Opioid Dependence by Carl R. Sullivan, MD
Carl Sullivan, MD
The United States is currently experiencing an epidemic of patients dependent on opioids. These drugs, which are also known as narcotics, opiates and pain killers include some of the most addictive drugs known to man.
Many people are familiar with the opioid drug heroin, which has been illegal in the United States for more than 100 years. While there has been a recent mild resurgence in the use of this drug, the problem of opioid addiction now is often more related to prescription drugs. Starting in the mid 1990’s there was a spectacular increase in the number of prescriptions written for opioid analgesics (painkillers). This occurred against the social backdrop and public perception that doctors in the United States had been inadequately treating patients with pain. And so opioids became relatively easy to obtain by prescription from a doctor.
Oxycontin came on the market during this time and quickly found favor with pain patients and doctors. It was promoted as being relatively free of addiction properties if taken correctly. However, in addition to being a terrific pain medicine Oxycontin also was easily divertible, frequently altered and quickly became a favorite of addicts. Since it is a pharmaceutical compound it was judged to be far safer than heroin which was often of dubious origin. Oxycontin usage spread with surprising rapidity. However, rumors of diversion, overdoses, crime and deaths began to appear.
It should be recalled that the prevalence of addictive disease including alcoholism in the US adult population is about 15%. Against this background Oxycontin quickly became the fast moving pharmaceutical of choice. However, starting in about 2001-2002 Oxycontin began to openly be perceived as dangerous by clinicians and patients. There were many stories of patients who had threatened doctors and/or legitimate pain patients in order to get this drug. And because of theses stories Oxycontin quickly went into decline as a favorite target for addicts. But the story does not stop there…….for there were a lot of other prescription opioids “waiting in the wings” to take its place. After all Oxycontin is just a long acting preparation of oxycodone. And oxycodone is also present in more common drugs such as Percodan, Percocet, Tylox, Oxy IR. In addition hydrocodone, which the DEA (Drug Enforcement Administration) lists as a Schedule III (meaning that refills of a prescription can be given) has seen an amazing increase. A couple of years ago 53% of all prescription opioids were one of the hydrocodones (e.g.Vicodin, Lortab, Lorcet). Methadone has seen a resurgence of usage as a long-acting analgesic that has largely supplanted Oxycontin in that capacity. Predictably there is now much more methadone available on the streets and the numbers of methadone deaths from over dosage has risen steadily.
In an attempt to find a “safe” opioid patches have been developed for fentanyl (Duragesic) which is one of the most potent medicines known to man. Initially it was felt that patches were safe but this has also proven to be a fallacy. I have heard of nine different ways that a patch can be altered to “get the fentanyl out”. Other opioids such as the old standbys like codeine and morphine have also seen an upswing in popularity. The idea of a “typical” addict just doesn’t hold up in 2007. As of last year the number one gateway drug for our youth is no longer marijuana….prescription opioids have now achieved this dubious distinction. This is a somewhat terrifying situation since opioids are far more likely to produce addiction and are much more lethal when taken in excess.
Most of these drugs are designed to be taken by mouth (some are liquid injections or patches). However, there is much diversion that goes on. Many of the pills are routinely crushed and snorted to get a quicker “high”. Some of the pills are crushed and dissolved in water. They are then directly injected into the vein of the user. For some patients they merely take the drugs by mouth but also” by the handful”.
Opioids are excellent pain medications. In addition they also can produce significant euphoria which is related to their seductiveness and addiction tendency. All opioids also cause constipation, pupillary constriction and can decrease the respiration. While there is no question that prescription opioids are excellent for acute pain, the data on their usefulness in chronic pain is very uncertain. Over time it appears that opioids actually may make a patient more sensitive to pain which causes the cycle of escalation in dosage followed by more pain. Sudden withdrawal from opioids can produce marked physical and psychological distress. Physically the patients appear very ill with prominent muscle and bone aches, runny nose, tearing, diarrhea or vomiting, profuse episodes of sweating and tremors. They can appear to have a severe case of the “flu”. Craving for opioids at this point can become all consuming and patients will forgo any normal social restraints in pursuit of more opioids. Many patients have said that their real fulltime job is to find an opioid supply every day.
Treatment for opioid addiction has been inadequate. In my professional life there have been times when I thought opioid addiction was an almost hopeless disease and that these patients were likely to either end up in prison or dead. In the early 1990’s, health insurance companies via the Managed Care industry dismantled three decades worth of addiction treatment gains and insisted on less costly and primarily unproven outpatient therapies. Opioid addiction was seen as “non-life threatening” and was judged to need outpatient treatment in almost all cases. Unfortunately there have been very few outpatient therapies that have shown effectiveness in treating these patients. Methadone maintenance has been available through specialized clinics since the early 1970’s. However, these clinics tended to be located in urban areas and didn’t reach a fraction of the addicts who might need service. In addition methadone itself is a divertible drug with considerable street value and a marginal safety profile. In 2002 the first physician office based treatment became available in the form of a partial opioid agonist called buprenorphine which is sold as Suboxone and Subutex. This medicine is extremely effective in allowing the opioid addict to feel normal, without craving or withdrawal, and to go about the work of getting into long term treatment. Buprenorphine clearly works best when combined with a treatment program that includes psychoeducational information about addiction and attendance at peer support programs like NA or AA. In 2007 opioid addicted patients at last have some options. I would encourage any patient or family member suffering from opioid addiction to seek out a physician who is capable of prescribing either Suboxone or Subutex. To find a physician near you go to www.Suboxone.com.
Opioid dependence, whether to heroin or prescription opioids, is a serious and very common disease. For the active addict it is unlikely to disappear without professional help. The good news is that patients do have choices and treatment options and I would encourage that those suffering with addiction seek the help that is available.
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