Is opiate pain medication safe for addicts? Part I

A recent user question on VYou (see my response here) addressed the issue of prescribing addicts with opioid pain medication. Since prescription medication abuse and addiction is on the rise and getting more and more attention in the media every year, the question of whether addicts in recovery, or people who have dealt with substance abuse and addiction problems in the past, should be prescribed these medications is a very relevant one.

Chronic pain affects a substantial portion of the population worldwide (as many as 30%, see here). Opiate medications are one of the most commonly used approaches to treating such pain, which if untreated can cause serious disruptions to sufferers’ lives. Even when treated, chronic pain can be pretty debilitating. Some research (1) brings up good questions about the true effectiveness of opiate therapy for chronic pain, especially among long-term opiate users (like heroin and prescription pain medication addicts) but also among other drug using populations.

So how common is the practice? What sort of results do drug addicts usually get from these opiate therapies? And finally, how many of the addicts or drug abusers who receive these therapies end up abusing them and can we identify those people early so we can stop prescribing to them? In this three-part series of articles we’re going to cover these questions in-depth.

Prescription pain medication use in addict populations

Clinicians treating chronic back pain choose from a range of options, including opioid medications, exercise therapy, nonsteroidal anti-inflammatory medications, tricyclic antidepressants, acupuncture, and electrical stimulation. One study (1)  found wide variability in the percent of chronic pain patients prescribed opioids (from 3%-66%) although the studies varied widely in their size and population served – some even looks at general back pain and not chronic pain alone (they tended to have much lower opioid prescription percentages). Among chronic pain clinic patients, chronic opioid pain medication use was estimated at 19% (2).

Among addicted populations, concerns about tolerance, withdrawal, and abuse tend to cut prescription rates for opioid pain medications. However, past drug abuse can exacerbate pain issues, especially for people who abuse, or have abused, opiates in the past. For this reason, it can sometimes be difficult to properly manage pain in people with a history of addiction. One study (3) found that as many as 67% of patients in a Methadone Maintenance Program and 52% of patients in short term residential treatment programs were being prescribed opiates for pain. It’s important to note that these numbers are higher than those reported in other studies but that populations in treatment do generally show prescription rates higher than the general population. A study in Finland (a country that has great medical record data) found that opiate prescription rates in substance abuse populations were equivalent (not higher or lower) to those in the general population. The College of Problems on Drug Dependence itself had released an official statement noting that a balance must be reached between fear of opioid prescriptions for pain and the usefulness of opioid pain medication for chronic and severe pain (4).

Interestingly, it seems that of all opioid pain medication prescriptions, the largest increases in troubling use has been around oxycodone (Oxycontin), which gets mentioned as often in emergency departments (ED) around the country even though it is prescribed about one-third as often as hydrocodone (Vicodin). This is less surprising when you consider the fact that many addicts report using oxycontin in different ways including smoking, snorting, and injecting the stuff, which is stronger and does not have the same amount of fillers as most hydrocodone preparations. The fact that oxycodone is stronger also means it is more effective for pain relief through higher activation of the opioid system that is relevant for addiction.

In our next piece we are going to explore whether opiate pain medication is helpful in controlling pain among addicts and substance abusers, see you then!

Citations:

1. Martell, O’Connor, Kerns, Becker, Morales, Kosten, Fiellin. (2007). Systematic Review: Opioid Treatment for Chronic Back Pain: Prevalence, Efficacy, and Association with Addiction. Annals of Internal Medicine, 146, 116-127.

2. Chabal, Erjavec, Jacobson, Mariano, Chaney (1997). Prescription Opiate Abuse in Chronic Pain Patients: Clinical Criteria, Incidence, and Predictors. Clinical Journal of Pain, 13, 150-155.

3. Rosenblum, Joseph, Fong, Kipnis, Cleland, and Portenoy (2003). Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities. The Journal of the American Medical Association, 289, 2370-2378.

4. College on Problems of Drug Dependence taskforce on prescription opioid non-medical use and abuse: position statement.

A million ways to treat an addict

When I was still attending my addiction counseling classes at UCLA, we often discussed the many different tools now available when treating drug abuse (CBT, 12 step, medications, rapid detox, etc.). Still, most of the class members focused on how many of these don’t work with everyone and how some have actually resulted in problems for certain patients. I think this is a mistake.

Like a physician treating any other chronic disease, I think that practitioners in the field of addiction need to come to terms with reality: Chronic conditions (and I don’t mean smoking good weed) are difficult to treat. Still, cancer treatment works by trying the best possible method, then the next, and then the next, until all options have been exhausted. In the addiction world, most therapists and counselors still stick to their guns with the method they believe work best.

Unlike with roses, an addict is not an addict, is not an addict… Different methods will work for different people. It isn’t hard to believe this when you consider the fact that while many addicts recover within outpatient substance abuse treatment settings, others need an intensive residential program, and some recover spontaneously with no real intervention.

It’s time to start focusing on results in this field and leave the moral dogma behind. If there’s a tool that can help, we need to put it into action. It’s that simple.

What makes the 12 steps (and other social support groups) a good part of addiction treatment aftercare?

I’m not a devout 12-step believer, though I think that AA and the offspring programs have some serious merit, especially when it comes to addiction treatment aftercare. In this discussion, I’m talking about all group-support based programs, including Smart Recovery and others. I’m personally a fan of non-religious groups, but that’s just me.

Chronic conditions require long term care

I’ve already talked about my view of addiction as a long-term, chronic condition. Regardless of the “disease” moniker, I think it’s undeniable that, at least for some people, addiction treatment needs to continue long past their initial “quitting” phase, regardless of whether they went through an inpatient or outpatient treatment (or quit alone at home).

Without getting hung-up on my misgivings about 12-step programs (I have a few), I’d like to talk about some of the factors that make me believe in the system as a continuous aftercare resource:

  1. It’s free – Most people, especially given current insurance limitations, can’t afford ongoing outpatient help be it through a psychologist or an addiction-treatment provider. While the latter two are can be superior in their knowledge about recent developments in addiction, they cost money.
  2. It normalizes behavior – One of the difficulties many addicts share is in talking to non-addicts about their problems. They feel ashamed, misunderstood, or judged. Being with like-minded individuals can eliminate some of those issues. Nevertheless, people often find understanding only regarding the specific issue a program deal with and therefore find they need to attend many different support groups to address all their issues.
  3. It provides ongoing support outside of meetings – The social connections people make in meetings can often help them outside the rooms. Your psychologist isn’t likely to do the same.
  4. It keeps the focus on relevant issues – When following the 12 step rigorously, one is always working on bettering his/her program. That sort of attention can help catch problems early on before they develop into real difficulties.
  5. It keeps people busy – Some addicts need to stay occupied to keep out of trouble, especially in the transition from their acute treatment back to everyday life. Attending social-support meetings can make the time go faster while providing a relatively safe social environment.

Even with all these advantages, I can’t help but object to some of the AA dogma, especially when it comes to religion and to the unwavering resistance to adapt their system as it was handed down in the late 30s. We’ve learned a lot since and I think 12-Step programs could benefit greatly by incorporating recent knowledge. In fact, reviews of studies regarding the effectiveness of AA find it no more useful than other interventions overall. This is why I believe that 12-Step programs are best used along with, and no instead of, additional treatment options.

Citation:

Cochrane Review – Alcoholics Anonymous and other 12-step programmes for alcohol dependence

Better rehab services – Addiction research at work

Fact: Addiction treatment success rates are often lower than 20% ! Addiction research shows that quarterly follow-ups may help us improve success by offering continuous support and recognizing problems earlier.

Addiction is a chronic disease

diabetesWhat do you do when you are sick? Typically, you would go to the doctor, get some treatment and expect a quick fix.  What would you do if you suffered from an addiction?  Most healthcare and insurance companies would expect you to do the same – get a quick treatment and be cured!

The thing is that addiction is much more similar to many chronic diseases like diabetes and hypertension. The compliance rates and follow-through with treatment for these conditions is fairly low. For example, only 27% of patients with high blood pressure have their hypertension under control and only 46% of diabetics have their diabetes effectively managed.  For these kinds of conditions, short term interventions (less than 3 months) have produced positive findings only 38% of the time while long term ones (12 months or more) produced success rates as high as 100%. Still, addiction treatment rarely extends past a few months.

Today’s rehab services

More than half of patients entering addiction treatment are there for their 3rd, 4th,  or 5th treatment episode. Still, most patients who leave treatment return to use within 30-90 days of their release. This use is associated with 6-11 times the risk of dying!!!

Relapsing

Addiction success is most often reached after 3-4 treatment attempts. Recent research may help us reduce the number of treatments needed, or at least the length of time between first drug use and successful recovery (currently estimated at 27 years). These numbers point towards a scary conclusion: Rehabs are abandoning addicts to fend for themselves too early leaving them, and society at large, in danger.

Better rehab services through addiction research

Recent research shows that following the few months of treatment with simple quarterly checkups allowed counselors to catch relapses sooner and get the patient back into some sort of treatment more quickly. The checkups included short phone calls and scheduled face-to-face meetings that allowed counselors to assess a patient’s condition. Although it might sound as if more days in treatment are a negative thing, the number of checkups and increased amount of time in treatment actually improved overall results.  Patients who received RMCs experienced more sobriety and less severe symptoms of abuse than those who received treatment as usual.

So even if more treatment costs more money, addiction is something that can be helped if dealt with appropriately.  It doesn’t have to follow the same non-compliance rates as other chronic medical disorders. If you are seeking addiction treatment, make sure that your provider plans to include follow up services AFTER you leave treatment.

Citation:

Christy K Scott & Michael L. Dennis (2009). Results from two randomized clinical trials evaluating the impact of quarterly recovery management checkups with adult chronic substance users. Addiction, 104, 959–971.