The Opioid Epidemic: Why It Happened And

What It Means For Pain Treatment

Joe Wegmann, R.Ph., LCSW

Joe@ThePharmaTherapist.com

504.587.9798

www.pharmatherapist.com

Are you receiving our free monthly e-newsletter?

On Tap For Today…

Describe the allure of opioids and marijuana, as well as factors associated with their appeal

Examine the pain – distress – disability cycle

Evaluate the potential therapeutic and adverse effects of prescription painkillers and medical marijuana

Discuss the psychotropic medications employed in pain management

Opiates and Opioids

Opium…An Ancient Psychotropic

These days, opiates, opioids are primarily prescribed to treat pain…but

There is a long history of using opiates to treat depression and other mental illness

In the 8th century, Arabian cultures used opium in mental hospitals in Baghdad, Damascus and Cairo

Victorian era – Laudanum (tincture of opium today) was used for depression and hysteria as well as to “soothe” small children with 25 drops selling for a penny

How People Get Started on Opiates

More people died from opioid overdose than those from homicides in 2015

145 Americans die from opioid overdoses every day

Opiates were the most prescribed drug class to Medicare patients this past year; prescription opiates were approved for children in 2016

The national opioid epidemic was born largely out of misguided attempts to treat pain by freely prescribing highly addictive narcotics

A confluence of factors make pain frustratingly hard to treat:

Medical students receive little training in pain management; PCPs are limited to 10 minutes, preventing in-depth discussions of other options

Insurance companies don’t cover other pain procedures or reimbursements are so low, pills move to the forefront

Doctors are increasingly afraid not to prescribe painkillers because of patient satisfaction surveys, so those who decline to prescribe these drugs risk getting a negative review by patients

Chronic pain is poorly understood, difficult to treat, frustrating to both patients and practitioners

Other Ways People Get Started

Curiosity – what’s it like

Cool Pharma parties – hip, accepted part of a new craze

Influence of pop culture in films, videos, music

Rogue MDs and a quid pro quo – opiates for sex, money, favors

Rogue pharmacies selling “out of the back door”

Other Ways (cont.)

Vehicle for dissociation from everyday life circumstances – poverty, hopelessness, despair, unemployment

Create a different emotional reality –relief from depression, anxiety, demoralization, low self-esteem, abuse, neglect

Most common path to opiate use is pain, acute or chronic – secondary to physical maladies, injury accidents, neuropathies

Opiates vs. Opioids

Opiates come directly from the opium poppy

Opioids are laboratory-created from naturally occurring substances in the opium poppy

Ranking Opiates, Opioids

The greater the potency, the stronger the allure

Duragesic (fentanyl patch)

Dilaudid (hydromorphone)

Heroin

Percocet,Oxycontin (oxycodone)

MS Contin (morphine)

Vicodin (hydrocodone)

Ultram (tramadol)

Tylenol #3 (codeine)

Clinical Uses of Opiates and Opioids Analgesia (pain relief) – in the presence of

pain, their pain-relieving properties are generally excellent; the absence of pain = euphoria and a dissociated state

Anesthesia

Cough suppression

Diarrhea suppression

Opioid dependence (Suboxone)

How They Work All opiates and opioids target corresponding receptor sites in the brain

Activating these receptors stimulates the production of naturally occurring brain endorphins – which are hormones released in response to adverse stimuli (pain)

These drugs supply an endorphin rush and with the brain as the instigator, trick the body into thinking that it’s “pain-absent”

This lasts only as long as it’s time for the next dose

When used to treat pain responsibly, opiates and opioids are less likely to become addictive

Still, when opiate and opioid receptors are flooded with drug –tolerance, dependence and prescription drug abuse begins ushering in higher and higher doses to obtain relief

Prescriptions run out; become too expensive forcing users toward other means to obtain drug to head off withdrawal

Forgery; “doctor shopping;” package theft; internet procurement

Ramifications of Opiate and Opioid Use

Tolerance

Indicative of the need for higher doses to achieve the desired effect, or experiencing diminishing returns if the dose remains the same

Kindling – cravings

Withdrawal

The brain sends the body a signal – feed me more drug or pay a price; users become frightened if they can’t obtain medication; tolerance and withdrawal define dependence

Physical dependence

A physiological need to continue feeding drug to the body to stay ahead of withdrawal; such patients became got dependent on these drugs via a doctor who didn’t recognize the tolerance, kindling or withdrawal potential

Ramifications

Addiction

A chronic, relapsing brain disease characterized by compulsive drug seeking and use despite harmful consequences

Tolerance and dependence are not the same as addiction

Common in pain management to see people who aren’t addicted to a drug but are chemically dependent upon it

Chronic Pain Management

Evaluation Understand the subjective experience of chronic

pain

Chronic pain is frustrating to all involved –patient, treating clinician and family

Patients with CP find themselves isolated from loved ones and trapped in a labyrinth of doctors, insurance companies, case managers and even quacks

A collaborative alliance is key – an alliance that views physical symptoms as part of a number of factors affecting the patient’s recovery

Communication and collaboration; communication and collaboration

Assessment Begin with a discussion of contributors to their pain such as

depression, or uncomfortable side effects of medications (cognitive impairment, chronic constipation, secondary to opiate use)

Pain patients have tremendously high rates of MDD which is undertreated and underdiagnosed

Many clinicians assume that depression is a reaction to living with CP – but in fact, it’s the other way around.

Opiate-induced hyperalgesia

Cognitive impairment with chronic pain patients – enlist the participation of a family member, look for the inevitable head nodding from family and patient comments such as “yeah, my wife has been telling me this for months, but what can I do?” This is alliance-building

Assessment The biggest obstacle to overcome: “If I’m in this

much pain on these narcotic medicines, how can I not be in MORE pain off these medicines?”

Patients have to be willing to make changes and accept treatment that is focused on rehabilitation as opposed to comfort

Rehabilitation then is concerned with being productive and functional with a higher quality of life

Move from a model that is palliative in nature to one focused on specific treatments that are motivational and will eventually moderate pain. “You can actually do more than what you’re doing despite your pain.”

Do Opiates Have a Role in Chronic Pain Management?

Tight management and observation is a must

Heidi, 53, worked as an executive secretary before brain-tumor surgery in 2010 left her with crippling headaches. She eventually wound up on disability, taking multiple daily doses of immediate-release oxycodone, which made her pain spike throughout the day. “I’d started to feel like a heroin addict,” she said. “Whenever I tried to stop taking them, I’d get horribly sick with withdrawal.”

Best Practices for Employing Opiates

Opiates are no longer considered the first treatment of choice for chronic pain

Absolutely avoid immediate-release formulations of OxyContin and Vicodin which are associated with high rates of overdose and withdrawal

Opt instead for controlled-release forms of morphine and OxyContin

Glide the patient down slowly over 3 months

Use Suboxone for pain relief and for minimizing withdrawal pursuant to opiate discontinuation

Suboxone Combines buprenorphine and naloxone

Buprenorphine – partial opioid agonist

Naloxone – opioid blocker

Buprenorphine

Occupies opioid receptors without all of the classic opioid effects (decreased respiration, euphoria, analgesic)

Tricks opioid receptors, prevents binding with “full” opioids

In the presence of opioid use – diminished opioid effect

Buprenorphine blocks opioid receptors much longer than opioids do

SuboxoneNaloxone

Opioid antidote

Reverses opioid intoxication and sedation

Works only if opioids are present in someone’s system

Blocks opioid receptors, so no euphoria and analgesic effects

Suboxone side effects

Sleepiness; dizziness; orthostatic hypotension

Case ExampleJames V. is a 37-year-old U.S. veteran honorably discharged after four tours of duty in Iraq and Afghanistan. During his last tour he sustained multiple injuries after an IED detonated near him. Three years after, he suffers from chronic back and shoulder pain, and has been diagnose with PTSD and depression. He takes Vicodin as needed for chronic pain. His referring psychiatrist notes he is responding somewhat to the Vicodin, but is still depressed and inactive.

CBT in Chronic Pain

CBT focuses on teaching people ways to identify and change counterproductive automatic thoughts and maladaptive behaviors.

James: “I’m a failure,” “I’m worthless to my family because I can’t work,” “I could have done much more with my life,” “ This is never going to get better,” “I better curb my activity or I’ll be in even more pain.”

With this type of patient I begin by discussing the “Cycle of Pain” which includes: pain, distress and disability

The essence of this vicious cycle is that chronic pain fosters negative automatic thoughts, isolation and insomnia; these in turn contribute to distress and depression

Result: These patients sit; muscles atrophy; they gain weight aggravating the pain

Interventions Employed I asked James: “Have you ever noticed a connection

between your mood and your pain?”

I taught him adaptive ways to challenge the validity of his negative thoughts and to get involved in activities that would be satisfying

James and I set goals for treatment including resuming his hobbies and pursuing his education

Sometimes it’s best to work backward with chronic pain patients: Get them moving first = “I can actually do more than I thought” = increased self-confidence = better results = improved esteem and image = more rational adaptive thinking

Pacing his day; realistic “to-do” list; “chunking down” tasks

Made sure he understood the connections between his thoughts, feelings, behavior and pain

Diaphragmatic breathing; Mindfulness; Thought restructuring

“My life is not ruined; no supporting evidence of this”

Final Point It’s imperative to approach chronic pain patients from the perspective that they would rather be healthy and living a gratifying life, than sick and living in a demoralized way. It’s our job to help them find their way to functionality – even if it means not being completely pain-free.

Medical Marijuana

What Is It; A Few Facts What we’re really talking about is Cannabis

It is the most commonly used illicit drug in the U.S.

In 2012, (research results are always lagging) 40% of American 12th graders had used it at some point; and 25% had used it in the last month

As of the November 2016 election, marijuana restrictions have been lifted in several states

Recreational marijuana is legal in 6 states and D.C.; medical marijuana is now legal in 28 states

America’s first pro-medical marijuana laws were passed in the 1970s

Regulatory Issues Federal law supersedes state law – always

Someone can still be arrested and prosecuted for using or possessing medical marijuana – even if it’s legal under state law

State laws don’t regulate buying and selling, but they do legalize possession for medical use, following a doctor’s “recommendation.”

Some states authorize doctors to prescribe marijuana for medical use, but since it remains illegal under federal law to prescribe it – and pharmacies can’t supply it – the laws are effectively void

FDA classified as a DEA Schedule I substance…because

“Marijuana has a high potential for abuse, has no currently accepted medical treatment use in the U.S., and has a lack of accepted safety for use under medical supervision.”

This is why it is so difficult to study and there are so few labs using marijuana in clinical research

How Marijuana Works

Much of the medicinal value of marijuana concerns THC – tetrahydrocannabinol

THC is a cannabinoid responsible for the euphoric and medicinal effects of marijuana

The human body naturally produces endocannabinoids; the cannabinoids in marijuana, like THC, bind to receptors –producing medicinal and euphoric effects

Medical Uses of Marijuana First, why use it when there are so many legal

medications available?

Supporters: Not just about getting high because there are certain symptoms and conditions that can be best treated with marijuana; better option than addictive narcotics with unpleasant side effects

Detractors: It’s all about getting high and dissociating from reality

Some Clinical Evidence of Efficacy

Certain mental health disorders (anxiety in particular); sleep disorders; neurological problems; some cancers; glaucoma

Nausea and vomiting; altering appetite; muscle spasticity

Seizure management; pain control; slowing cancer growth

Marijuana Consumption

Smoking is Most Common

Rapid intoxication due to deep inhalation

Chronic bronchitis and cough

Phlegm production

Respiratory tract infection

Marijuana-laced Foods and Beverages

Brownies; candies; cookies; teas; proliferation of marijuana bars – particularly in Colorado

Vaporizer

Burns marijuana at a lower temperature than when smoked; releases THC from the plant with fewer harmful by-products

Vaporizers sell for about 500 bucks

Risk FactorsIs It Addictive?

90% of users develop NO problems related to marijuana addiction

The point: It is not just a property of the substance that determines a substance use disorder regarding cannabis or anything else; it’s the properties of the individual –genetics; biology; multiple psychosocial factors;

Gateway drug – strong clinical evidence points to YES

Risk of Psychosis?

For the majority of users, risk is very low

Exceptions – family history of psychosis such as schizophrenia; substance abuse history

Age-related risks?

Yes. Risk of harm is highest among children and adolescents

Distinctive effects on brain development

Cognitive function – Adverse effects on IQ related only to those who started smoking prior to age 18

Potential Negative Consequences

MJ use is clearly associated with time distortion, hallucinations, tachycardia, sleepiness, impaired memory and problem solving

MJ can lead to heart disease through long-term use or worsen existing heart disease; not the mellow drug, as it can worsen anxiety, panic attacks and depression

MJ has negative long-term effects on chronic users –especially those starting in their teens – these include: amotivational syndrome, less success in school and career; possible reduction in IQ

Smoking and driving is well…Cheech and Chong-like; judgment and perception are impaired; fatalities, arrests, DUIs; highest risk period is during the 1st

hour after starting

More…

Withdrawal from regular use does occur; MJ detox in a heavy user may last 3-5 days and be accompanied by irritability, insomnia, headache, nausea and vomiting

Currently there are NO medications for treating marijuana use disorder

I can’t think of any psychiatric disorder for which I would recommend marijuana

My take on medical marijuana

Resources

Adapted from:

Wegmann, J. 2015. Psychopharmacology: Straight Talk on Mental Health Medications. Third Edition. Eau Claire, WI: Premier Publishing & Media

Thanks for

Attending!

Joe Wegmann, R.Ph., LCSW