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.

U.S. Drug overdose deaths are increasing

The second leading cause of accidental death in the US is drug overdose (JAMA 2007). Prescription painkiller overdose deaths (opioid analgesics like OxyContin, Vicodin and methadone) account for nearly half of the 36,450 total fatal overdoses with 15,000 deaths that have claimed a number of celebrity lives including famous actor Heath Ledger (CDC 2011).

With so much concern over illegal drugs, it seems silly not to focus on a problem that is at least as deadly but far more accepted.

Drug overdose deaths increasing quickly

Drug overdoses are normally considered accidental and they're on the riseWe’ve reported on this phenomenon before, so for the regular A3 readers this report might not seem new. But what’s staggering is just how quickly these numbers are moving up.

In 2004 there were 19,838 total accidental overdose deaths, with about 9,000 caused by prescribed drugs, and 8,000 more caused by illegal drugs like cocaine, heroin, and methamphetamines (Paulozzi, LJ, Budnitz 2006). That signals a near doubling in about 7 years, and when you look at numbers from 1999, we’re talking about triple the accidental drug overdose deaths in just over a decade! Fastest growing cause of death in our country ladies and gentlemen.

SAMHSA Reports that use of prescription pain relievers (opioid analgesics) have increased since 2002 from 360,000 to 754,000 people in 2010. That means that people are twice as likely to use these drugs now, which would be fine if 5% of the users weren’t dying every year.  A study I talked about on ABC’s Good Morning America earlier this year (see here) reported that people taking heavy doses are especially likely to die and that this might be at least partially due to additional opioid use over and above the prescribed regimen.Time to get this under control prescribers!!!

This increase in usage opioid analgesics like Oxycontin, Vicodin, and methadone has made them the some of the most deadly drugs in the USA (Paulozzi, LJ, Budnitz 2006). In 1999 to 2004 prescription overdose related to opioid analgesics increased from 2,900 to at least 7,500, this equates to 160% increase in just 5 years (Paulozzi).

A JAMA study conducted between 1999 to 2004 reported that white women showed a relative increase in unintentional drug related deaths of 136.5% followed by young adults aged 15-24 years (113.3%). But the latest report from the CDC suggest that Men and middle aged individuals are most likely to be affected by this growing epidemic. The bottom line is this problem is either moving around or is universal enough affect essentially every major group of Americans. One of the scariest findings from this most recent CDC study may be the conclusion that states are generally unprepared to deal with this growing epidemic.

What can we do about overdose deaths?

First of all, it is seriously time that we had more consistent state and federal computer systems keeping track of prescriptions for heavily controlled drugs in this country. We can keep track of packages moving across state lines with no problem, why is it so damn hard to watch pills that lead to 35,000 deaths? Most states have them in place but they’re not heavily used and there’s nothing at all that looks at cross federal prescription patterns.

Second, we wrote about some harm-reduction methods to reduce overdose deaths, things like intranasal naloxone, safe injection sites, and more. As far as I’m concerned, we need to get off our national moral horse and start acting responsibly when it comes to saving lives. If we have simple solutions that have been shown to reduce deaths while not increasing abuse, I say let’s implement!!! Anything else is simply wrong.

Citations:

Paulozzi, LJ, Budnitz, DS, Xi, Y. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiology Drug Safety 2006; 15: 618-627. (originally published in 2006 and recently updated)

Monitoring the Future by NIDA: Teen alcohol and drug use data from a national survey

Teen drug useOne of the perks of being an alcohol, drug use, and addiction researcher, as well as of writing for a website like this and Psychology Today, is that sometimes we get to talk to people that most can’t reach or to receive information that others might not have access to. NIDA‘s Monitoring the Future, a national survey of about 50,000 teens between 8th and 12th grades is a huge annual undertaking the results of which will be released tomorrow for general consumption.

But we got a little sneak peek before everyone else.

If you follow this sort of stuff, you know that teen alcohol and drug use is always shifting as new drugs become more popular and others lose favor with that group of Americans that can’t make up their minds. This year seems to give us more of the same.

Monitoring the future: Early alcohol and drug use results

  1. Daily marijuana use, after being on the decline for a short while is apparently rising once again among teens, following last year’s continuing trend of a reduction in teens’ perceptions of marijuana harmfulness – We’ve written on A3 about some of the specific issues relevant to marijuana use including writing about Marijuana’s addictive potential and its medical benefit. There’s no doubt that the national marijuana debate will continue but the idea of 8th graders smoking weed doesn’t seem to be part of anyone’s plan.
  2. Among some groups of teens drug use is proving more popular than smoking cigarettes – I guess this could be taken as evidence of the effectiveness of anti-smoking campaigns, though until we see the full numbers I’m not going to comment any further on that.
  3. While Vicodin use among high-school seniors (12th graders) is apparently down, non-medical use of prescription medications is still generally high among teens, continuing a recent upward trend – Abuse of prescription stimulants has been on the rise for a number of years as the number of prescriptions for ADHD goes up, increasing access. It is interesting to see Vicodin use go down though the data I’ve received says nothing about abuse of other prescription opiate medications such as oxycontin, so I’m not sure if the trend has to do with a general decrease in prescription opiate abuse among teens.
  4. Heroin injection rates up among high-school seniors (12th graders) – I think everyone will agree that this is a troubling trend no matter what your stance on drug use policy. The associated harms that go along with injecting drugs should be enough for us to worry about this, but again, I’ll reserve full judgment until I actually see the relevant numbers. I’m also wondering if this is a regional phenomenon or a more general trend throughout the United States.
  5. Binge drinking of alcohol is down – As we’ve written before, the vast majority of problems associated with the over consumption of alcohol (binge drinking) among high-school students has to do with the trouble they get themselves in while drunk (pregnancies, DUI accidents, and the likes), so this is an encouraging trend though hopefully it isn’t simply accounting for the above mentioned increases in marijuana and heroin use.

Some general thoughts on NIDA’s annual Monitoring the Future results

I am generally a fan of broad survey information because it gets at trends that we simply can’t predict any other way and gives us a look at the overall population rather than having to make an educated guess from a very small sample in a lab. NIDA‘s annual MTF survey is no different although until I get to see all of the final numbers (at which point there will probably be a follow-up to this article) it’s hard to make any solid conclusions. Nevertheless, I am happy to see binge drinking rates among teens going down and if it wasn’t for that pesky increase in heroin injection rates I would say that overall the survey makes it look like things are on the right tracks.

I’ve written about it before and will certainly repeat it again – I personally think that alcohol and drug use isn’t the problem we should be focusing on exclusively since it’s chronic alcohol and drug abuse and addiction that produce the most serious health and criminal problems. Unfortunately, drug use is what we get to ask about because people don’t admit to addiction and harmful abuse because of the inherent stigma. Therefore, I think that it’s important for us to continue to monitor alcohol and drug use while observing for changes in reported abuse and addiction patterns. Hopefully by combining these efforts we can get a better idea of what drugs are causing increased harm and which are falling by the wayside or producing improved outcomes in terms of resisting the development of abuse problems.

Addiction stories: Alcohol, marijuana, crime, and John’s life

The following story was shared by a young reader. I was first drawn to it because it mirrored mine to a large extent. Fortunately, John decided to pull out before he let his life go down as far as I allowed myself to go. For that, and for his courage in sharing his story, I applaud him.

John’s addiction story

My name is John and I am an alcoholic and a raging drug addict. I’m seventeen years old and only used for about 2 and a half years, but that was more than enough for my life to fall to pieces because of my addiction.

When I was fourteen I got a little drunk for the first time. I hated the way the alcohol tasted, and I hated how it made me so sick. The effects were nice, but I wished that I could get them without having the unpleasant side effects.

I found a solution to this problem at age 15 with marijuana. Within my a few months of my first time smoking, I was getting high multiple times every single day. My friends were changing rapidly because the ones who really cared didn’t approve of my heavy usage. I responded to this by getting new friends. Around this time I also became addicted to stealing in order to support my addiction and also in order to look cool by having a lot of money. My friends and I would get high and drunk and then go out at night and steal hundreds and hundreds of dollars from people’s unlocked cars.

I began selling pot at age 16. Dealing was a new experience for me. I won’t lie and say it wasn’t fun – it was, definitely. But the rush of making heaps of money and being loved by all your peers becomes an addiction in itself. I was dealing pretty heavily, for a high schooler selling pot – some days I would sell a thousand dollars worth of it at school. Afterward, I lived what I thought was a carefree and safe lifestyle; I smoked weed with friends all day, and eventually we moved onto harder drugs.

My usage increased heavily and I began using other drugs as well. I slowly began trying all the things I said I would never do, and before long, my life was absolutely governed by cocaine, alcohol, prescription medications, and lots and lots of pot. I got really into cocaine a few months into it – and then everything changed. Walls fell down; suddenly opiates weren’t anywhere near as scary to me, hence my common run-ins with Vicodin, Valium, Percocet, and Oxycontin. None of the prescription pills had the same kind of power coke had over me, though; my teeth still chatter sometimes when I start craving the rush of that manipulative white powder going up my nose. Cocaine is a pretty serious drug, and I was hooked before I even realized what was happening. This is unlike my experience with getting hooked on pot and booze; with those, I could recognize the kind of path I was going down, but I just couldn’t stop. There is a reason coke is called a “hard drug” – because you’ll fall for it. Hard. People go into with the mindset that they can handle it. Maybe some people can. I, however, am not one of those people – the second I pop a pill or blow a line, all I can think about is getting more to keep my buzz going.

Of course I also began getting into trouble with the law. February 16, 2009, I was arrested for the first time after picking up a couple ounces of weed. I met some buddies in town to smoke, but they didn’t inform me that they had vandalized a building at a school earlier. Before I knew it we were being followed by policemen. They caught up with us, encircled us in cop cars, causing a roadblock, and searched all of us. They immediately found my bag of weed and cuffed me, along with all my buddies. I played the innocent child, though, and got off with a possession charge.

The second arrest took place only four months later. I was back to my old dealing ways – by now I was suicidal, addicted to all kinds of drugs, and had no faith in other people. I got high and brought an ounce of weed with me to school, and was found by the school officer in a bathroom stall, selling a few grams to a 14 year old. I was arrested with intent to sell, endangering a minor, possession on school grounds, and possession of marijuana. Also, I was expelled from school. I began saying I was going to kill myself to gain some sympathy, at which point I was placed in a 2 week long mental ward. After that, it was off to rehab for me, where I had sex, did drugs, lied and stole.

A few days after getting out of treatment, I was using again. I remember feeling like an empty shell – I would stay up for days at a time, stealing, lying, and using people to get my drugs and liquor. My family thought I was sober at this point, and I began at a character-based boarding school in August.

I brought a lot of pot with me and resisted everything the school was trying to offer me. Once the pot ran out, I began huffing up to 2 cans of computer duster every day, along with a daily dosage of booze and a whole lot of cough medicine.

I hit bottom on November 16, 2009. As far as I’m concerned, that’s the most important day of my life – that was the day I finally decided I had had enough. I called up my mother, crying and saying I was really done this time, but she didn’t believe me (who could blame her). So I then called up an old friend who I knew was heavily involved in a 12-step group. This man is my sponsor today. We work our program together, and maintain daily contact.

At almost 90 days sober, I can honestly say I have never been so grateful and serene in my entire life. If you’re reading this and you can relate to my story, please know that there is a way out of the twisted insanity that is drug addiction and alcoholism. I should be dead right now, but I’m still here – as far as I’m concerned, that’s proof enough for me to believe in a loving Higher Power. As long as I remember to help other addicts, talk to my sponsor, work my 12 step program, and remain honest, I don’t have to drink and drug today. And to me, this is a miracle.

A little insight

John’s story mirrors that of many other addicts: Early innocent use followed by the dissolution of self-imposed rules about what one will, and won’t, engage in. Cocaine might seem scary at first, but after a lot of weed, alcohol, and some ecstasy, it might just lose that edge. As I’ve talked about in other posts, there are quite a few common personality issues that make it even less likely that a future addict will say no to increasing degrees of abuse.

Once again I want to make a point that I think it important: Drugs are the road, but not the problem per se when it comes to addiction. The vast majority of people who try drugs don’t get addicted to them – What we need to get better at is understanding the process by which those who do, develop problems. This includes earlier identification, better targeted prevention, and more effective treatment. That’s my take on all of this at least.

Brittany Murphy dead at 32 – Anemia, pneumonia, and yes, drugs…

Toxicology update

Well, it seems the toxicology reports are in and Brittany’s death was, at least partially, caused by her taking of multiple prescription drugs. Still, it seems that she was trying to medicate a host of conditions brought on by her underlying anemia and pneumonia. It’s sad to think that this death could have likely been prevented had she simply taken better care of herself and gone to seek emergency care rather than loading her body with those pills. Unfortunately, this seems to be another in a string of medically preventable deaths… Sad.

Original post:

Brittany Murphy, the actress from “Clueless,” and “8 Mile” died last night at Cedars-Sinai in Beverly Hills at the age of 32. Brittany has been rumored to be suffering from severe eating disorders, and recent pictures seem to support that notion. Given that she apparently died from cardiac arrest, I’m wondering if drugs (even prescription drugs) played a role in the death as well… I’ll keep updating the story as more becomes available.

My heart goes out to her family and friends. Certainly a loss suffered far too early.

UPDATE: According to the police report, a number of prescription drugs were discovered in Brittany’s bedroom including (read past the list for my take on this):

  1. Topamax –  While TMZ reported this drug to be used as anti-seizure medication, it is also used to reduce weight-gain associated with the use of many other prescription drugs on this list. Lastly, it is considered to be a mood stabilizer.
  2. Methylprednisolone – An anti-inflammatory that may be used to treat bronchial infections
  3. Prozac – A commonly prescribed SSRI anti-depression med.
  4. Klonopin – A benzodiazepine anti-anxiety prescription medication that is also used to help with insomnia. Like most benzos, the probability of overdose is low if used properly, but overdose would lead to cardiac arrest.
  5. Carbamazepine – Another anti-convulsant mood stabilizer often used to treat bipolar disorder. This prescription drug can be very dangerous when combined with other medications due to its actions on GABA and extensive alteration of Sodium channel activity. It is also a bipolar med.
  6. Ativan – Once again a benzodiazepine that is often used to treat anxiety and insomnia.
  7. Vicoprofen – A pain reliever that includes an opioid (it sounds like vicodin for a reason).
  8. Propranolol – Prescription med used to treat hypertension and as an alternative, less habit-forming anti-anxiety drug.
  9. Biaxin – An antibiotic.
  10. Hydrocodone – Same as Vicoprofen, an analgesic (pain reducing) prescription drug.

What do I think killed Brittany?

With 2 benzodiazepine medications, 2 opiates, and antidepressant, and a drug that is made to lower one’s heart pressure, it’s no wonder that Brittany was found not breathing. I’m going to wait until the final toxicology report to draw a definite conclusion, but from this list, it seems highly likely that a dangerous combination of these prescription drugs was taken, which resulted in Brittany’s heart stopping. Even when taken at their prescribed strengths, these medication, when combined, can form a lethal cocktail.

You should ALWAYS check with your doctor regarding interactions between different prescriptions you’re taking, especially when those medications haven’t all been prescribed by the same physician!