Is opiate pain medication safe for addicts? Part II

In our previous article on pain medication and addicts we looked at how common opiate prescriptions are among people who are, or ever have been, identified as having substance abuse issues. We saw that although clinicians are often aware of the problem of possible prescription addiction developing, the issue of managing pain often results in the eventual prescription of opiate medications for chronic pain even in this population.

This time we’re going to explore whether these prescriptions end up resulting in benefits to the patients. We are going to look both at opiate and non-opiate pain relief as it applies to addicts or past addicts with chronic pain.

Pain medication benefits among addicts

Stimulant users (cocaine, amphetamines, and methamphetamine) are not expected to experience many physical or chemical (neurophysiological or neuropharmacological) changes in their brain and nervous system that would interfere with opioid medication therapy. Additionally, their use of meth, cocaine, and similar drugs is not expected to increase their experience of pain unless they’ve been injured while using those drugs. That by no way means that their drug abuse prevents them from experiencing pain, but it less of a direct influence on the future likelihood that they’ll suffer with chronic pain.

But those who do, or have, abused alcohol, benzodiazepines, and obviously opiates (heroin, morphine, oxycontin, etc.) are much more likely to be differentially affected by these medications. Physicians know this well, and in preparation for serious medical procedures specifically ask about such drug use to properly manage patients during surgery (don’t want someone waking up in the middle).

One of the most obvious factors has to do with the high tolerance opiate abusers and users build up to these drugs. For this reason, the doses often needed to help long-term opiate abusers with chronic paid using opiate pain medications can be so extreme that they would easily kill an inexperienced opiate user. We’ve talked about tolerance many times on A3, so I’ll just summarize by saying that the body and brain of opiate addicts will have a much reduced response to opiate medications because their bodies have become less sensitive to the substances in response to the extended high dose use they have put it through. This can happen through reduction in available opiate receptors as well as increased responsiveness in other regulatory systems meant to counteract the opiates (the opponent process theory).

In short, since pain perception and experience is so dependent on the body’s natural opiate response, people addicted to opiate drugs (heroin, morphine, oxycontin, vicodin) have essentially neutralized their natural pain machinery and are more likely to feel pain for an extended period after they quit. By super-activating their pain-blocking response using drugs they have weakened the body’s natural pain-response and are more likely to experience pain when they stop.

These factors are also important when considering pain medication for people in addiction treatment. Indeed, research (1) has found that patients in Methadone Maintenance programs, who are maintained on long-term opiate therapy, are more likely to experience severe pain and more likely to get opiate pain medication prescriptions for it when compared with people in drug-free residential treatment. However, the patients in the drug-free environments were more likely to have used alcohol or benzodiazepines to deal with their chronic pain, so it seems like a bit of a case of choosing between the better of two evils.

The specific medications for opiate-experience patients can also be different, and using more long-release or extended release formulations of these drugs can reduce the abuse liability of the medication itself while also offering better outcomes. I have to say though that the results differ when looking at different populations and it’s always important to consult, and be very honest and clear, with your doctor.

Overall, research suggests that opiate pain medications are as effective for patients who have a history of substance abuse as hey are in the general population (but our Part I article suggests that effectiveness is itself limited). One issue, especially for heroin addicts (or people addicted to other opiates) who are in recovery or active use is balancing pain management with potential abuse problems. Unfortunately, it is true that the medications most effective in treating the pain are also the ones most likely to be abused (2). Our next article is going to cover the issues of prescription abuse in this population but I think it’s important to point out that chronic pain can be debilitating in itself and that it is likely not useful to withhold medication from someone because of the possibility that they will abuse it if the medication itself will help them.

There are certainly approaches to pain-management that do not use medication (exercises, meditation, cognitive behavioral approaches, and more) and an initial recommendation can be that those be tried first, followed by non-opiate pain-relief and then the opiates. However, other options do not manage to deliver results, opiate pain medication can be effective in managing pain symptoms, especially if physicians are aware of methods to spot abuse and control it.

Next up – how to identify prescription abuse in patients, what does it mean, and what should we do about it?

Citations:

1. 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.

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

Naltrexone the addiction cure?

CNN released a news article a little while back titled “With anti-addiction pill, ‘no urge, no craving‘” that seems to suggest that a cure for addiction has been found. As usual, news reporting on these sort of topics revolves around a kernel of truth, with nice window dressing an a serving of embellishment.

While naltrexone, and topiramate, have been shown to improve outcomes in addiction treatment, they have by no means revealed anything that would warrant giving them the title “anti-addiction pills.”

Indeed, there are now a few different preparations of Naltrexone, including a long acting version called Vivitrol that while relatively expensive, has been shown to be relatively effective at cutting relapse rates for both alcoholics AND heroin (or opiate addicts). Note the difference though here between my language and that used by CNN; Naltrexone has been shown to reduce relapse rates, not eliminate them, and current research seems to show that it is most effective only for specific groups of alcoholics who have a specific type of Mu opioid receptor.

As the article points out, a combination of therapies, including behavioral therapies, medications, and social-support, are still the best option when it comes to addiction treatment.

We’re a long way off from finding anything that can be considered a cure for addiction, no matter what some treatment centers like to claim, but these pills should help us stem the tide while we keep looking…

Saving lives made easy – Treating opiate overdose with intranasal naloxone

oxycodone-addiction-big1Contributing co-author: Andrew Chen

Imagine that you and your friend have been using heroin (or another opiate). A few hours go by and you notice your friend is progressively becoming more and more unresponsive. You check on him and find that his breathing is shallow, his skin is cold, and his pupils are constricted. You recognize these as signs of opiate overdose and call for help. Now what?

Well… If you had some naloxone around, you might be able to treat the overdose and save your friend’s life before the paramedics even arrive.

Naloxone hydrochloride (naloxone) is the standard treatment for opioid overdose. Naloxone works by blocking opioid receptors, thereby removing opioid agonists, such as heroin or oxycodone, from those same receptors. As a result, the overdose is reversed and death is prevented.

What makes naloxone great is that it has no potential for abuse. In fact, it makes the user feel pretty crappy.

Naloxone is typically delivered through an injection, which makes it pretty much useless in many situations. However, it can also be delivered using an intranasal spray device. This intranasal form of naloxone is getting lots of attention recently because it is relatively easy to administer.

In 2006, The Boston Public Health Commission (BPHC) implemented an overdose prevention program, providing training and intranasal naloxone to 385 individuals deemed likely to witness an overdose. These individuals were often family members of opiate users or drug-using partners.

15 months later, the BPHC conducted a follow-up:

  • Contact was made with 278 of the original participants.
  • 222 reported witnessing no overdoses during the 15-month span.
  • 7 had their naloxone stolen, lost, or confiscated.
  • 50 reported witnessing at least one overdose during the 15-month span. Together, these 50 individuals reported a total of 74 successful overdose reversals using intranasal naloxone!

The BPHC program is not the only example of successful use of naloxone in opiate overdose prevention programs. Similar programs have popped up in Chicago, New York, San Francisco, Baltimore, and New Mexico.

Unlike injections, using a nasal spray isn’t rocket science. All of the participants in the BPHC program were trained by non-medical public health workers, which makes the idea relatively cheap. As the data shows, the participants were able to effectively recognize an opiate overdose and administer intranasal naloxone. By targeting at-risk populations and providing proper training, distribution of intranasal naloxone can help in saving lives.

For more information, check out our post Addiction and the brain part IV – Opiates

Citation:

Doe-Simkins, M., Walley, A.Y., Epstein, A., & Moyer, P. (2009) Saved by the nose: Bystander-administered intranasal naloxone hydrochloride for opiod overdose. American Journal of Public Health. 99(5)

Opioid prescription overdose and abuse – Staying safe while reducing pain

A new article just published in JAMA (see here) reports a strong relationship between high-dose opiate prescribing and accidental overdose deaths. The authors focused on a sample of Veterans and found that those prescribed more than 50mg of morphine per day, or the equivalent of other opiate drugs, we much more likely to die of such overdose than patients being prescribed lower doses. Fortunately, only about 20% of the patient-months (a measure of how many people were prescribed a specific dose for how long) were prescribed these high doses but the rate of overdose for this group was 3 to 20 times higher! Continue reading “Opioid prescription overdose and abuse – Staying safe while reducing pain”

Addiction Treatment Admissions in the United States: Everyone, meet TEDS

Dirk Hanson

What a difference a decade makes.

Do you know what drug use trends are ongoing?Between 1998 and 2008, addiction treatment admissions in the U.S. increased markedly for methamphetamine (crystal meth), prescription opiates, and marijuana. Treatment admissions for alcohol and cocaine declined over the same period, while heroin admissions remained roughly the same.

The Treatment Episode Data Set (TEDS), which the Substance Abuse and Mental Health Services Administration (SAMHSA) uses to compile its report, includes only those addiction treatment facilities that receive state alcohol or drug agency funds, and which are represented in state administrative data systems. Despite this caveat, the TEDS study matters, because states use reports of this kind to shift limited resources from one treatment focus to another, based on demand. Continue reading “Addiction Treatment Admissions in the United States: Everyone, meet TEDS”

About Addiction: Smoking, Drugs, Drinking and Cancer

New links for interesting articles about addiction. Check them out!

Tobacco, nicotine, and Smoking

Medical News Today: According to a recent study in China there is a new effective strategy for treating tobacco addiction.  Researchers have developed a novel tea filter that seems to help with cigarette addiction. (Note: this link doesn’t give direct access to the article so we’re basing the summary on the article itself)

SAMHSA: According to a new nationwide study, adolescent smoking may be influenced by mothers’ smoking or depression. The study states that adolescents living with mothers who smoke are 25.6% more likely to smoke. It’s frightening to think that 1.4 million 11-17 year old kids started smoking in the past 12 months!

Science Daily: Exposure to prenatal smoking may lead to psychiatric problems. According to new research, exposure to prenatal smoking can increase the need for psychotropic medications in childhood and young adulthood.

Hard drugs

Science Daily:  A newly developed and tested modified enzyme has been shown to break down cocaine into inactive products nearly 1000 times faster than the human body. The article states further that cocaine toxicity due to drug overdose results in more than half a million emergency room visits annually. This new enzyme could help prevent OD deaths by breaking down the drug.

Fox News: The number of soldiers seeking opiate abuse treatment has been increasing, going up from 89 in 2004 to 529 last year.

Addiction Inbox: A study that uses the Stroop test (have to name the colors of words and not the words themselves) seems to be a good predictor for addiction treatment effectiveness and drop out rates. Pretty cool stuff!

Alcohol

Join Together: This is a short article summarizing research which shows that rare childhood leukemia is tied to drinking during pregnancy. According to this research, children whose mothers are drinking during pregnancy are 56 percent more likely to develop a rear form of leukemia called AML.

Addiction Tomorrow: Britain is considering raising the prices of their very low-end alcohols most likely in an attempt to damper the young adults that binge drink and of alcoholics since they are most often the ones that drink the low-end alcohol.

Crystal meth withdrawal – It’s not like heroin, but don’t expect it to be easy

Heroin, or opiate, withdrawal symptoms is the gold standard of addiction withdrawal. Imagine the worst flu of your life, multiply it by 1000, and then imagine knowing that taking a hit of this stuff will make it all better. Think sweats, fever, shaking, diarrhea, and vomiting. Think excruciating pain throughout as your pain sensors get turned back on after being blocked for way too long. Now you have an abstract idea of the hell and it’s no wonder why heroin withdrawal has become the one every other withdrawal is judged against.

Crystal meth withdrawal

Withdrawing from crystal meth use is nothing like opiate withdrawal and there’s no reason that the withdrawal symptoms should be. Opiates play a significant role in pain modulation and opioid receptors are present in peripheral systems in the body, which is the reason for the stomach aches, nausea, and diarrhea. Dopamine receptors just don’t play those roles in the body and brain, so withdrawal shouldn’t be expected to have the same effect.

But dopamine is still a very important neurotransmitter and quitting a drug  that has driven up dopamine release for a long time should be expected to leave behind some pain, and it does.

One of the important functions of dopamine is in signaling reward activity. When a dopamine spike happens in a specific area of the brain (called the NAc), it signifies that whatever is happening at that moment is “surprisingly” good. The parentheses are there to remind you that the brain doesn’t really get surprised, but the dopamine spike is like a reward signal detector, when it goes up, good things are happening.

Well guess what? During crystal meth withdrawal, when a crystal-meth user stops using meth, the levels of dopamine in the brain go down. To make matters worse, the long-term meth use has caused a decrease in the number of dopamine receptors available which means there’s not only less dopamine, but fewer receptors to activate. It’s not a surprise than that people who quit meth find themselves in a state of anhedonia, or an inability to feel pleasure. Once again, unlike the heroin withdrawal symptoms, anhedonia doesn’t make you throw up and sweat, but it’s a pretty horrible state to be in. Things that bring a smile to a normal person’s face just don’t work on most crystal-meth addicts who are new to recovery. As if that wasn’t bad enough, it can take as long as two years of staying clean for the dopamine function of an ex meth-addict to look anything like a normal person’s.

This anhedonia state can often lead to relapse in newly recovered addicts who are simply too depressed to go on living without a drug that they know can bring back a sense of normalcy to their life. The use of crystal-meth causes the sought-after spike in dopamine levels that helps relieve that anhedonic state.

When it comes to more physiological sort of withdrawal symptoms, the meth addict doesn’t have it that bad, I guess. After an extended period of sleep deprivation and appetite suppression that are some of the most predictable effect of meth, the average addict will do little more than sleep and eat for the first week, or even two, after quitting the drug. Many addicts experience substantial weight gain during this period as their metabolism slows and their caloric intake increases greatly. Like everything else, this too shall pass. With time, most addicts’ metabolism return to pre-use levels and their appetite catches up and returns to normal as well. Still, there’s no doubt that a little exercise can help many addicts in early recovery steer their bodies back on track.

There’s some research being talked about around the UCLA circles to see if detoxification from meth may help people do better in treatment for meth addiction by reducing the impact of their withdrawal. Detox before addiction treatment is an accepted fact in opiate and benzodiazepine addiction, but because of the supposedly “light” nature of crystal meth withdrawal, it’s been ignored. Hopefully by now, you realize that was a mistake.