Information on chronic pain and addicton

Christopher Frandrup, M.D., DABPM, FIPP

Category: Addiction (Page 1 of 2)

What is a drug addiction?

Source: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services
Drug Facts: Understanding Drug Abuse and Addiction
Many people do not understand why or how other people become addicted to drugs. It is often mistakenly assumed that drug abusers lack moral principles or willpower and that they could stop using drugs simply by choosing to change their behavior. In reality, drug addiction is a complex disease, and quitting takes more than good intentions or a strong will. In fact, because drugs change the brain in ways that foster compulsive drug abuse, quitting is difficult, even for those who are ready to do so. Through scientific advances, we know more about how drugs work in the brain than ever, and we also know that drug addiction can be successfully treated to help people stop abusing drugs and lead productive lives.Drug abuse and addiction have negative consequences for individuals and for society. Estimates of the total overall costs of substance abuse in the United States, including productivity and health- and crime-related costs, exceed $600 billion annually. This includes approximately $193 billion for illicit drugs,1$193 billion for tobacco,2 and $235 billion for alcohol.3 As staggering as these numbers are, they do not fully describe the breadth of destructive public health and safety implications of drug abuse and addiction, such as family disintegration, loss of employment, failure in school, domestic violence, and child abuse.

What Is Drug Addiction?

Addiction is a chronic, often relapsing brain disease that causes compulsive drug seeking and use, despite harmful consequences to the addicted individual and to those around him or her. Although the initial decision to take drugs is voluntary for most people, the brain changes that occur over time challenge an addicted person’s self-control and hamper his or her ability to resist intense impulses to take drugs.Fortunately, treatments are available to help people counter addiction’s powerful disruptive effects. Research shows that combining addiction treatment medications with behavioral therapy is the best way to ensure success for most patients. Treatment approaches that are tailored to each patient’s drug abuse patterns and any co-occurring medical, psychiatric, and social problems can lead to sustained recovery and a life without drug abuse.Similar to other chronic, relapsing diseases, such as diabetes, asthma, or heart disease, drug addiction can be managed successfully. And as with other chronic diseases, it is not uncommon for a person to relapse and begin abusing drugs again. Relapse, however, does not signal treatment failure—rather, it indicates that treatment should be reinstated or adjusted or that an alternative treatment is needed to help the individual regain control and recover.

What Happens to Your Brain When You Take Drugs?

Drugs contain chemicals that tap into the brain’s communication system and disrupt the way nerve cells normally send, receive, and process information. There are at least two ways that drugs cause this disruption: (1) by imitating the brain’s natural chemical messengers and (2) by overstimulating the “reward circuit” of the brain.Some drugs (e.g., marijuana and heroin) have a similar structure to chemical messengers called neurotransmitters, which are naturally produced by the brain. This similarity allows the drugs to “fool” the brain’s receptors and activate nerve cells to send abnormal messages.Other drugs, such as cocaine or methamphetamine, can cause the nerve cells to release abnormally large amounts of natural neurotransmitters (mainly dopamine) or to prevent the normal recycling of these brain chemicals, which is needed to shut off the signaling between neurons. The result is a brain awash in dopamine, a neurotransmitter present in brain regions that control movement, emotion, motivation, and feelings of pleasure. The overstimulation of this reward system, which normally responds to natural behaviors linked to survival (eating, spending time with loved ones, etc.), produces euphoric effects in response to psychoactive drugs. This reaction sets in motion a reinforcing pattern that “teaches” people to repeat the rewarding behavior of abusing drugs.As a person continues to abuse drugs, the brain adapts to the overwhelming surges in dopamine by producing less dopamine or by reducing the number of dopamine receptors in the reward circuit. The result is a lessening of dopamine’s impact on the reward circuit, which reduces the abuser’s ability to enjoy not only the drugs but also other events in life that previously brought pleasure. This decrease compels the addicted person to keep abusing drugs in an attempt to bring the dopamine function back to normal, but now larger amounts of the drug are required to achieve the same dopamine high—an effect known as tolerance.Long-term abuse causes changes in other brain chemical systems and circuits as well. Glutamate is a neurotransmitter that influences the reward circuit and the ability to learn. When the optimal concentration of glutamate is altered by drug abuse, the brain attempts to compensate, which can impair cognitive function. Brain imaging studies of drug-addicted individuals show changes in areas of the brain that are critical to judgment, decision making, learning and memory, and behavior control. Together, these changes can drive an abuser to seek out and take drugs compulsively despite adverse, even devastating consequences—that is the nature of addiction.

Why Do Some People Become Addicted While Others Do Not?

No single factor can predict whether a person will become addicted to drugs. Risk for addiction is influenced by a combination of factors that include individual biology, social environment, and age or stage of development. The more risk factors an individual has, the greater the chance that taking drugs can lead to addiction. For example:

  • Biology. The genes that people are born with—in combination with environmental influences—account for about half of their addiction vulnerability. Additionally, gender, ethnicity, and the presence of other mental disorders may influence risk for drug abuse and addiction.
  • Environment. A person’s environment includes many different influences, from family and friends to socioeconomic status and quality of life in general. Factors such as peer pressure, physical and sexual abuse, stress, and quality of parenting can greatly influence the occurrence of drug abuse and the escalation to addiction in a person’s life.
  • Development. Genetic and environmental factors interact with critical developmental stages in a person’s life to affect addiction vulnerability. Although taking drugs at any age can lead to addiction, the earlier that drug use begins, the more likely it will progress to more serious abuse, which poses a special challenge to adolescents. Because areas in their brains that govern decision making, judgment, and self-control are still developing, adolescents may be especially prone to risk-taking behaviors, including trying drugs of abuse.

Prevention Is the Key

Drug addiction is a preventable disease. Results from NIDA-funded research have shown that prevention programs involving families, schools, communities, and the media are effective in reducing drug abuse. Although many events and cultural factors affect drug abuse trends, when youths perceive drug abuse as harmful, they reduce their drug taking. Thus, education and outreach are key in helping youth and the general public understand the risks of drug abuse. Teachers, parents, and medical and public health professionals must keep sending the message that drug addiction can be prevented if one never abuses drugs.

References

  1. National Drug Intelligence Center (2011). The Economic Impact of Illicit Drug Use on American Society.Washington D.C.: United States Department of Justice. Available at: http://www.justice.gov/archive/ndic/pubs44/44731/44731p.pdf(PDF, 2.4MB)
  2. Centers for Disease Control and Prevention. Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 2000–2004. Morbidity and Mortality Weekly Report. Available at:http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a3.htm (PDF 1.4MB).
  3. Rehm, J., Mathers, C., Popova, S., Thavorncharoensap, M., Teerawattananon Y., Patra, J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet, 373(9682):2223–2233, 2009.

Sorry, opioids probably aren’t helping your back pain

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It’s time to really talk about opioid use. Chronic pain is no laughing matter, and it’s nothing to be flippant about. We see thousands of patients a year who suffer terribly from lower back pain and other conditions. The struggles that they face in their daily lives, and the challenges that their chronic pain presents to their friends and family, are very real. We take them very seriously. We live our mission of helping patients get their lives back every day, and we want them to know that we consider them like our own family. And as with our own family, it’s time for some tough talk: opioids are probably not helping your lower back pain. In fact, opioids may be making your lower back pain worse.

Research on opioids for lower back pain comes up short

For years now researchers have been looking deeply into opioids for chronic pain of all types. They have amassed hundreds of studies over decades looking at opioids for both short- and long-term use.

Again and again, the evidence shows that opioids have limited effectiveness in treating lower back pain. The most recent findings come just weeks before this post. In a meta-analysis of 20 trials looking at the safety and side effects of opioids for lower back pain with no clear identifiable cause, researchers found that opioids had about half the effectiveness for pain relief as that of an inactive placebo. In addition, many of the study participants were unable to handle the side effects of opioids, with over 50% experiencing side effects so severe that they withdrew from the studies.

So why are doctors and patients alike still working under the assumption that opioids are effective?

A brief history of opioids and lower back pain

Opioids have been around in some form since 3400 BCE (in the form of poppies). Fast forward thousands of years to the 1990s when undertreatment of pain became a rallying cry for more aggressive interventions and pain management.

One of these interventions was the development of extended release opioids, including morphine, oxycodone, and fentanyl. Pain lobbyists pushed for wide release and prescription of opioids for all types of pain beyond non-cancer pain, which has generally always been the standard of care.

These slow-release medications produced in pain patients an overwhelming feeling of euphoria and a perception of pain relief. It stands to reason that a person suffering for years from chronic pain would embrace this feeling, but there was one huge caveat: the body’s adaptability to this type of medication.

Doctors began prescribing these miracle drugs to excess, with patients understandably clamoring for relief.

We want to note again that we truly understand why patients and their doctors adopted opioid prescription practices so readily. To see patients who had been suffering for decades report pain-free days and a restored hope for the future is what every doctor hopes for.

But in the ten-year period from 1998 to 2008, opioid prescriptions doubled. Along with that prescription doubling came over 730,000 visits to the emergency room due to misuse or abuse of prescription opioids, doubling in just five years. In 2002, over six million people in the U.S. were abusing prescription drugs.

The changing face of addiction

The vast majority of those with opioid dependence are not who you might think they are. Many people who begin taking opioids for acute pain find themselves physically dependent on them in a short time. In fact, many patients leave the hospital physically dependent on opioids after an operation, suffering minor withdrawal symptoms that they may believe is a cold or a virus contracted at the hospital.

It should be noted that physical dependence is not the same as addiction. Physical dependence on opioids is the same as physical dependence on insulin for Type 1 diabetics. The body becomes used to functioning in a certain way with their medications and struggles to acclimate after those medications are withdrawn. Addiction is characterized as a behavioral component that usually accompanies a physical dependence.

That being said, it is remarkably easy to become dependent on opioids, and the longer you take them, the more likely you are to develop both physical dependence and an increased tolerance to their effects. Patients may find that previous prescriptions may no longer help with their pain, and they may begin to suffer withdrawal symptoms such as nausea, fatigue, muscle pain and weakness, and irritability or anger.

The person who finds themselves “addicted” to opioids may still be able to function in daily life, but the longer they take opioids, the more dangerous they become. Long-term use is associated with disruption to the menstrual cycle, a weakened immune system, and affected sex hormones. Additionally, side effects may include nausea, constipation, and difficulty concentrating, problems which worsen as time goes on.

Roger Chou, M.D., associate professor of medicine at Oregon Health and Science University in Portland points out that new research has utterly debunked opioids’ effectiveness against lower back pain, noting:

“The old perception about opioids is that they are reasonably effective and safe for chronic pain, but what we’ve come to realize is for many types of pain they don’t work all that well and are actually associated with significant harm.”
Gary Franklin, M.D., research professor of environmental and occupational health sciences at University of Washington in Seattle believes that the evidence has become overwhelming against prescribing opioids for chronic pain:

“What concerns me is that there is no clear evidence that people who take opioids over the long term can do more or get around more easily. But we do know that the higher the dose of the drug and the longer you take it, the greater your risk.”
Opioids – what are they good for?

In specific, controlled instances, opioids work well for pain management. End-stage cancer pain and pain as a result of surgery or in the acute, short-term stage of an injury are two times when opioids are recommended and are the standard of care.

But for chronic lower back pain? There is no evidence that the benefits from opioids outweigh the risks. Indeed, it does not seem that opioids have any more affect on chronic lower back pain than a placebo.

Opioids and chronic lower back pain – the bottom line

The bottom line for opioids and chronic lower back pain is this: there is no evidence that opioids are effective in treating chronic lower back pain, and the risk of side effects, dependence, and death increase the longer a patient takes them.

If you are currently taking opioids for chronic lower back pain, it’s time to talk to your doctor about other options. It is never too late to make changes in your health, and a conversation with your pain management specialist is a great place to start.

DEA COLLECTS RECORD-SETTING AMOUNT OF MEDS AT LATEST NATIONAL R/X TAKE-BACK DAY

 

  FOR IMMEDIATE RELEASE

 Contact: DEA Public Affairs

Press Release

DEA COLLECTS RECORD-SETTING AMOUNT OF MEDS AT 

LATEST NATIONAL R/X TAKE-BACK DAY 

WASHINGTON, D.C. – Americans turned in more unused prescription drugs at the most recent DEA National Prescription Drug Take-Back Day than on any of the previous ten events since it began in 2010, demonstrating their understanding of the value of this service. 

 

Last weekend the DEA and over 4,200 of its state, local, and tribal law enforcement partners collected 893,498 pounds of unwanted medicines—about 447 tons—at almost 5,400 sites spread through all 50 states, beating its previous high of 390 tons in the spring of 2014 by 57 tons, or more than 114,000 pounds.  The top five states with the largest collections, in order, were Texas (almost 40 tons); California (32 tons); Wisconsin (31 tons); Illinois (24 tons); and Massachusetts (24 tons). 

 

The majority of prescription drug abusers report in surveys that they get their drugs from friends and family.  Americans understand that cleaning out old prescription drugs from medicine cabinets, kitchen drawers, and bedside tables reduces accidents, thefts, and the misuse and abuse of these medicines, including the opioid painkillers that accounted for 20,808 drug overdoses—78 a day—in 2014 (the most recent statistics from the Centers for Disease Control and Prevention).  Eight out of 10 new heroin users began by abusing prescription painkillers and moved to heroin when they could no longer obtain or afford those painkillers.

 

“These results show that more Americans than ever are taking the important step of cleaning out their medicine cabinets and making homes safe from potential prescription drug abuse or theft,” said DEA Acting Administrator Chuck Rosenberg.  “Unwanted, expired or unused prescription medications are often an unintended catalyst for addiction.  Take-Back events like these raise awareness of the opioid epidemic and offer the public a safe and anonymous way to help prevent substance abuse.”

Prince overdosed on Percocet

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As a Minnesota native I was devastated to learn of Prince’s death.  It turns out he suffered from a percocet addiction.  His addiction started innocently as a prescription from his doctor to treat his chronic hip pain.  In fact, he was scheduled to see an addictionologist the day he was discovered dead.

America is in the midst of an opioid epidemic.  According to the CDC, 40 Americans die every day from prescription opioid overdoses.  The number of opioids prescribed in this country has quadrupled in the past decade.   This problem is now out of control with both doctors and patients to blame.  Years ago, the Joint Commision made pain the “fifth vital sign” and many physicians blame them for starting the epidemic.  However, it is much more complicated.  Many factors including marketing by pharmaceutical companies, increased access to care, patient empowerment, and legal issues have contributed to the increased use of opioids in this country.  I used to prescribe large amounts of opioids a decade ago and personally contributed to this problem.  Although thousands have already died, we can still save thousands by reducing the number of opioid prescriptions and treating patient on opioids and those addicted to pain killers.

White women, dying young.

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A recent article in The Week caught my eye.  The byline asks, “Why are so many working-class women in rural America dying in their middle age?“. The life expectancy of virtually every class of American has increased in the past half-century with the exception of rural women.  In fact, 300,000 have died from from overdose and addiction in the past 8 years.

Why is this happening now….

“It’s a loss of hope, a loss of expectations of progress from one generation to the next,” said Angus Deaton, a Nobel Prize–winning economist who had studied the data.

“What we’re seeing is the strain of inequality on the middle class,” President Obama said. “Erosion of the safety net,” Hillary Clinton said. “Depression caused by the state of our country,” Donald Trump said. “Isolated rural communities,” Bernie Sanders said. “Addictive pain pills and narcotics,” Marco Rubio said.

It is a sad story I have seen many times as a physician.  The causes of addiction are as various as the people who become victim to its grasp. Regardless, the outcomes are tragically similar.  The path to recovery is difficult and requires assistance.  If you or a loved one suffer from addiction, I urge to seek professional help.

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