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.

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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: https://dphhs.mt.gov/assets/publichealth/EMSTS/opioids/Naloxonebrochure.pdf

Information for the public as well as prescribers can be found on the Naloxone (mt.gov). 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 diversion problems from becoming irreversible.

There are many considerations for treatment. However, it starts with recognizing a need and then seeking professional assistance. You should always seek professional treatment – detox from prescription painkillers can be dangerous and may require medical treatment throughout the process.

The National Institute on Drug Abuse offers treatment resources for patients and families and a publication called Seeking Drug Abuse Treatment: Know What to Ask, that can assist individuals in finding the right kind of treatment for them.

Montana Pain Management Clinics:

Montana Drug/Alcohol Treatment Centers:

Medication-assisted treatment (MAT) is a strategy that uses both medications and behavioral therapies to treat substance use disorders.  This combination approach is effective for treatment of and recovery from substance use disorders.   These medications curb cravings and may block the effects of opioids.  This helps people manage their disease, enter recovery and avoid relapse.

Strong scientific studies show that for opioid addiction, medication is overwhelmingly the essential component of treatment.  Treatment of opioid use disorder without medication-assisted treatment may be dangerous and may increase the risk of death from overdose.  Several guidelines have been published recommending the use of medications in the treatment of opioid addiction for almost all patients.

Medication Assisted Treatment (MAT) is by far the most effective treatment and should be considered for every person who needs treatment for opioid addiction.

The most common medications used to treat opioid addiction are buprenorphine, methadone and naltrexone.  Each medications works differently and each has risks and benefits.  Medication therapy is individualized based on patient needs, goals and response

Watch Video: “Treatment Can Help Curb the Opioid Epidemic”

SAMHSA provides a Treatment Service Locator

ASAM Pocket Card “Opioid Addiction Treatment Guide for Patients, Families and Friends”

Storage & Disposal

Join Operation Medicine Cabinet Montana in your area.

Montana DPHHS maintains a map of locations where you can dispose of all prescription drugs safely. The map can be found below so you can find your nearest location

DISPOSAL LOCATIONS

How To Properly Store Prescription Drugs

70% of prescription drug abusers over the age of 12 report that they are able to get prescription drugs from family and friends. Safe and secure storage is important in helping to prevent prescription drug abuse and diversion.

Safe: Store medication in a cool, dry area

Secure: Secure all medications away from children and pets.  Consider locking up all controlled substances to prevent theft and accidental poisoning.

Expiration: Check all expiration dates.  Properly dispose of expired meds.

The National Council on Patient Information and Education has information on properly storing your medications.

How To Properly Dispose of Prescription Drugs

Protect children, pets, family members, our community and our environment.

Montanans can properly dispose of unwanted or unused prescription drugs in the following ways.

  • Drop unwanted drugs at a permanent prescription drop location or participate in a drug take-back in your community. Prescription drop locations across the state are available by clicking here.
  • Follow the disposal steps recommended by the Office of the National Drug Control Policy.
  • Take your prescription drugs out of their original containers.
  • Mix drugs with an undesirable substance, such as cat litter or used coffee grounds.
  • Put the mixture into a disposable container with a lid, such as an empty margarine tub, or into a sealable bag.
  • Conceal or remove any personal information, including the prescription number, on the empty containers by covering it with black permanent marker or duct tape, or by scratching it off.
  • Place the sealed container with the mixture and the empty drug containers in the trash.

Patient FAQs

What are the physical signs of abuse or addiction?

The physical signs of abuse or addiction can vary depending on the person and the drug being abused. For example, someone who abuses marijuana may have a chronic cough or worsening of asthmatic symptoms. Each drug has short-term and long-term physical effects. Stimulants like cocaine increase heart rate and blood pressure, whereas opioids like heroin may slow the heart rate and reduce respiration.

NIDA and other agencies track trends in drug abuse through various surveys and data collection systems. Annually, NIDA supports the collection of data on drug abuse patterns among secondary school students and young adults through the Monitoring the Future Study (MTF); for more information, see DrugFacts – High school and Youth Trends. NIDA also supports a Community Epidemiology Work Group, a network of researchers who meet twice yearly to discuss drug abuse patterns in major metropolitan areas across the nation and in regional “hot spots,” such as within and across border cities and areas.

For information on commonly abused drugs, see Commonly Abused Drugs, for a chart containing information on street and commercial names of abused drugs and their health consequences.

Drug addiction is a complex, and often chronic, brain disease. It is characterized by drug craving, seeking, and use that can persist even in the face of devastating life consequences. Addiction results largely from brain changes that stem from prolonged drug use—changes that involve multiple brain circuits, including those responsible for governing self-control and other behaviors. Drug addiction is treatable, often with medications (for some addictions) combined with behavioral therapies. However, relapse is common and can happen even after long periods of abstinence, underscoring the need for long-term support and care. Relapse does not signify treatment failure, but rather should prompt treatment re-engagement or modification. For more information, see “Drugs, Brains, and Behavior – The Science of Addiction.”

There is no easy answer to this common question. If and how quickly you become addicted to a drug depends on many factors, including your biology (your genes, for example), age, gender, environment, and interactions among these factors. Vast differences characterize individual sensitivity to various drugs and to addiction vulnerability. While one person may use a drug one or many times and suffer no ill effects, another person may overdose with first use, or become addicted after a few uses. There is no way of knowing in advance how quickly you will become addicted—but there are some clues, one important one being whether you have a family history of addiction.

If a person is compulsively seeking and using a drug(s) despite negative consequences, such as loss of job, debt, family problems, or physical problems brought on by drug abuse, then he or she probably is addicted. And while people who are addicted may believe they can stop any time, most often they cannot, and will need professional help—first to determine if they in fact are addicted, and then to obtain drug abuse treatment. Support from friends and family can be critical in getting people into treatment and helping them to maintain abstinence following treatment. For information on substance abuse treatment providers, see: findtreatment.samhsa.gov or call 1-800-662-HELP.

Many substances including alcohol, nicotine, and other drugs of abuse can have negative effects on the developing fetus because they are transferred to the fetus across the placenta. For example, nicotine has been connected with premature birth and low birth weight as has the use of cocaine. Heroin exposure results in dependence in the newborn, requiring treatment for withdrawal symptoms. It is often difficult to tease apart the confluence of factors that go with drug abuse during pregnancy—poor nutrition, inadequate prenatal care, stress, and psychiatric comorbidities—all of which may impact fetal development.

Drug addiction can be effectively treated with behavioral therapies and, for addiction to some drugs such as heroin, nicotine, or alcohol, medications. Treatment will vary for each person depending on the type of drug(s) being used. Multiple courses of treatment may be needed to achieve success. Research has revealed 13 basic principles that underlie effective drug addiction treatment discussed in NIDA’s Principles of Drug Addiction Treatment: A Research-Based Guide.

For referrals to treatment programs, call 1-800-662-HELP, or visit the Substance Abuse and Mental Health Services Administration online at findtreatment.samhsa.gov.

Detoxification is the process of allowing the body to rid itself of a drug while managing the symptoms of withdrawal. It is often the first step in a drug treatment program and should be followed by treatment with a behavioral-based therapy and/or a medication, if available. Detox alone with no follow-up is not treatment.

Withdrawal describes the various symptoms that occur after long-term use of a drug is reduced or stopped abruptly. Length of withdrawal and symptoms vary with the type of drug. For example, physical symptoms of heroin withdrawal may include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, and cold flashes. These physical symptoms may last for several days, but the general depression, or dysphoria (opposite of euphoria), that often accompanies heroin withdrawal may last for weeks. In many cases, withdrawal can be easily treated with medications to ease the symptoms, but treating withdrawal is not the same as treating addiction.

Drug abuse costs the United States economy over $600 billion dollars annually in increased health care costs, crime, and lost productivity, broken down as follows by type of drug:

  • Illicit drug abuse: $181B
  • Alcohol abuse: $235B
  • Tobacco: $193B

Beyond the raw numbers are other costs to society, including:

  • the spread of infectious diseases such as HIV/AIDS and hepatitis C either through sharing of drug paraphernalia or unprotected sex;
  • deaths due to overdose or other complications from drug use;
  • effects on unborn children of pregnant drug users; and
  • other effects such as crime, unemployment, domestic abuse, family dissolution, and homelessness.

NIDA produces a variety of educational materials for the general public and healthcare providers. NIDA’s materials are available via our website, which houses the NIDA Drug PUBS Research Dissemination Center Drugpubs.drugabuse.gov. Multiple featured publications are listed for downloading and for ordering print copies, along with a lookup feature to access materials on particular drugs, for specific audiences, and within the array of NIDA series. The latter includes:

For teachers and students, NIDA Goes Back to School provides science-based drug abuse education materials geared to students in grades K-12 and their teachers. All of these materials are free. Students are encouraged to join Sara Bellum, a budding neuroscientist, as she explores the effects of various drugs on the brain. Students and teachers can learn through the Mind Over Matter curriculum, or they can go online to join in Sara’s Quest an interactive web-based program. Educationally appropriate materials from NIDA’s collaboration with Scholastic Marketing Partners, the in-school marketing division of Scholastic, the global children’s publishing and media company, also are available in compilations by year from NIDA’s publications catalog and online through NIDA Goes Back to School. These products include articles and posters from the Heads Up: Real News About Drugs and Your Body program through which Scholastic features NIDA science-based articles on drug abuse and addiction in its Classroom Magazines. ScholasticNews.com also maintains a Heads Up Web site at headsup.scholastic.com. Also available is Marijuana: Facts for Teens and a companion booklet, Marijuana: Facts Parents Need to Know.

NIDA is a Federal scientific research institute under the National Institutes of Health, U.S. Department of Health and Human Services. NIDA is the largest supporter of the world’s research on drug abuse and addiction. NIDA-funded scientific research addresses the most fundamental and essential questions about drug abuse, including tracking emerging drug use trends, understanding how drugs work in the brain and body, developing and testing new drug treatment and prevention approaches, and disseminating findings to the general public and special populations.

Unless otherwise specified, NIDA’s products are in the public domain and can be copied as a whole without seeking permission from NIDA. Also, text selections and graphics that do not have source citations listed beside, above, or below them can also be used without permission. If the person or organization using such material wishes to cite the document or text, standard citation formats relating to publications and Web sites should be followed.

YES!  The good news is there are alternatives to opioids.

Acetaminophen
Non-steroidal anti-inflammatory drugs (NSAIDs)
Antidepressants
Anticonvulsants
Muscle relaxants
Topical therapies

Acupuncture
Behavioral therapies
Biofeedback
Chiropractic
Diet and nutritional counseling
Exercise
Health coaching
Massage
Pain group
Stretching
Weight management
Yoga, tai chi

Taking Prescription Opioids

Risks of taking opioids include: respiratory depression and death, overdose, sedation, confusion, memory problems, motor vehicle accidents, falls, worsening pain, addiction, and reduced quality of life.  Other side effects may include nausea, vomiting, constipation, itching, urinary retention and dry mouth.

  • Do take only as prescribed and ask questions
  • Do tell your doctor about all other medications you take
  • Do read instruction sheets included with your prescriptions
  • Do keep all medications secure
  • Do dispose of all leftover medications properly
  • Do know signs and symptoms of an overdose
  • Do know how to use naloxone rescue medication
  • Do get HELP 1-800-662-HELP (4357) if you or someone you know is struggling with addition
  • Don’t take more medication than prescribed
  • Don’t mix medications with alcohol or other drugs
  • Don’t share your medications – sharing controlled substances is a felony
  • Don’t ever take medications not prescribed to you
  • Don’t dissolve crush, cut or chew medications unless instructed to do so
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If your doctor prescribes an opioid pain medication, be sure to ask these simple questions.

  • Is my pain medication an opioid?
  • When should I take this medication?
  • How long should I take this medication?
  • What level of pain relief is considered effective?
  • Do I need to take every pill?
  • How can I stop taking this medication?
  • Are there non-opioid alternatives that I could choose?
  • What if I have a history of tobacco, alcohol or drug addiction?
  • Could this medication interact with my sleeping or anxiety medication or OTC?
  • What else should I be doing to manage my pain?
  • Is naloxone rescue medication right for me?

Useful Links