Prescription Pain Killer Abuse: From Understanding to Action

Pain is an unpleasant experience that tells you something is wrong. The pain experience happens in the brain and may be a signal to protect part of the body.  Acute pain is short-term pain, while chronic pain persists for more than a few months. Chronic pain can be complex and may or may not involve actual tissue damage, emotions, memories and other factors.

Watch Video: “Understanding pain & what to do about it in less than 5 minutes”

Opioids are a class of drugs that alter the chemistry in the brain and body by attaching to opioid receptors.  Medically, this class is used as painkillers.  These include prescription opioids such as oxycodone, hydrocodone, codeine, morphine, fentanyl and hydromorphone.  However, this class also includes illegal drugs like heroin, which is not used medically, but does have a very high abuse potential.

Medically, opioids are used to relieve moderate to severe pain, short-term pain, cancer pain or for anesthesia during surgery. However, opioids are not always indicated for pain and are usually not the best way to treat long-term pain. There is very little science supporting opioid use in long-term non-cancer pain.  And side effects and serious risks of these medications, especially when used long-term, are well documented.

Watch Video: “Best Advice for People Taking Opioid Medication”

The Choosing Wisely Initiative provides information to help determine when opioids or alternatives may be considered.

In addition to the serious risks of overdose and addiction, there are additional potential side effects of taking opioid pain medications including developing tolerance to opioids, which means you might need more of the medication for the same pain relief, developing physical dependence on opioids, which means that you have symptoms of withdrawal, like drug craving, anxiety, insomnia, abdominal pain, vomiting, diarrhea, and tremors, if the medication is abruptly stopped.

Chronic opioid use may also cause narcotic bowel syndrome, where the medications may actually cause pain, constipation, bloating and nausea.

Other side effects include constipation, nausea, vomiting, dry mouth, sleepiness, dizziness, confusion, and increased sensitivity to pain.

Some people who start taking opioid pain medications eventually have serious problems with them and become addicted.  The opioid epidemic refers to a dramatic increase in the amount of opioids prescribed and the continued increase in drug overdose deaths in the United States.  Use of prescription pain medication has nearly quadrupled from 1999 to 2015.  In that same time period, opioid overdose deaths have also quadrupled.  More Americans die from drug overdoses than in motor vehicle accidents.

Now that the DEA and other agencies have started cracking down on unrestricted prescribing, some people are turning to heroin, which has become cheaper and more available, to support their addiction.  Increased opioid use and the lack of supporting science along with more adverse drug events like overdose and death is now being called the opioid epidemic.

First we must understand that drug addiction is a complex chronic brain disease characterized by drug craving, seeking and use despite the negative consequences.  Opioid addiction refers to craving, seeking and use of opioids despite negative consequences such as relationship problems, financial problems, functional decline and loss of a job.  Opioid addiction can change how the brain works and change how the person thinks, acts and feels.

There is hope for people who have become addicted to prescription opioids or heroin to lead normal lives again.  The American Society of Addiction Medicine (ASAM) has been spreading the news with a simple message:  “Treat Addiction – Save Lives.”

Opioid abuse refers to taking opioids in a manner that is not prescribed.  This includes taking illegal opioids, taking opioids prescribed to another person, taking more than prescribed doses or mixing opioids with other substances.  Both illegal and prescription opioids can be abused.

Most often, prescription opioids of abuse are obtained from a friend or relative.  Most people don’t know that sharing prescribed opioids is a felony.

People who become addicted to opioids are not able to quit or cut back on them.  They often experience issues in their lives linked to opioid use.  Signs of addiction include:

  • Using more of the opioid than intended or prescribed.
  • Attempts to cut back or quit, usually many times and with little success.
  • Significant “down time” when you are not very functional due to either intoxication or withdrawal.
  • Cravings for opioids when you don’t have them.
  • Failure to fulfill important roles and responsibilities in life because of opioids.
  • Problems with relationships with family, friends, or co-workers related to opioid use.
  • Decreased social or recreational activities, preferring to use or seek after drugs instead.
  • Hazardous use, such as driving when you probably shouldn’t be behind the wheel.
  • Continued use in spite of known physical or mental health problems caused by the opioids.
  • Tolerance, where higher doses are required to get the same effect.
  • Withdrawal symptoms when the drug is stopped abruptly.

If you meet at least 4 of these 11 criteria, you have at least a moderate addiction, and if you meet 6 or more you have a severe addiction problem.

Physical dependence is when your body gets used to having a substance on board and without it you will have symptoms of withdrawal.  People who take opioids on a daily basis for long enough will become physically dependent.  This is not the same thing as addiction.

Opioid withdrawal refers to the symptoms that happen when opioids are stopped.  Although symptoms such as headache, nausea, vomiting, diarrhea, cramping, sweating, and flu-like symptoms can be severe and uncomfortable, withdrawal is rarely life-threatening.  These withdrawal symptoms typically last for several days.  However, depression or mood changes may last for several weeks or even months.

Withdrawal symptoms may be minimized with some medications to treat nausea, aches, cramps or diarrhea.  Slowly decreasing opioid dosing may also help minimize withdrawal symptoms.

Opioids may cause death by effecting the part of the brain that regulates breathing.  This may cause respiratory depression (slow, shallow or no breathing) and death.

Accidental overdose can happen if a person takes too much pain medication, mixes pain medication with other substances (medications, drugs, or alcohol) or has an adverse drug reaction to prescribed doses of pain medication.

There is an opioid reversal agent called naloxone (also known as NARCAN).

Learn More

It is important to understand the risks of opioids which include:

  • Central nervous system and respiratory depression
  • Sedation, memory problems or difficulty thinking
  • Risk of falls and fractures
  • Worsening pain syndromes, referred to as opioid induced hyperalgesia
  • Motor vehicle accidents
  • Sexual side effects (hypogonadism)
  • GI side effects such as nausea, constipation, dry mouth
  • Narcotic bowel syndrome
  • Reduced overall quality of life

Abstinence-based treatment programs may not be effective and may be dangerous.  When a person goes through a period of time not taking opioids, their tolerance for opioids decreases.  If they relapse or begin using opioids again, risk of overdose is high.  Studies have shown that the months after leaving an abstinence-based treatment program have a much higher risk of overdose than if the patient received no treatment at all.

Medication-assisted treatment (MAT) includes medication to treat opioid use disorder. MAT increases success of OUD treatment and decreases risk of overdose.

In order to achieve and maintain sobriety off of opioids, most patients will need medication in addition to counseling.  All patients with serious opioid use disorders should be considered for MAT.

Learn More

12 step programs such as Alcoholics Anonymous and Narcotics Anonymous (as well as other self-help groups such as Celebrate Recovery and Rational Recovery) can be helpful to many people with addictions.  These programs are not the same as treatment – their focus is to help people stay in recovery.  Patients who are on medication for addiction should stay on the medication – even though some 12 step groups discourage medications, it is important to find groups that support the best treatment practices.

12 step programs are not for everyone – they are highly effective for some people but they are not a “one size fits all” solution.  Each person suffering from addiction is unique and should have a treatment plan tailored to his or her specific needs.  Addiction is a difficult condition to treat, and patients should take advantage of as many aspects of their recovery program as they can, including counseling, medication, spiritual and family involvement, work place recovery, and 12 step groups as appropriate.

Opioid Overdose Rescue and Response: Naloxone

Remember: An overdose is a medical emergency – call 911 immediately

Naloxone is a medication used to REVERSE the effects of opioids, including overdose.  Naloxone is an opioid antagonist, which means it binds to the opioid receptor and blocks the opioid.  This reverses the effects of the opioid on that receptor.  When this blocks or reverses the opioid, breathing is restored.  This also may cause abrupt opioid withdrawal.

No.  Naloxone cannot be used to get high.

Naloxone is supplied as a single dose nasal inhaler, a single dose auto-injector or in a kit that may require some items be put together before use.  Be familiar with the option available to you.

             

Naloxone should be used when an overdose is identified or suspected.

Signs of an overdose:

  • No response when you yell the person’s name or rub the middle of their chest with your knuckles.
  • Slow breathing or no breathing (less than 1 breath every 5 seconds)
  • Pale or clammy face
  • Blue or gray lips, fingernails or skin
  • Slow, erratic or no pulse
  • Choking or gurgling noises

Recognizing an overdose:

  • Check for unresponsiveness, shaking won’t wake the person
  • Listen for snoring or choking, slow breathing or no breathing
  • Look for blue or gray lips or fingernails
  • Touch sweaty or clammy skin

If the person is unresponsive or showing signs of overdose:

Give Naloxone

Then What?

  • Call 911!  Activate emergency medical services (EMS).  EMS should always be contacted if an opioid overdose is suspected.  If EMS has not been called before naloxone is administered, call directly after use.
  • Begin CPR if the person is unresponsive and not breathing.
  • Consider second naloxone dose.  If the person does not respond by waking up in 2-3 minutes, administer another dose of naloxone.  Continue CPR.
  • If the person is breathing but unresponsive, place the person on their side in the recovery position and watch them closely until EMS arrives.
  • If the person does respond, keep them calm, and be ready to give the second dose if the person becomes unresponsive again.

Naloxone is safe regardless of opioid use status.  Naloxone will have no effect on a person that does not have opioids in their body.

Naloxone may cause withdrawal symptoms including headache, nausea, vomiting, diarrhea, tremor, sweating, and changes to heart rate and blood pressure.  Withdrawal symptoms can be uncomfortable but are not life-threatening.

Remember:

  • Naloxone is safe regardless of opioid use status.  If the person does not have an opioid in their body, naloxone will not have an action.
  • Naloxone is safe in pregnancy.
  • Naloxone should be used if an overdose is suspected and the person is not responsive or breathing slowly, irregularly or not at all.
  • Naloxone will cause withdrawal – expect it.

Naloxone is available by prescription from your doctor/provider.

Naloxone is also available from participating pharmacies by standing order.  This means that the pharmacist may dispense naloxone without a prescription from your doctor/provider.

The Montana DPHHS Opioid Overdose Recognition and Response Guide can be found here: http://dphhs.mt.gov/Portals/85/publichealth/documents/EMSTS/Opioids/Opiod%20Brochure%202017.pdf

Information for the public as well as prescribers can be found on the Montana DPHHS Opioid Overdose Prevention webpage. The webpage provides an overview of the opioid crisis in Montana along with the standing order, education about overdose recognition and response, and the CDC guidelines for prescribing opioids.

Check with your local pharmacy to see if they are participating in the Standing Order for Naloxone Program.

How to Get Help

If you are in need of immediate help, or experiencing thoughts of suicide, call 9-1-1. Prevention and early intervention is very important and can potentially prevent addiction or