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.

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.

Prescription opiates (pain killers) and NFL careers

There’s been a lot of talk about athletes using drugs in the last decade. Still, most of the attention has been either to steroids and other performance enhancing drugs or to illegal drug use, the kind that has cost some players their careers (Ricky Williams anyone?). But how many people know that prescription medication abuse is a huge problem among athletes long into their retirement?

A recent study using phone interviews with 644 retired NFL players has revealed that the 7% o them are currently abusing prescription opiates (pain killers like oxycontin). This rate is a full 3 times greater than in the general population!!! When it comes to lifetime abuse, the NFL players were also 3 times more likely to abuse these drugs during their career than the rest of the population is during their lifetime!

With these sorts of collisions, is it ay wonder football players are in severe pain when they retire?Some of this is obvious, NFL players are likely to cause some serious abuse to their bodies (their reporting of moderate to severe pain was also 3 times greater than the general population) and opiate medications are very good at taking away the pain. Indeed, the players who used these drugs during their careers reported more injuries overall as well as more career ending injuries. Still, I was surprised to find that more than half of the players who began using prescription opiates during their NFL career got at least a portion of their pills from illicit sources. I would have imagined that professional athletes would have no problem getting prescription pain killers from doctors but apparently, many of them also used teammates, coaches, and trainers (less shocking) as their sources. Not surprisingly, retired NFL players who drink heavily or who reported misusing prescription drugs during their playing career were 2-3 times more likely to be misusing, or abusing, prescription opiates now. That finding supports past notions about the association between abuse of one drug (like alcohol) and abuse of others and about the good ol’ finding that past behavior is one of the best predictors of future behavior. Still, there were other important factors including  undiagnosed concussions, severe playing pain, and mental impairment, which all contributed further to the likelihood that ex-players would be abusing prescription opiates currently.

Since prescription abuse is one of the leading causes of accidental death in the U.S. and high doses of prescription opiates specifically have been reported to increase the risk of overdose greatly even among people who are taking them regularly (like V.A. patients), it seems there should be at least some focus dedicated to prescription drug use and abuse among athletes, including retired athletes, in order to reduce the risk of death in this population. For all my searching I couldn’t find a good estimate of the current rate of overdose death among athletes so maybe we should start there.

I’m pretty sure that if we look, we’ll find similar patterns among athletes from sports other than football and that there is something more we can do to reduce the abuse of these drugs. I have absolutely no problem with people using opiate pain kills for pain, I just think we need to do whatever we can to cut the overdose risk so that we don’t lose more than 20,000 people to this stuff every year…

Citation:

Linda B. Cottler, Arbi Ben Abdallah, Simone M. Cummings, John Barr, Rayna Banks, Ronnie Forchheimer (2011). Injury, pain, and prescription opioid use among former National Football League (NFL) players. Drug and Alcohol Dependence, 116, 188-194.

inda B. Cottler, Arbi Ben Abdallah, Simone M. Cummings, John Barr, Rayna Banks, Ronnie Forchheimer

Sometimes it just takes blind faith – Depression and drug use

I don’t normally like sharing this kind of stuff, but I think that if the point of the blog is be truthful, I need to cover all bases. When it comes to depression and drug use, I have personal experience with the connection.

When depression hits – Drug use and self-medication

I don’t always wake up ready to take on the day.

I know that what I’m doing is important, and I know that if I keep going I’ll be successful. Still, sometimes I wake up and feel like there’s really no point; like getting out of bed is useless and that I’m doomed to be nothing. Continue reading “Sometimes it just takes blind faith – Depression and drug use”

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”

Trauma and Addiction – The often ignored reality about addiction

In previous post, I’ve talked about some of the links between addiction concepts like cravings and trauma disorders like PTSD (see here). The reality is that there is a closer link between addiction and trauma that is often overlooked.

I spend a lot of time on this site covering some of the neuroscience that explains why the repeated use of addictive substances can lead to the kind of behavior that is so common in addiction. Still, most of that neuroscience ignores the portions of a person’s life that come before the actual drug use. The one exception would have to be all my writing on impulsivity, and some work on the relationship between early life stress (or trauma) and depression, which is known to be associated with drug abuse.

The way I see it, there are at least 3 distinct stages to addiction :

  • What happens before drug use.
  • What happens once chronic drug use begins.
  • What happens once a person stops using.

Though we often like to pretend otherwise, trauma is a common part of the first stage.

How do we define trauma?

In this context, trauma is any event that affects a person in a way that can be seen to have caused a substantial, long term, psychological disturbance. The key to this way of looking at trauma is its subjective nature.

Things like divorce, bullying, rejection, or physical injury can all be considered traumatic if the subjective experience can be thought to conform to this definition. Anything counts as long as it leaves a painful emotional mark.

While we’re all pretty adapt at covering up such trauma, the emotional pain often needs to be soothed and a good way to soothe it is with drugs that make it temporarily go away. The first drink of alcohol, or hit of some other drug, will often take care of that.

The reality of early trauma and addiction

Some call the experience of covering up the pain of trauma with drugs “self-medication” (though the term also applies to other situations), some dislike the term, but I think the fact remains that often, emotional pain can begin a search that often leads to risky behaviors and drugs.

I’m nowhere near calling self-medication the only reason for drug abuse as some others do, but I think it’s an important factor and one that can’t be ignored. As the stigma of emotional pain, or emotional responding in general, is reduced, people’s ability to deal with such pain in a healthy way should lead to a reduction in seemingly helpful, but ultimately self-destructive behaviors.

One of the most useful roles of psychotherapy for addicts is in dealing with the trauma in a healthy, constructive manner. This way the shame, guilt, and other negative emotions associated with it stop guiding the person’s behavior. While this is rarely enough to stop the need for self-medication by itself, it can be a very useful part of a comprehensive treatment plan. It’s important to remember that once someone has entered the realm of chronic drug use, there are brain and body changes that can often trump whatever the reason for beginning drug use was.

The ignored reality about addiction is that it often has an origin in behavior and unfortunately, trauma is often that starting point.

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.