Issue: Epidemic of deaths due to overdoses and increased numbers of addicted people since the 1990’s.
Cause: Research and development of new opioid drugs by pharmaceutical companies with the intent of making drugs that are less effective at producing euphoria and more effective at decreasing pain. Once the drugs were approved they were marketed aggressively to MD’s, who then increased prescribing them In 2009, the American Geriatric Soc. encouraged MD’s to Rx opiates to treat moderate to severe pain in older patients. At the time it was thought that older patients were less likely to become addicted to opiates.
Problems: These new drugs when over prescribed can still cause addiction and are less effective at treating chronic pain than many other methods currently available. Addiction can occur within the first week of use. Many patients became addicted without knowing that they were taking opioids. (1, 2, 3)
In March 2016 the CDC, US Department of Health and Human Services, FDA and multiple medical societies declared an Opioid Epidemic calling for changes in prescribing opioids.
Ramifications for: health care, economics, social issues, legal issues – national and international crime, political issues, insurance issues.
Effects on people aged 50+. The rate of hospital admission for Opiate Overdoses among Medicare recipients increased 4 fold from 1993 to 2012. (1,3) A Harvard School of Public Health study found nearly 1/3 of Medicare beneficiaries (12 million people) received at least 1 opioid Rx in 2015. The average number of opioid Rx’s/patient was 5, lasting for 6 months or more. (2)
A study by the CDC reported that 2.7 Million Americans over age 50 abused painkillers. Nearly 14,000 deaths of people aged 45+ were attributed to opioid overdose in 2015 = 42% of deaths due to overdoses. This may be an underestimate as deaths due to heart failure and falls may have been caused by opiates. (2)
Aging leads to slower rates of clearance of drugs from the body by the liver and kidney à overdoses. Memory loss can lead to difficulty managing medication intake. Some have turned to crime selling their Rx opioid pills to support their drug habit or their basic living needs. Some have turned to buying heroin on the street to save money, or to continue use of opioids after MD’s stop providing opioid Rx’s. Compared to the legal opioids, many opioids available on the street are cheaper but more powerful than legal Rx’s, mixed with other drugs, and of unknown strength. (2)
Economic/Political issues: High cost of both Rx opioids to treat pain and Rx cost for drugs that decrease opioid actions to treat opioid addicts. Medicaid spent $500 million in 2015 on Suboxone to treat addicts who chose to stop using opioids. Many addicts depend on expanded Medicaid coverage in the 31 states and Washington DC to treat their addiction.
Alternatives: Health issues: How to treat pain without using opioids. Social/political/legal Issues: How to cope with people who are already addicted: as criminals or people with a chronic illness.
Addiction. Addiction can set in with just one week of use. A 2016 National Safety Council survey found that 99% of the MD’s prescribe opioids past the CDC recommended dosage limit of 3 days. (2) The biological changes that occur in the brain are the same to any addiction. Some people have gene variations in Dopamine receptors that increase their likelihood of becoming addicted to something: chemicals and/or behaviors. Dopamine is secreted in response to anything that causes pleasure and drives us to repeatedly seek those things that produce our own opiates: Dopamine is coupled with the release of our own opiates in response to things that cause pleasure. Excessive exposure to exogenous opiates can cause the Dopamine drive to uncouple from the Endorphin high, leaving people using higher doses of drugs without pleasure. Opiates affect most body functions including pain, pleasure, sleep, and alter autonomic nervous system function suppressing heart function, respiration, the digestive system, reproduction etc. The body’s actions to compensate for these changes produce the symptoms of opiate withdrawal.
Problems: Decreasing euphoria may decrease the risk of addiction but not eliminate it. Physiological responses that compensate for the presence of elevated levels of opiates lead to toleration of increasingly higher doses of opiates and changes that cause withdrawal symptoms to occur when the external source of opiates is removed. Some people can become addicted within one week on opiate drugs.
Older people are more likely to suffer side effects from opiates including memory and cognition problems and falls and take multiple other drugs that can interact with opiates. As the new opiates are stronger (Fentanyl is as much as 400 times more potent) it is easy to overdose.
Alternatives: 1. Treatment of Opioid Addicts As criminals or invalids. Prison and/or recovery programs. Even after withdrawal, the cravings remain for life leading to high recidivism.
Most addicts in treatment receive drugs that bind to opioid receptors that help control cravings and decrease withdrawal symptoms. Pharmaceutical companies are pouring lots of money into research to come up with “better drugs” to control cravings. New drugs are coming on the market with controversy over whether they are better than the current drugs.
Other options include counseling and support programs that require withdrawal and living without drugs and use of recovering addicts as peer counselors for addicts, in addition to health care professionals. Lane County has highest incidence of opioid overdose deaths in Oregon. Local community responses to treat addicts in Lane County include treatment court, and rehabilitation programs. Utube has many individual accounts of using a variety of methods to withdraw on their own at home.
Needs: More treatment centers. Counseling tailored to older patients. Addiction counseling and treatment for homeless addicts, and military veteran addicts. Education for health care workers on medications used to treat opioid addiction. Attitude change: from Addiction as a moral failing to chronic medical condition.
Pain: A 2011 study by the Institute of Medicine estimated 100 million American adults live with persistent or chronic pain. (3) Causes of chronic pain include: inflammation, osteoarthritis, multiple sclerosis, neuropathic pain (damage to neurons), cancer, chemotherapy. Opioids can increase pain sensitivity within the central nervous system. Chronic pain can affect sleep, thought, depression, and anxiety. Pain can be considered a “brain state”. Patients with chronic pain may be on opioids, valium and Ambien, a deadly combination. (3)
- How to deal with pain without using opioids. Our endogenous opiates Endorphins, Enkephalins, and Dynorphins are produced in response to anything that gives us pleasure. Such as food, caffeine in coffee, tea, and chocolate , alcohol, nicotine, cocaine, exercise, empathy, altruistic behavior, meditation, gambling, sex, internet use, TV, cute pets, children etc. We can become addicted to any of these.
We have analgesic (pain suppressing) neural pathways in the spinal cord and brain that activate the release of opiates in response to pain and placebos.
Pain Pathways: Physical pain (Short term. Long term) and Emotional pain (Anxiety, depression etc.) Vicious cycle: Pain à anxiety àincreased sensitivity to pain à more anxiety etc. Decreasing emotional pain signals can decrease concern about physical pain, even if physical pain is still present.
Analgesic (Pain inhibiting) pathways –release our endogenous (internal) opiates: Endorphins, Enkephalins, and Dynorphins. These can decrease our sensitivity to pain as well as influence most body functions.
Analgesic spinal pathways: activated by peripheral touch, pressure, vibration, muscle stretch receptors and joint receptors cause the release of endorphins in the spinal cord and inhibit the pain sensory neural pathways to the brain. This may be a way that acupuncture, acupressure, and massage reduce pain.
Analgesic brain pathways: Neurons within the periaqueductal gray area of the brain send out endorphins within the brain that influence pathways down to the spinal cord to decrease the rate of information transmitted about pain from pain sensory neurons to the brain. They are activated by multiple neural processes: Experience of strong pain, Meditation/ prayer, Mindfulness based stress reduction, and Exercise. Placebos have been shown to activate the brain analgesic center in placebo responders. Empathy from care takers may decrease pain sensitivity by decreasing anxiety. Cognitive Behavior Therapy helps patients cope with pain and anxiety. (3) Altruistic behavior by the person in pain (as well as seeing altruistic behavior of others), sunshine and laughter have been shown to increase endogenous opiates in body fluids. Distraction and intentional focusing strongly can activate inhibitory signals from the cerebral cortex to the thalamus and block the transmission of pain sensations from the lower brain to a conscious level . (Medical Physiology text books).
Opiates are best at treating short term pain immediately following injury, but are not effective at dealing with long term pain. More effective treatments for long term pain include: Non-steroidal anti-inflammatory drugs (NSAID’s) and other suppressors of inflammation, such as turmeric, cherries, olive oil, ginger, and magnesium. Selective reuptake inhibitors of Serotonin and Norepinephrine, Acupuncture, Acupressure, Chiropractic adjustments, Heat. Cold, Trans epidermal nerve stimulation, electrical stimulation within the spinal cord and analgesic regions within the brain, magnetic stimulation of the brain and the behaviors listed above that activate the release of endogenous opiates. (3) In some cases, which of these will work depend on the physiological source of the pain.
People with chronic pain have been found to have decreased levels of one or more of Serotonin, Norepinephrine and Cannabinoids. These individuals may respond well to raising these levels. Norepinephrine and Serotonin are both involved in the analgesic pathways from the brain to the spinal cord.
The use of Cannabinoids to treat pain is still under investigation. While individual studies provide some positive reports for cannabinoids for some causes of pain, Meta-analysis studies that rate the quality of the investigations find only small changes = about 1 point on a pain scale of 0-10, in the best quality studies. One meta-analysis found that none of the cannabinoid studies reviewed reduced pain by as much as 30-50% (4 and 5). Some studies found that using cannabinoids could decrease the dose of morphine needed to control pain.
Questions to ask when getting a new Rx
Is this Rx an opioid? Is it safe to take with my other medication? Are there non opioid pain relievers I could take? Could I take a lower dose of opioid? How should I taper off the medication? Should I have naloxone (antidote for opioid overdose) on hand? (1)
- 7 questions to ask when you’re given a prescription for an opioid. Harvard Women’s Health Watch vol 24:10 June 2017.
- The opioid menace AARP Bulletin June 2017 page 8 -12
- Pain: New ways to find relief without opioids. Scientific American Mind: May/June 2017: 28 – 35
- Selective Cannabinoids for Chronic Neuropathic Pain: A systematic review and meta-analysis. Meng et al Aneshth Analg, 2017 May 19 E pub ncbi.nim.nih.gov.NCBI>literature
- Cannabinoid Buccal Spray for Chronic Non-Cancer or Neuropath Pain: A review of clinical Effectiveness, Safety and Guidelines. Internet. 2016 Sep Canadian Agency for Drugs and Technologies in Health.
References 4 and 5 were found on Pub Med at www.ncbi.nim.nih.gov >.NCBI>literature. Search for “Medical Cannabinoids and Pain”.