain program to deal specifically with this issue. There are two types of pain: acute and chronic. With the former, you anticipate the pain diminishing; for example, the pain that accompanies a broken bone. This may be a legitimate case for opioid pain medication and the common practice has been to prescribe opiates; however, many of these patients often don’t require opiates, as non-narcotic medications will provide effective relief.

Chronic pain, defined as lasting more than six months, can be treated in several ways. It’s totally different from acute pain and strategies other than opiates work. In fact, data suggests that when managing chronic pain, opioids often have a detrimental effect. While a few patients do well with long-term opiates for their pain, the majority actually show a worsening of function without substantial improvement in pain.

Alternative recommendations for treating chronic pain include yoga, acupuncture, massage, physical, and occupational therapy, relaxation techniques, and fitness and wellness programs. Prayer and meditation can also benefit people, as well as non-addictive medications. Caron’s chronic pain and addiction program incorporates all of these modalities. Many patients come in on multiple addictive substances that often were started for their pain syndrome. When these medications are medically withdrawn and alternative strategies are employed, almost all of our patients report less pain and more function.

Naïve physicians, physicians who are poorly trained in managing pain, and unethical doctors who prescribe for monetary gain are helping to fuel the current epidemic, but aside from this problem, patients’ expectations can add to the burden. Many patients still expect that they need pain medication to relieve their suffering and some good doctors feel obligated to give it to them. Patients themselves have to bear some responsibility for what they take.

 

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