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.

Addiction brain effects : Opiate addiction – Heroin, oxycontin and more

Okay, we’ve talked about crystal meth and cocaine and how they affect the brain during drug use. As I mentioned, both cocaine and meth interfere with the way the brain stores and cleans up important neurotransmitters, including, most importantly, Dopamine and Norepinephrine.

opiates-morphine & heroinThe class of drugs known as opiates, which includes morphine, heroin, codeine, and all their derivatives (including oxycontin), acts on the brain in a completely different manner. Since our goal at All About Addiction is to explain drug use and abuse as comprehensively as possible, let’s turn our attention to this opiate addiction next.

Heroin, morphine, oxycontin, vicodin and other opiates

While cocaine and crystal meth work by disrupting the normal functioning of molecules responsible for cleaning up released neurotransmitters, opiates work by activating actual receptors that naturally occuring neurotransmitters activate. Substance like this are known as agonists; they perform the same action (identically as, to a lesser, or greater extent) as a substance the body already manufactures.

In the case of morphine, heroin, and most other opiates, the most important receptors activated are knownOpiate Receptors as µ-opioid receptors. Activation of the µ-opioid receptors is associated with analgesia (suppression of pain), sedation, and euphoria, which makes sense given the relaxing, pleasure inducing effects of opiates.

Natural opioids (also called endogenous opioids), which include endorphins, are used by the body to relieve pain and increase relaxation, especially during periods of extreme stress. These are the chemicals that make sure we can function during accidents, like after breaking our leg…

Opioids and dopamine

Opioids also increase the amount of dopamine in the brain indirectly. As I mentioned in the earlier posts, dopamine is thought to be the reward indicator in the brain. Unlike crystal meth and cocaine, heroin and its relatives increase the activity of dopamine neurons by releasing the hold that other neurons (that use GABA) have on them. Think of this as the release of pressure on a hose spraying water on a lawn. When the pipe is pinched, only so much water can get through, but once the clasp is released, water can flow in greater quantity; this is essentially what opiates do.

Heroin addiction and long term opiate use

Like I said before, this doesn’t sound so bad, does it? All we’re talking about here is the increasing of the functioning of system that already exists in the brain. The problem isn’t so much in the process, the problem starts when this system gets activated for long periods of time.

HeroinHeroin addicts, and other frequent users of opiates complain about the extreme discomfort they feel when they stop using the drugs. This discomfort has been described as the worse case of the flu you could imagine. Doesn’t sound too appealing, does it? In fact, withdrawal symptoms associated with stopping opiate use are at least one of the main reasons many users return to the drug after trying to clean up. This in addition to all the other effects of the drug on the brain to make wanting to stop so much harder.

The reason for the pains and aches? Given the overactivation of its pain suppression system, the body not only reduces its own supply of opioids, but it also turns up the sensitivity on its pain receptors. Heroin users notice this as an increase in tolerance, but they compensate for it by simply using more. However, when they stop, they’re left with a body unable to suppress its own, hyper sensitive pain system. The results are more than uncomfortable, they’re simply excruciating…

Another common complaint of addicts is diarrhea. This, again, is simply the reversal of the constipation caused earlier by heroin’s actions on opioid receptors that are present in the peripheral system (outside the central nervous system).

I’ve heard addicts speak online about the slow recovery from opiate addiction and I want to dispell a myth here:

Opiates DO NOT stay in your system for weeks or months – The drug itself is gone from the body within days. The reason for the continued suffering is the slow adjustment of your brain and body back to the way things were before the drugs. Think of how long the tolerance took to develop… Now play the tape back in reverse. That’s what happening to you. You can help relieve the pain, but know that if you use anything in the opiate family, you’re making the process last much longer…

So, in summary: As usual, the actions of opiates on the body and brain are not all the severe, extreme, or inappropriate. Opiates are still used in medicine for pain suppression, not only because they work, but because the potential for abuse when used in this way are minimal to non-existent. However, as with all drugs, continued, chronic, abusive use of opiates will change the way your body functions in ways that will produce the exact opposite effects of those users like so much. This leaves people not only with possible addiction problems, but also with a terrifyingly uncomfortable return back to normal functioning.

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