Managing Opiate Addiction During Pregnancy

By Lisa Simpson

According to figures from the National Survey on Drug Use and Health, 5% of pregnant women in the US use illicit drugs, which rises to just over 20% in the under 18 age group. While heroin is used by only around 0.1% of women during pregnancy, a further 1% admit to using opiate based medications for purposes other than pain relief; prescribed opiates include codeine, fentanyl, hydrocodone, meperidine, morphine and oxycodone. Women are usually asked about their use of drugs early in their obstetric care to identify those who, along with their developing baby, are at risk from this habit. Displaying erratic behavior, signs of intoxication or withdrawal are easy to spot, but waiting till later in pregnancy to seek obstetric care, poor attendance at appointments and below expected weight gain are also indicators that a woman may be using opiates.

Risks from opiate use

Women who continue to use heroin during pregnancy risk reduced growth of their developing baby, fetal death, separation of the placenta from the uterus and premature labor. While birth defects have rarely been observed in babies born to women using opiates during pregnancy, a number of studies have demonstrated codeine use during the first trimester is linked to heart abnormalities; though this has not been seen with other prescribed opiates that have also been studied.

Methadone program during pregnancy

As well as treating pregnant women addicted to heroin with methadone, a similar maintenance plan is starting to be used with addiction to other opiates; there is also evidence that buprenorphine may be used as a safe alternative for management of opioid use, so this option may be presented to women. The dosage of methadone is determined by addiction specialists, who adjust the dose as required throughout pregnancy to avoid withdrawal; symptoms of this include cravings, anxiety, difficulty sleeping, feeling irritable and nauseous. Not only does this prevent these unpleasant symptoms for the mother, but protects her unborn baby; while withdrawal from opiates is rarely fatal for adults who are in good health, fetal death may occur in women who do not seek help with their addiction and try to withdraw on their own.

However, as with others who access help with opiate addiction, therapy goes beyond the prescription of methadone for pregnant women; she will also receive dependency counseling and have access to other medical and psychological interventions, as well as any other services deemed necessary. This ensures that by engaging in a program for therapy, women are more likely to receive prenatal care, which reduces the likelihood that complications will arise during their pregnancy. It is possible for most pregnant women to attend a methadone program on an outpatient basis, though in some cases it may be advisable to initiate methadone during a short stay at an opiate treatment center. While maintenance with methadone is preferred to withdrawal during pregnancy – even when medically supervised – due to the high risk of relapse, if participation within a methadone program is refused by a woman, the second trimester is the safest time for her to withdraw under the guidance of a specialist.

Neonatal Abstinence Syndrome

Although treatment with methadone is more likely to lead to a healthy pregnancy than if illicit opiate use was to continue, her newborn baby is at risk of developing a condition known as neonatal abstinence syndrome, which affects the nervous syndrome. As a result a baby’s sucking reflexes are uncoordinated, which interferes with feeding, and they are also more prone to be irritable. Babies who were exposed to methadone in the uterus usually develop withdrawal symptoms within their first three days after birth and while in some cases this may only last for a matter of days, in other infants they may remain for weeks. It is protocol for babies born to women who took opiates during pregnancy to be monitored for this syndrome so that treatment can be initiated as necessary; the obstetric and pediatric team work closely to ensure that the newborn receives optimal care to achieve normal feeding, weight gain and sleep patterns. As neonatal abstinence syndrome can be successfully managed and does not appear to have any lasting adverse consequences to physical or mental health, the advantages of initiating methadone in pregnancy far outweighs the risks.

Adderall use and college students

All About Addiction has profiled stories of college addiction in the past, but most have centered on illegal drugs and the rampant problem of alcohol abuse. Education blogger Valerie Harris joins the community today to talk about a very disturbing new trend: the rise of “study aid” dependencies, usually in the form of prescription ADHD meds like Adderall. Valerie writes a student resource website for those looking into different college and grad school options, and is an expert in many of the issues modern students face.  As prescription drug abuse is a major problem in our society, a specific focus on prescriptions relevant to college studentsis noteworthy.Study Drug Addiction Plagues Students From Masters Programs to Community College Illicit Adderall usage on college campuses has been on the rise in recent years, mostly stemming from its use as a study aid. The amphetamine salts that make up Adderall accelerate the heart rate and increase alertness, enabling students to put in long hours of continuous and focused study. However, due to its amphetamine base, Adderall can also be addictive, leading some students to use the drug as a crutch, causing long term issues both academic and social.

Increasing Use
A 2009 article in the Cornell Sun stated that Adderall was estimated to be used by 6% of college students, while a 2011 survey in the journal Addiction reported that on some campuses, as many as 25% of students were abusing the drug. A study conducted by the National Survey on Drug Use and Health found that 15% of college students have illegally ingested Adderall, Ritalin or another stimulant in the past year, while only 2% of these hold a prescription for the drug. This suggests that there might be an overall increase in Adderall abuse although longitudinal data from single sources is relatively scarce.

Campus Responses

In light of this possible increase, and the problems associated with it, universities are beginning to fight back. Recently, Duke University added “the unauthorized use of prescription medication to enhance academic performance” to its student conduct policies that equate to academic dishonesty. Wesleyan and Dartmouth have also amended their policies to include a ban on prescription drug abuse, while students with ADHD prescriptions at George Washington University are told to purchase a safe for their dorm. Other schools more aggressively target potential dealers.

The Illusion of Safety

Due to its prescription drug status, many college students believe Adderall to be safe and non-addictive. It’s true that when used with a prescription and with the supervision of a doctor, Adderall can be safe. However, when used without a prescription Adderall use  is essentially akin to unregulated speed abuse. As an amphetamine drug, Adderall is listed by the Drug Enforcement Agency as a Schedule II Controlled Substance, meaning anyone caught with pills not prescribed by a doctor is subjected to the same criminal charges as those possessing opiates or methamphetamine. Schedule II drugs involve an extremely high risk of addiction and overdose, as well as a potential to lead to depression or heart failure.

A University of Pittsburgh newspaper notes that side effects can include irregular heart rate, increased blood pressure, headaches, sleep deprivation, and loss of appetite, among others. When abused, the adverse effects of the drug can be substantially exacerbated. Instances of acute exhaustion or psychosis during withdrawal have been documented, and when it’s mixed with alcohol, Adderall can even cause death. Among young people with developing prefrontal cortexes, the effects can be even more pronounced and long-term, essentially changing the chemistry of the brain.

Safer Solutions
Perhaps the biggest hurdle schools and medical professionals face in weaning students away from prescription drug addiction in their genuine effectiveness. Still, statistics show that students using Adderall illicitly are often far from the highest achieving, with an average GPA among abusers of less than 3.0. The fact that the vast majority of students who take Adderall use it legally and likely suffer with learning disabilities clearly affects these performance numbers, but it is clear that Adderall is not a panacea. Students who truly achieve long term success usually do so by disciplining themselves and utilizing time effective time management skills. “The most important thing to have for time management is some kind of system” says Kelci Lynn Lucier, author of The College Parent Handbook. “Some students use the calendars are their phones: others use things like Google Calendar; others still use the classic paper-calendar model.”Lucier also asserts the importance of maintaining a regular and appropriate sleep schedule. “While it may be common among college students, a lack of sleep is more detrimental than you might think,” says Lucier. “It can throw everything out of whack: your mental health, your physical health, your stress level, and, of course, your schedule.”There is no doubt that Adderall offers a short-term solution for students that are behind in their studies, their sleep, or generally overwhelmed by their many burdens. However, the adverse effects of continued use on one’s mental and physical health, as well as the potential risks towards one’s education and future success, can prove devastating. Students who are genuinely invested their academics and career training are often best served by taking the time to study while maintaining a disciplined and manageable lifestyle.

Quitting smoking without help is hard: Effects of motivation and other personality factors

Quitting smoking is hard, but that suggestion probably isn’t terribly exciting all on its own since most of our readers probably knew it already. Still, while we’ve talked about quitting smoking using nicotine replacement and medication, we haven’t really touched the subject of all those people out there who just decide to give quitting smoking a try one day without those patches, gums, or pills.

Since something like 95% of those who try their hand at quitting smoking relapse within one year, and most of these people try to quit unaided, I think this is an important topic to touch on. Fortunately, recent research conducted in the U.K. tried to assess the personality and cognitive aspects that end up predicting who will succeed, or fail, in their quit attempt.

The effects of expectation, motivation, and impulsivity when quitting smoking

Quite a bit of research has already shown that when smokers are trying to quit (so we’re talking early on during abstinence), their brains react differently to stimuli in the environment depending on the relationship between those stimuli and nicotine. Stimuli that aren’t associated with smoking (or some other form of nicotine intake) get less attention and show overall less activation of important brain circuits while nicotine associated cues light up the brain just as if nicotine was on board (even though participants were drug free at the time). Essentially, if a stimulus predicts getting a hit, the brain gets smokers to pay attention to it so that they can do whatever is necessary and get a little drug in. Throw in some of that reduced ability to control behavior that we talk about so much (like impulsivity), and which is common not only in smokers but in users of almost every other drug (heroin might be the exception) and you have a recipe for disaster, or at least for a good bit of smoking relapse. And yet if we want to fight the horrible health consequences of cigarettes, then quitting smoking has to be made easier, which nicotine replacement and medications like bupropion have done to some extent.

As part of this equation, knowing the specific predictors of early relapse in people who are quitting smoking may be useful so that professionals planning smoking interventions can do a better job of targeting the most important factors. The study recently published the journal Psychopharmacology tried to assess the relationship between the severity of smoking, the above-mentioned personality factors, and the success of the quitting attempt.

The cool thing about this study is that the 141 people who participated were assessed on a whole set of these cognitive tests twice – once after a smoking free night and a nicotine lozenge and another time after a smoking free night followed by a nicotine-free lozenge. While they couldn’t tell which was which, the procedure gave the researchers an assessment off how different participants’ reactions were with or without nicotine on board. Following the assessments participants were directed to begin their attempt at quitting smoking. While they were asked not to use nicotine replacement options or other medications, they were allowed to use any other resource available and were given a set of information pamphlets that explained expected side effects and likely difficulties during the quit attempt. They were then followed up after 1 week, 1 month, and 3 months. Quitting was identified as minimal smoking (less than 2 cigarettes per week) and was verified both by self report and cotinine testing. There was a small financial incentive to quitting, with people who relapsed after a week getting only £40 (about $60) and those who made it through month 3 getting £150 (about $250), though I’m pretty sure that if $200 was enough to make people quit we’d have just paid up already…

The first thing to note in the results was that 24% of the participants were still not smoking at the 33 month followup. This seems to be about on par with the usually low success rates at 1 year though I’m sure this research group will try to continue following these participants at least up to the 1 year mark and hopefully produce another paper.

The overall most reliable predictor of who quit and who relapsed ended up being the level of nicotine dependence as measured by the participants’ pre-quit attempt cotinine levels and the number of cigarettes they smoked every day. Since cotinine assessments are less biased, it was the most predictive of all throughout the experiment (# of daily cigarettes was no longer predictive at 3 months). Interestingly, self reported impulsivity and smokers’ initial ratings of cravings for cigarettes didn’t end up predicting relapse at all, but those cognitive tests assessing the quitters’ reactions to nicotine associated cues told a pretty interesting story: It seems that early on during their quitting attempt smokers who had more general interference with their cognitive function relapsed sooner. These cognitive problems can be thought of as interfering with normal thinking by nicotine-related cues and maybe even more general interference with brain function. After the 1-week follow-up, at the 1 and 3 month assessment, the odds of quitting had more to do with baseline assessments of motor impulsivity as well as those initial cotinine levels assessing the degree of nicotine dependence.

The take-home: Quitting smoking is hard for different reasons in the first week and later on

If you’ve ever tried to quit you’ve been told you that the first week is the hardest and that once you make it through that the rest is a piece of cake. While this research doesn’t necessarily support that notion, since about 25% of the sample relapsed between each of the followups, it does seem to indicate that the reasons for relapse change after that first week.

It seems that the first week may be difficult because of general cognitive interference by stimuli and cues that are nicotine associated. Those cues make it hard to pay attention to much else and they interfere with normal thinking and attention process, making sticking to the quit attempt difficult. After that point, successfully quitting smoking seems to be associated more with the level of initial smoking and that damn motor impulsivity test. The finding that heavier smokers have a harder time quitting isn’t new and isn’t surprising, but the fact that cognitive effects and predictors of relapse change does suggest that the interventions likely to help smokers quit may need to be different during week 1 and afterward.

Overall, these findings suggest that the cognitive function problems associated with quitting smoking (or smoking in general) may recover faster than do some of the other physiological factors associated with quitting since the initial levels of smoking continued to be highly predictive throughout the 3 month period of followup. Another explanation could be that initial smoking levels affected brain function in ways not assessed by these researchers.

Since so many smokers relapse within the first week (more than 50%), it seems to me that interventions that really focus on the cognitive interference and the extreme attention towards nicotine associated cues and stimuli would be helpful for those quitting smoking. Maybe if we can reduce relapse numbers at 1 week we can have a more gradual fall-off for the following month resulting in significantly higher quit rates.

Interestingly, NIDA and other research organizations are getting really interested in the use of technologies like virtual reality for help in addiction training. It seems that in this context, these sorts of treatments might be useful in helping early quitters train to avoid that cognitive interference. Additionally, medications like modafinil, and maybe even other ADHD medication could be used very early on for those quitting smoking to help recover some of their ability to control their attention thereby reducing the power nicotine associated stimuli have over them. I guess we’ll have to wait and see as those who develop interventions start integrating this research. In the meantime, I’d love to hear from readers who have quit or tried to quit: Does this research seem to support your own experiences?

Citation:

Jane Powell, Lynne Dawkins, Robert West, John Powell and Alan Pickering (2010). Relapse to smoking during unaided cessation: clinical, cognitive and motivational predictors, Psychopharmacology.

 

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The first thing to  note in the results was the 24% of the participants were still not smoking at the 33 month followup. This seems to be about on track for the normally low success rates at 1 year though I’m sure this group will try to follow these individuals up at that point and hopefully produce another paper. The overall most reliable predictor of who quit and who relapsed ended up being the level of nicotine dependence as measured by the participants’ pre-quit attempt cotinine levels and the number of cigarettes they smoked every day. Since cotinine assessments are less biased, it was the most predictive of all throughout the experiment (# of daily cigarettes was no longer predictive at 3 months). Interestingly, self reported impulsivity and smokers’ initial ratings of cravings for cigarettes didn’t end up predicting relapse at all, but those cognitive tests assessing the quitters’ reactions to nicotine associated cues told a pretty interesting story: It seems that early on during their quitting attempt smokers who had more general interference with their cognitive function relapsed sooner. These cognitive problems can be thought of as interruption with normal thinking by nicotine-related cues and maybe even more general interference with brain function. After that point, at the 1 and 3 month follow-ups, had more to do with baseline assessments of motor impulsivity as well as those initial cotinine levels assessing the degree of nicotine dependence.

The take-home: Quitting smoking is hard for different reasons in the first week and later on

If you’ve ever tried to quit you’ve heard someone telling you that the first week is the hardest and once you make it through that the rest is a piece of cake. Well, this research doesn’t really support that notion since about 25% of the sample relapsed between each of the followups, but it does seem to indicate that the reasons for relapse change after that first week. It seems that the first week may be difficult because of general cognitive interference by stimuli and cues that are nicotine associated. Those cues make it hard to pay attention to much else and they interfere with normal thinking and attention process, making sticking to the quit attempt difficult. After that point, successfully quitting smoking was associated more with the level of initial smoking and that damn motor impulsivity test. The finding that heavier smokers have a harder time quitting isn’t new and isn’t surprising, but the fact that cognitive effects and predictors of relapse change does suggest that the interventions likely to help smokers quit may need to be different during week 1 and afterward. Overall, these findings suggest that the brain function problems associated with quitting smoking (or smoking in general) may recover faster than do some of the other physiological factors associated with quitting since the initial levels of smoking continued to be highly predictive throughout the 3 month period of followup. Another explanation could be that initial smoking levels affected brain function in ways not assessed by these researchers.

Since so many smokers relapse within the first week (more than 50%), it seems to me that interventions that really focus on the cognitive interference and the extreme attention towards nicotine associated cues and stimuli would be helpful for those quitting smoking. Maybe if we can bring the relapse numbers down at 1 week we can have a more gradual fall-out for the following month resulting in significantly higher quit rates. Interestingly, NIDA and other research organizations are getting really interested in the use of technologies like virtual reality for help in addiction training. It seems that in this context, these sorts of treatments might be useful in helping early quitters train to avoid that cognitive interference. Additionally, medication like modafinil, and maybe even other ADHD medication could be used very early on for those quitting smoking to help recover some of their ability to control their attention thereby reducing the power that nicotine associated stimuli have over them. I guess we’ll have to wait and see as those who develop interventions start integrating this research. In the meantime, I’d love to hear from readers who have quit or tried to quit: Does this research seem to support your own experiences?

Citation:

Jane Powell, Lynne Dawkins, Robert West, John Powell and Alan Pickering (2010). Relapse to smoking during unaided cessation: clinical, cognitive and motivational predictors, Psychopharmacology.

Teens and drugs: Drug use statistics and treatment that works

Here are some drug use statistics:

  • Over 80% of teens engage in some form of deviant behavior (1).
  • Over 50% of high-school seniors admit to having used drugs (2).
  • Only 10%-15% of the population develop drug addiction problems related to their drug use (1).

The question is:

If the majority of teens experiment with drug use, and so few eventually develop drug addiction problems, should we be focusing on something other than stopping kids from trying drugs? Continue reading “Teens and drugs: Drug use statistics and treatment that works”

Bath Salts – Pressing the Issue

Q &A – Dr. Adi Jaffe PhD Interviewed By Tony O’Neil of The Fix

“A man was attacked on the side of the highway, authorities find the attacker eating a the victims face, and only after multiple bullet wounds is the attacker stopped.” This Zombie-like behavior is common in Hollywood scary movies, but as of late the new “Bath Salt” epidemic has turned places is like Miami into a real life Zombieland, or at least that’s what we have been told.

UPDATE: We now know that the assailant in this case (Rudy Eugene) had only traces of marijuana in his blood and no evidence of bath salts use. However he was previously diagnosed as schizophrenic and we know that especially for those at risk, marijuana use is associated with psychotic breaks.

What are “Bath Salts”?

Bath Salts are a street name given to a number of meth like drugs, so we’re not talking about your everyday Epson salt here. Although drugs like MDPV have just been made illegal, most of these substances seem to be cathinone derivatives and are central nervous system stimulants that act through interruption of dopamine, norepinephrine and to a more limited extent serotonin function.

It’s very important to note that research on this is still in its early stages and so reports are limited. However, it seems that at low to moderate doses the most common effects for MDPV can be thought of as either meth-like or like very strong adderall or ritalin – so users experience stimulation, euphoria, and alertness. Mephedrone seems to act more like MDMA (ecstasy) than meth, at least in early animal research with these drugs. At high doses however, and obviously there is no one regulating the dose since these drugs are sold as if not for human consumption, the effects can look like psychosis. These are not necessarily very different from meth induced psychosis which can include panic attacks, severe paranoia, self-mutilation, and violence.

There are several confirmed research reports (individuals who had only MDPV in their system) of people injecting or snorting MDPV and developing severe psychosis, “running wildly throughout the local neighborhood,” foaming at the mouth and being combative when approached. Worse still, these individuals can develop severe organ failure, require intubation (breathing tube insertion through throat), and at times die even in the face of extreme medical intervention.

How do Bath Salts affect the nervous system?

These drugs tend to be sympathomemetic, which means they induce sympathetic nervous system activation – the increased heart rate, temperature, etc. This is also where they can be most dangerous even when people don’t develop the possible psychotic effects (due to organ failure from the hyper activation).

Can one become addicted to Bath Salts?

I think that there’s no question that this stuff can cause physical dependence. I personally know of a client at matrix here in west la who came in specifically for “over the counter stimulant addiction” to drugs like these. He was snorting, then injecting them and stayed up for days. Eventually he was hospitalized with severe agitation and mild psychosis. These high doses are almost certainly, based on what we know with meth and MDMA, also causing neurotoxicity (some of the effects irreversible).

What Harm Reduction model should be used for Bath Salts?

It seems that MDPV and mephedrone are indeed drugs worth worrying about, at least in so much as they are completely unregulated when sold “not for human consumption.” While their effects at low/moderate doses are not severe are can be thought of as related to those of other stimulants, at high doses they can be lethal and can certainly bring about serious negative psychological effects. I always think that there is some room for harm reduction when trying to get some control over abuse of such drugs. In this case, while it’s probably best to stay away completely, I would urge people who are going to use to be careful and not to use large amounts of this stuff before seeing how they react. The neurotoxicity and cardiac effects can be too extreme and may lead to severe irreversible consequences at high doses.

How can the media help resolve this epidemic?

Press coverage always makes more people aware of an issue than they were before the topic was covered. In this case, especially if we can sneak in some of the above harm-reduction messages along with the overall “don’t use this stuff” text we normally see, we might be able to use the opportunity to save some lives. I think, as I’ve said before, that people (especially kids) are going to be on the lookout for ways to change their experience no matter what. The question is how we react when they do things we don’t like and how does our reaction affect their future behavior.

I think that we can use the real information – possible death and psychosis, especially when snorted or injected – to alter the ways people use Bath Salts, allowing for a campaign that isn’t only looking to stop the use of the drug but that is focused on minimizing consequences. However it seems that the press isn’t covering the range of possible effects but is choosing instead to focus on the most outrageous. These types of scare tactics haven’t worked too well in the past for curving drug use, but it doesn’t hurt TV ratings so I don’t expect it to stop.

Will banning bath salts help?

I believe that in this case, as we can already see, we are once again going to be playing a cat and mouse game that congress seems happy to play. They’ll outlaw more components of Bath Salts (MDPV, mephedrone, and methylone apparently already are controlled) but new ones will continue to come out. To me, the question is whether we believe we will one day ban all psychoactive substances we have issue with or whether we will be successful in developing a strategy for dealing with their abuse in a way that helps recognize and intervene early.

I think that the banning approach makes it less likely that people with abuse problems, or even acute medical problems, will contact authorities for help. Worse yet, it makes it nearly impossible for us to get a handle on safer use practices for a specific drug as they all get replaced by new variations – often ones that are even more dangerous.

Although the press has made the Bath Salt epidemic much more like a Hollywood production than reality, there are issues that need to be addressed. I just don’t believe in scaring the public into action, I’d prefer if popular media were just honest with the public about these drugs so that people can draw their own conclusions.

DARE – Drug Abuse Prevention that doesn’t work

  • DARE (Drug Abuse Resistance Education) is the largest school-based drug abuse prevention program in the United States.
  • 80% of school districts across the country teach the DARE curriculum, reaching an estimated 26 million children (1).
  • Every year, over $1 billion goes into keeping the program running. A billion dollars may be a small price to pay to keep America’s children drug-free, but there is plenty of evidence to suggest that DARE isn’t doing what it’s supposed to.

What is DARE?

dareFounded in 1983, DARE began as a 17 week long course taught to 5th and 6th graders. The course is taught by a uniformed police officer who teaches the students about drug use and gang violence. The DARE curriculum includes role-playing, written assignments, presentations, and group discussions.

DARE uses a zero tolerance policy towards drug use. Students are told to adopt mottoes like “Drug free is the way to be” and “Just say no to drugs!” Pictures of blackened lungs and drunk driving accidents are methods used to discourage experimentation. The focus of the program is clearly flat out refusal. Students are not taught what to do if they are already experiencing problems with drugs.

Is DARE effective?

The effectiveness of DARE has been called into question since the early 90s. A meta-analysis of 11 studies conducted from 1991-2002 shows no significant effect of DARE in reducing drug use (1). Several studies have even reported an opposite effect, with DARE leading to higher rates of drug use later on in life. Reports from the California Department of Education, American Psychological Association, and U.S. Surgeon General all label DARE as ineffective.

The results seem clear, but statistics don’t seem to be enough to convince concerned parents and policy makers to shut down any drug abuse prevention program. With drug use on the rise, it seems that DARE is here to stay. But perhaps getting rid of DARE isn’t the best option. The framework and funding already exist for a potentially successful prevention program. Maybe all we need to do is apply some science and develop new techniques that will provide results.

*It should be noted that in 2001, DARE made substantial revisions to its program under the title “New DARE.” The effects of these revisions have yet to be measured, so we’ll wait and see.

 

Citation:

1. West, S.L., O’Neal, K.K. (2004) Project D.A.R.E. Outcome Effectiveness Revisited. American Journal of Public Health. 94(6)

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.