“Many clinicians have told me they weren’t aware of just how bad the problem had gotten. Many were not aware of the connection between the epidemic and prescribing habits.”
~ Dr. Vivek Murthy, then-Surgeon General of the United States
According to a recent study, 2 out of every 3 people receiving medications to treat their opioid addiction continue to be prescribed painkillers after completing treatment. This creates a potential hazard because it leaves the door open for a possible relapse.
The reason for this is that people who were once addicted to opioids have experienced changes to their brains that make them forevermore extremely vulnerable, at any dosage. Even therapeutic doses can complicate recovery and jeopardize their sobriety. In this way, researchers say, opioid addicts are like alcoholics who should never drink again.
Just as concerning, however, is the fact that over 40% of patients who are currently taking the anti-addiction drug buprenorphine also take opioid pain medication. This interaction could potentially counteract the treatment they are receiving.
In other words, doctors are giving opioid painkillers to the very group of people who should not be receiving them.
The researchers say there is no valid medical reason why both types of medication should be prescribed at the same time. But Dr. Caleb Alexander, who directed the study, says, “The statistics are startling but are consistent with studies of patients treated with methadone showing that many patients resume opioid use after treatment. But the high rates of combined use of buprenorphine and other prescription opioids is cause for concern.”
These findings raise serious questions about how some American physicians are not following established guidelines and how they are not using some of the tools they have at their disposal. And those errors may be one of the major factors behind the continuing—and worsening—the opioid crisis in this country.
How Bad Is the Opioid Problem in America?
“One of the most heartbreaking problems I’ve faced as CDC Director is our nation’s opioid crisis. Lives, families, and communities continue to be devastated by this complex and evolving epidemic.”
~ Dr. Thomas Frieden, then-Director of the Centers for Disease Control and Prevention
The American drug crisis is worse than at any other point in our history.
The Centers for Disease Control and Prevention reported 72,300 drug overdose deaths in 2017—an all-time high. To put that in perspective, in 1999, there were “only” 16,849 drug deaths, and that number has increased every single year. Every year, a tragic new record is set.
Within a single 20-year generation, the number of fatal overdoses has skyrocketed 429%.
Most of those deaths involved opioids – prescription pain medications, resurgent heroin, and with increasing frequency, super-powerful illicit synthetics such as fentanyl. In fact, over two-thirds of all drug poisonings are opioid-related. In 2017, that worked out to approximately 49,000 opioid drug deaths.
Opioids claim an average of 115 American lives per day.
Some experts believe that it’s going to get worse before it gets any better. It is estimated that between 2015 and 2025:
- The number of opioid-related deaths will spike sharply, rising from 33,100 to 81,700.
- That is a 10-year jump of 147%.
- 700,000 people will die because of opioid overdoses.
- 80% of those deaths will be due to heroin or fentanyl.
- Illicit opioid deaths will continue to surpass those from prescriptions, climbing from 19,000 to 68,000.
- That is an increase of 260%.
Addressing the Changing Problem
At first, it is difficult to comprehend. Opioid deaths are continuing to rise even though a number of significant steps have been taken:
- Expanded campaigns aimed at increasing public awareness
- New federal prescribing guidelines
- Shareable physician databases
- Greater availability of Narcan
- Needle exchange programs
The primary issue is that not all of these measures are being employed across-the-board. Different states and even individual cities have their own way of dealing with the problem. Of even more concern is the fact that even when there are programs in place, established best practices are always being followed.
Dr. Lawrence Brown, an addiction expert located in New York City, says, “The driving force isn’t the CDC, it’s the states. States are the ones that license doctors, but state regulations tend to lag behind Federal guidelines.”
Problem Prescribing Plays a Role
“Individuals were prescribing drugs without even performing a history and physical exam. They never did any kind of testing, they didn’t provide informed consent. They don’t have a treatment plan or objectives. They just continue to prescribe and prescribe.”
~ Kim Kirchmeyer, Executive Director, Medical Board of California
According to the National Safety Council:
- 99% of Us doctors exceed the federal recommendation of three-day prescription limits.
- Nearly three-fourths prescribe 30-day supplies.
- 55% of dentists and 70% of doctors give painkillers for dental and back pain, even though opioids are not the recommended first-line treatment for those problems.
- Good news—85% of healthcare providers ask patients about their personal history of Substance Use Disorder.
- Bad news—just 1 in 3 screen patients for a family history of addiction.
- When patients exhibit signs of prescription misuse, only 40% of providers provide addiction treatment referrals.
- Just 5% of providers offer direct treatment for SUD.
In fact, the overprescribing problem is so prevalent that in 2016, The U.S. Surgeon General, the Food and Drug Administration, and the CDC all recommended changes to the way that opioids are prescribed.
For a snapshot of how bad the problem can be, a 2012 investigative article in the LA Times, found that in four Southern California counties, over half of all accidental prescription deaths were among patients with a legitimate doctor’s prescription. The CDC estimates that just 15% of the prescriptions misused by “chronic abusers” come from illegal sources.
Coroner’s records in the Counties of Los Angeles, Orange, San Diego, and Ventura, and Orange revealed that during one 5-year period, 47% of fatal overdoses involved drugs for which the victim had a prescription that was later determined to be the sole or a contributing cause of death.
Of special relevance, a tiny fraction of all the practicing physicians in those four counties – just 0.1% – prescribed the drugs involved in 17% of the deaths. Among that 0.1%, each doctor had three or more patients who died.
Doctors May Face Charges
“(She) either didn’t know or didn’t care what she was doing.”
~ Oklahoma investigators talking about Dr. Nichols
But the tide may be turning against problem prescribers:
- In 2016, a doctor in Southern California was sentenced to 30 years to life in prison after being convicted of murder following the overdose deaths of three of her patients.
- Significantly, Hsiu-Ying “Lisa” Tseng had already been on notice from the Los Angeles County Coroner’s Office about three earlier patients’ deaths.
- In 2017, an Oklahoma doctor was with second-degree murder after five of her patients fatally overdosed.
- Between 2010 and 2014, Dr. Regan Ganoung Nichols prescribed more than 3 million doses of dangerous drugs.
- In 2018, a Queens doctor, Lawrence Choy, faced 231 counts, including reckless endangerment and manslaughter, after the overdose deaths of three patients.
- Choy routinely prescribed a dangerous drug combination of Oxycodone, Xanax, and Somo, a powerful muscle relaxant.
- Also in 2018, a doctor in Massachusetts, Richard Miron, was charged with involuntary manslaughter, illegal prescribing, and fraud after a patient overdosed on a combination of prescription drugs that included both morphine and fentanyl.
- Miron continued to dispense large doses to the patient, even after she had non-fatally overdosed on opioids he had prescribed.
DEA Agent Mark Normandy said, “One doctor can turn a town upside down.”
Why are Opioid Painkillers So Addictive?
“It has become increasingly clear that opioids carry substantial risk but only uncertain benefits—especially compared with other treatments for chronic pain. We lose sight of the fact that prescription opioids are just as addictive as heroin.”
~ Dr. Thomas Frieden
The key thing to remember about prescription painkillers is that they don’t precisely eliminate pain. Instead, they merely mask that pain by blocking signals from the brain.
But opioids also trigger pleasurable feelings of euphoria, freedom from worry and stress, and well-being. These effects are common to all intoxicants, including marijuana, alcohol, and other drugs.
When used for longer than just a few days, pain medications physically and chemically alter the user’s brain. In other words, they train the person that use is an enjoyable activity that is necessary for survival.
Addiction is a progressive disease – when high-dose painkillers are taken frequently or long-term, the receptors within the brain become fatigued. The user experiences a diminished response to opioids. Now, to feel the same pleasurable effects, they must continually increase both the frequency and dosage.
This is known as tolerance.
Opioid use affects the pleasure centers of the brain so profoundly that eventually, the person becomes unable to feel the joy or motivation from any source unless they are under the influence. This is known as dependence. Gradually, the person loses the ability to function normally. In fact, a drug-dependent brain makes opioid use even more important than everyday obligations, personal hygiene, sex, or even eating.
Opioid dependence can develop in as little as five days.
And, when the prescription runs out – or is even delayed –an opioid-dependent person will start to suffer severely-unpleasant symptoms of withdrawal. Sometimes, withdrawal begins within just a few hours following the last dose.
Opioid withdrawal symptoms include
- Muscle cramps
- Joint pain
- Severe depression
- Excessive perspiration
- Uncontrollable tremors
- Alternating cycles of chills and fever
In the beginning, the opioids were consciously taken to make the person feel better. Now, they are compulsively used to keep from feeling worse. And when the person becomes willing to do ANYTHING to fulfill this compulsion, despite the cost or negative consequences, that is an addiction.
The Link Between Pain and Addiction
“In fact, my need for the opioid painkillers had reawakened an addiction to narcotics that had been in hibernation for over 15 years…My chronic pain gave me medical permission to dive into my real dope of choice, as the serpent of my addiction awoke full force and began to devour me.”
In 2016, researchers with Columbia University found for the first time a direct link between significant pain and the risk of Opioid Use Disorder . According to the study, people in moderate-to-severe pain are 41% more likely to struggle with opioid addiction than people who are without pain.
Significantly, people in pain also report other relevant problems more often, such as:
- A family history of alcoholism
- A personal history of substance abuse
- Mood disorders such as anxiety or depression
Different demographic groups also show different tendencies. For example, males and younger adults are more likely to abuse prescription painkillers, while females and older adults experience pain more often.
CDC Sets Guidelines for Opioid Prescribing
“This is the first time the federal government is communicating clearly to the medical community that long-term use for common conditions is inappropriate. It’s one of the most significant interventions by the federal government.”
~ Dr. Andrew Kolodny, head of Physicians for Responsible Opioid Prescribing
According to the CDC, fatal prescription opioid overdoses killed over 165,000 Americans between 1999 and 2014. And that was just the tip of the iceberg. For example, it is estimated that in 2013 alone, nearly two million U.S. residents abused or were dependent on/addicted to painkillers.
In March 2016, the CDC—the top federal health agency in the country—for the first time ever released guidelines about how and when opioid painkillers should be prescribed. Among the recommendations:
- Opioid medications should not be considered routine or first-line therapy for patients in chronic pain.
- The preferred options are, in order, non-medication therapy, followed by the use of non-opioid medications.
- Opioid painkillers should only be offered when the expected benefits to pain and function and greater than the potential risks.
- When of opioids absolutely must be prescribed, they should be dispensed in the lowest dose and for the shortest duration possible.
- When in individual cases opioids must be prescribed longer, physicians should conduct frequent follow-ups with the patient to reevaluate the benefits and risks. These should be done at least every three months.
In the subsequent three years, the results are somewhat encouraging, even if there is a long way to go.
In 2017, for example, the number of Americans filling opioid painkiller prescriptions dropped significantly:
- The total number of prescriptions filled decreased by more than 10%.
- The number of higher-dose painkiller prescriptions dropped by over 16%.
- By volume, prescriptions for pain medication fell by 12%.
- This is the largest single-year drop in 25 years.
New research also reached some promising conclusions. Initial prescriptions for painkillers have decreased by 50%, and the number of doctors who started patients on opioid therapy has gone down by 29%.
Not all the news is good, however. According to the report, 115,000 high-dose prescriptions are still written every month. Around 8000 of these are written with doses so high that the risk of overdose increases substantially.
Dr. Nicole Maestas, of Harvard Medical School, says, “The good news is that we’re making progress curtailing prescription opioids, but we have to temper our excitement because a large subgroup of providers is still using high-dose prescriptions or long prescriptions.”
Medications to Treat Opioid Use Disorder
“With medication-assisted treatment (MAT), which is using a medicine to treat a disease, success rates are over 70 percent – 70 percent of people will be abstinent in one year.”
~ Raj Masih, the Potomac Highland Guild’s Substance Abuse Anti-Stigma Initiative
Medication-Assisted Treatment, which combines psychosocial counseling with FDA-approved anti-addiction drugs has become the “Gold Standard” among top evidence-based recovery programs. MAT provides several benefits to anyone with SUD:
- Reduces drug cravings
- Eases withdrawal symptoms
- Treats co-occurring mental illnesses
- Helps reduce the risk of relapse
Replacement medications are used during Opioid Substitution Therapy. This is when the dangerous opioid of abuse is replaced with a safer opioid medication. Opioid Replacement Therapy is a medically-supervised attempt to reduce the health and societal risks by “managing” the addiction.
Medication frequently given during opioid recovery include:
- Buprenorphine (Subutex, Butrans, Buprenex, Belbuca)
- Buprenorphine/Naloxone combination (Zubsolve, Suboxone)
- Buspirone (Buspar)
- Gabapentin (Horizant, Fanatrex, Gralise, Gabarone, Neurontin)
- Methadone (Methadose, Dolophine)
- Naloxone (Evzio, Narcan)
- Naltrexone (Vivitrol, ReVia)
There are also other supportive medications that can treat specific symptoms:
- Clonodine (Kapvay, Catapres)—Lowers heart rate and blood pressure
- Chlorpromazine (Thorazine, Largactil)—Reduces anxiety, nausea, and vomiting
- Imipramine (Tofranil)—Boosts serotonin and norepinephrine levels, thereby helping with depression
- Methocarbamol (Robaxin)—Reduces muscle spasms
The Substance Abuse and Mental Health Services Administration estimates that these kinds of medications are used by 80% of alcohol or drug of detox clients.
More about Buprenorphine
“Buprenorphine is a safe and effective treatment that decreases deaths due to opioids and stops heroin and other opioid use. People on buprenorphine are able to get their lives back together.”
~ Dr. Todd Korthuis, MD, MPH, Professor of Medicine and Public Health, Oregon Health and Science University
Buprenorphine is a long-lasting opioid medication that binds to specific receptors within the users’ brain, thereby blocking the effects of much more dangerous abused opioids. It is classified as a “partial agonist”, because it produces a lesser “high” and less respiratory depression than most opioids of abuse.
One major advantage of buprenorphine is its low “ceiling effect”. This means the effects of the drug are limited. Once this limit is reached, the user is unable to get high from ANY opioid, regardless of dosage. In other words, taking buprenorphine greatly reduces the motivation to continue illicit drug use.
Even though it is a safe option, buprenorphine can still be abused by determined addicts, who will crush the drug and then either snort it or inject it. However, the combination medication most often sold as Suboxone addresses this problem by adding Naloxone to the buprenorphine.
Naloxone is a deterrent medication that blocks the effects of all opioids. In people who are opioid dependent, it may even trigger unpleasant symptoms of withdrawal.
There is a disadvantage to buprenorphine, however. This medication is extremely tightly-controlled by the federal government. In order to be able to prescribe it, doctors must receive extra training and qualify for a special license. Even after this, there are limits on how many buprenorphine patients a doctor may have had one time.
How big of a problem is this in reality?
Only 3% of American physicians are licensed and available to prescribe medications containing buprenorphine. In some areas, that can mean long waiting lists.
Is Buprenorphine Treatment Just Trading One Addiction for Another?
“Taking medication for opioid addiction is like taking medication to control heart disease or diabetes. It is NOT the same as substituting one addictive drug for another. Used properly, the medication does NOT create a new addiction. It helps people manage their addiction so that the benefits of recovery can be maintained.”
We are still learning much about Substance Use Disorder, the disease commonly known as addiction. But because the concept of addiction as a legitimate medical brain illness is still relatively new, many rehab programs still treat patients using the same methods that they “always” have, regardless of new information.
For instance, for decades, addiction providers completely rejected the idea that substance abusers can really recover by using other drugs, especially those that are themselves potentially habit-forming and have a potential for abuse.
This is a viable concern. The end goal for any rehab program should always be complete abstinence and freedom from all addictive or intoxicating substances. Abstinence is the safest way to support a successful return to sobriety and a happier, more productive life.
But the best recovery programs base their treatment strategies on scientific data and verifiable evidence. And by all measures, MAT using buprenorphine and other approved medications is far more effective than just detox or traditional behavioral counseling alone.
In fact, the evidence about MAT tells us three important things:
- Not all each MAT medications are addictive. They are safe, non-habit-forming, effective, and have very little potential for misuse. In other words, certain MAT drugs fully support abstinence.
- Even those MAT drugs that carry a risk of misuse or dependence can be safely prescribed if the proper safeguards are in place, including:
- Inclusion as part of a more comprehensive treatment program
- Close supervision by trained medical specialists
- Short-term, low-dose prescribing
- Frequent re-evaluation
- Most importantly, the risks associated with “harm reduction” techniques such as OST are far less than those resulting from active, out-of-control addiction—crime, disease, overdose, death, etc.
The Main Benefits of MAT
“The majority of opioid users would not stop using opioids without medication-assisted treatment. Could people go cold turkey and stop? Maybe, but their long-term success is better with the medications. Medication-assisted treatment (MAT) helps people get through the cravings and withdrawal so they can manage some of the other things that are essential to recovery.”
~ Chrissy Smith, Human Service Center
There are proven benefits to MAT. Patients who receive such treatment are far more likely to:
- Stay in treatment longer
- Successfully complete the treatment program
- Refrain from drug use during treatment
- Remain drug-free at the three-month, six-month, and one-year follow-ups
- Reduce arrests and criminal behavior
- Have a and keep a job
- Stay married
About anti-addiction medications, Dr. Marc Fishman, an Associate Professor in the Psychiatry Department at Johns Hopkins University, says, “60-plus years of data have shown that they are our best tool..”
Why Can’t Opioid Painkillers be Taken During Recovery?
“Clients in recovery can get prescribe a medication that triggers the addiction process to cause a relapse to the original drug of choice or a new drug.”
~ Dr. Michael Baron, MD, MPH, FASAM, a specialist in addiction and chronic pain
To understand why opioid painkillers can jeopardize sobriety and successful recovery, you have to understand the nature of addiction. People who have struggled with Opioid Use Disorder in the past will always be extremely sensitive to the effects of all opioids. Even after a period of abstinence, any exposure can trigger strong cravings and compulsive drug-seeking behavior.
To be clear, addiction is an incurable and chronic disease. This means that SUD cannot be “beaten ” once and for all, only “managed” with extensive lifestyle changes, constant vigilance, and ongoing support. And one of the most important lifestyle changes required is the need to avoid all intoxicating substances and potential drugs of abuse.
This includes opioid painkillers.
The responsibility starts with the prescribing physician. As Dr. Baron recommends, “When a patient has a history of addiction, the physician needs to take note and be careful with the amount, type, and refill frequency of pain medications.”
But the patient also has responsibility. Even if the doctor neglects to adequately screen for risk factors, patients should proactively discuss their personal and family histories, including any addictive or emotional disorders. Having such a frank discussion will help the doctor make the proper recommendation.
How to Treat Chronic Pain Without Opioids
“In light of the national opioid abuse epidemic, these new results underscore the importance of developing effective, multimodal approaches to managing common painful medical conditions.”
~ Mark Olfson, Dr. MD, MPH, Professor of Psychiatry, Columbia University Medical Center
But that doesn’t mean that someone with a family or personal history of substance abuse needs to unnecessarily remain in pain. There are many recommended alternatives to opioids, such as:
- Diet/Weight loss
- Physical therapy
- Hot compresses
- Cold packs
- Non-opioid pain relief, such as aspirin, Tylenol, or ibuprofen
- Non-opioid analgesics such as lidocaine
Opioids in all cases should only be considered as a last resort, after all, other pain management techniques have proven to be ineffective. When they absolutely MUST be prescribed, they should be for the lowest effective dose possible and for no longer than three days at a time. Refills should not be provided without a follow-up appointment.
It might also be a good idea for patients in recovery to share information.
“The recovering substance abuser needs to let their sponsor, spouse or significant other, and other people in their support system know the pain medication they are on, why they are on it, and how they are supposed to take it… (They) cannot have secrets about medication,” explains Dr. Baron.
Prescription Drug Monitoring Programs: The Tool That Could Help
“More cautious prescribing for acute pain will help prevent people from becoming opioid-addicted. Efforts to get the doses down will save lives.”
~ Dr. Andrew Kolodny, Co-Director of opioid policy research at Brandeis University, Founder of Physicians for Responsible Opioid Prescribing
The problem of simultaneous prescribing of both painkillers and anti-opioid medications would be virtually eliminated if all healthcare providers properly used the Prescription Drug Monitoring Programs that most states have in place. PDMPs allow doctors to review patients’ complete history. And while it may not necessarily show if an individual patient is receiving treatment for addiction, it will show the medications they are and have been prescribed.
PDMPS are an effective weapon in the fight against drug abuse and overdose because when used properly, day:
- Reduce the quantity of dispensed opioids
- Greatly reduce the incidence of doctor or pharmacy shopping
- Prevent dangerous drug interactions
In most states, physicians are not required to consult patient databases before writing a prescription. It is a guideline, rather than a mandate. The most frequently cited reason why some doctors don’t fully follow the recommendations of their state’s PDMP is the additional time it costs. Doctors are already stressed for time, and accessing the system just adds more work.
However, the cost in physician time is more than made up for by the ability to more easily identify potential abusers, to prevent harmful or contradictory drug interactions, and to reduce the risk of a relapse among those patients in recovery from addiction.
Should Patients Sign Opioid Contracts?
“I speak honestly about the opioid epidemic and tell patients that this is a piece of paper to confirm that they understand all of the issues around using opiates…It is really meant to be used as a clear way to establish an understanding of (opioid) treatment guidelines and expectations of the patient and physician.”
~ Dr. Kavita Sharma, DO, a pain medication specialist
Some doctors are addressing the opioid crisis by taking the additional step of requiring chronic pain patients to sign ” opioid contracts” if they want to keep to continue receiving opioid painkillers.
In these agreements, patients must consent to certain stipulations, or the doctor can refuse to prescribe any pain medications. These conditions can include:
- Random drug screens
- Pill counts
- Frequent in-office follow-ups
- Scheduled medication reviews
- Non-opioid efforts to improve pain and function
- A strict adherence to the recommended dosage and frequency
- Safeguarding of all prescriptions
- When possible the use if only one pharmacy
- No doctor-shopping
- Full disclosure by the patient about history, other relevant conditions, and all medications
Patients with a history of SUD may also be required to promise not to use drugs or alcohol and must agree to seek appropriate addiction treatment if the doctor feels that it is necessary.
Opioid contracts make patients responsible for their own actions, something that is too-often missing from most doctor-patient relationships. They clearly establish expectations, potential violations, and possible consequences.
Some critics feel that opioid contracts undermine the trust between doctors and their patients, but supporters believe this is not at all the case. Because as Dr. Mark Malone, an anesthesiology specialist, says, “Quite the contrary, it supports the relationship by clarifying the rules and conditions under which we can prescribe opioids. Like other written agreements, this helps us avoid any misunderstandings.”
What Does All of This Mean to YOU?
“Until we see overdose mortality come down, we can’t say we’ve figured this out.”
~ Dr. Nicole Maestas, Ph.D., Associate Professor of Health Care Policy, Harvard Medical School
The biggest takeaway from all of this information is that doctors are not infallible. Whether it is through honest error, workload, inattention, lack of information, or willful noncompliance, not every decision they make is the correct medical decision.
Dr. Maestas believes that patients can and should take a larger, more proactive role in determining how their pain is treated, and ultimately, minimize the risk of dependence, abuse, or addiction. “Patients can ask their doctor for options. They can say, don’t start me on a high dose or don’t give me so many pills.”
This highlights the fact that the only way to ensure your safety is to educate yourself about all of the medications you are taking, including how they interact with each other. If you don’t understand something, ask questions. And if you don’t agree with your treatment, seek a second opinion.
Finally, the biggest positive is that it IS possible to obtain effective pain relief without sabotaging your recovery. There are many non-opioid pain management strategies that don’t put your sobriety at risk.