Lesson 8: The Opiate Epidemic

Attention

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Elliot Krane: The Mystery of Chronic Pain

The current opiate epidemic is very much related to pain medications and understanding pain and how to help people in pain is very much a part of the answer to the problems we are seeing.

We think of pain as a symptom, but there are cases where the nervous system develops feedback loops and pain becomes a terrifying disease in itself. Starting with the story of a girl whose sprained wrist turned into a nightmare, Elliot Krane talks about the complex mystery of chronic pain, and reviews the facts we're just learning about how it works and how to treat it.

Learning Outcomes

Upon completion of this lesson's material, students will be able

• Understand the recent opiate epidemic
• Be able to state issues in chronic pain and how various treatment approaches work together
• Be able to state the risks and benefits of medication assisted treatment for Opiate Use Disorder
• Compare and contrast other treatment approaches for OUD to MAT (medication assisted treatment)

Teaching

Reading: Chapter 10 and Chapter 11 in Nutt and Nestor. Also this

Reading PDF: PAIN

PAIN

Pain is the primary cause of the recent upsurge in OUD. An aging population and changes in how doctors are trained to deal with pain are some of the reasons why use of opiates and consequent  increases in OUD have occurred. After the Civil War, there was a big increase in OUD because of wounded veterans  with chronic pain. With the popularization of psychodynamically oriented psychotherapy and the concept of "hysterical" pain, there was a movement towards seeing pain as "just in your head" and encouraging people to get over it and tough it out. In the last half of the 20th Century, the pendulum began to swing back and doctors were encouraged to listen to and give validity to their patients' experiences. Opiate prescriptions increased because opiates work to medicate the symptoms of  pain. But tolerance rapidly occurs and often the dose must be increased. Also with chronic use of any pain medication (not just opiates) a reflex hyperalgesia may develop. These are two reasons why for chronic pain, a more complex strategy than simple administration of analgesics must be developed. As described in Dr Krane's TED talk, this strategy includes cognitive behavioral therapy to deal with emotional response to the pain and to look at non-medication pain management strategies (e.g. meditation, exercise, staying busy, normalizing the experience of pain, etc.). Also physical therapy and occupational therapy are necessary in all cases of chronic pain although not always prescribed and often not followed through by the patient. This complex approach to pain is one that MHRT/Cs can help their clients to understand and practice and to find the resources to implement.

Dr Krane mentions allodynia. Also important in understanding chronic pain is neuropathic pain which is caused by damage to the nerves. A good example of neuropathic pain is phantom limb pain for example when a foot has been amputated but the person still feels pain in the missing foot because the nerves in the stump are sending pain messages.

PAIN AND ADDICTION

Researchers have previously emphasized that opiate use is safe for most patients (c.f. http://www.medscape.com/viewarticle/715452 ) with only 5 to 10% developing the more severe symptoms of OUD such as loss of control (using more than the doctor prescribes or using it to get high), preoccupation (becomes the center of the person's life and all that they think about) or interfering with daily function (e.g. missing work or failure to parent or carry out other obligations).

Most people who have opiates prescribed in heavy doses for a long time will develop tolerance and may have withdrawal symptoms if the dose is suddenly stopped. But most people can also taper off opiates and live without them when no longer needed. In fact, it may only be the 10% of the population who have the right genes for addiction  who are at risk when prescribed opiates. And even this at risk group may be able to use opiates with proper medical supervision such as pill counts, prescription monitoring, urine monitoring and monthly visits with a pain specialist before renewing prescriptions. The bottom line for prescribing any treatment is that it increases functionality (the person handles activities of daily living better). This concept of increased functionality is also the bottom line when we come to consider medication assisted treatment for opiate use disorder.

OPIATE USE DISORDER

The endogenous opioid system (endorphins) is central to our feeling of well-being. Natural opiates (from the opium poppy) have been used not only for pain relief but to relax and get high. Because of the centrality of the endogenous opioid system to our function, once it becomes unbalanced through heavy chronic use it is difficult for some people to return to non-use. They may relapse after months or even years of abstinence because they never feel quite right again.

Conventional addiction treatment has not worked as well for OUD as for other SUDs. Because it is physically safe to use opiates for long periods of time, physicians even in the late 19th and early 20th centuries were willing to prescribe opiates for their opiate addicted patients until forbidden to do so by the Harrison Narcotics Act. In the last half of the 20th Century,  physicians in New York (Vincent Dole and Marie Nyswander) developed clinics where people with OUD could be prescribed daily methadone ( a long acting opioid which sticks to the opiate receptor so that not only is craving satisfied but other opiates can't get in and the person can't get high). People receiving methadone were able to leave the life of drug seeking and crime and to resume normal daily function including work, school and family care. And because tolerance develops, people on a maintenance dose of methadone are not high or impaired in any way. But like people who take other medications (e.g., beta blockers for blood pressure), once they have stabilized on their med, they can do any normal activity.

Picture of a typical Methadone Clinic

Methadone alone is not enough. People whose lives have been derailed by OUD also need therapy to repair what was damaged by addiction and to achieve maximum life function. Also there are often co-occuring addictions which do not go away just with a methadone prescription.

The MHRT/C can help their clients who are at the methadone clinic to adhere to their prescribed regimen and to plan for their best possible life. 

Buprenorphine was licensed for OUD around the beginning of this Century. It is prescribed by regular physicians and does not require attendance at a special clinic like methadone. So clinic-related stigma and crime are eliminated. No one knows you are taking buprenorphine except you and your doctor. Physicians must do an online training to prescribe this med and most doctors don't seem to want the trouble so that there is always a shortage of doctors willing to prescribe it. Buprenorphine is preferable to methadone for all but the most heavily addicted patients because 1) It is outpatient and you take your med at home; 2) buprenorphine acts differently on the opiate receptor than methadone being both a partial agonist and an antagonist---so that there is little or no intoxication and completely blocking other opiates;3) Overdose is not possible with this med---it reaches a ceiling after 30mg and after that there is no further effect.

Usually patients on Suboxone (Buprenorphine plus Naloxone which is added to keep it from being injected) are required to see an addictions counselor at least for an evaluation and often for several months of treatment. But eventually the Suboxone patient is able to function normally without further treatment providing that they are not using other addictive substances and that co-occurring mental disorders are stable.

Some OUD patients choose and are able to maintain abstinence. Opiate withdrawal is unpleasant but not life threatening and usually can be done outpatient. Clonodine ( a blood pressure medication) may reduce the unpleasantness of detox. Usually Intensive Outpatient Treatment for 4 weeks followed by 8 to 12 sessions of OP are advisable.

The MHRT/C can help by working with the client to find resources and follow through. Once treatment has concluded the MHRT/C  can help by reminding the client of their skills and helping them with relapse prevention.

Naltrexone is a useful medication both for clients choosing abstinence and for those on MAT when they are ready to taper off their med. Naltrexone is an opiate blocker that reduces craving and prevents the person from getting high even if they do use. It is only effective in clients highly motivated for abstinence because the client must continue to take the dose to block the effect of opiates. A problem here is that cravings may continue even with use of naltrexone and the client may therefore decide to stop the med and take the drug just to stop the unending torment.

Methadone is intended to be  a long-term therapy but when the client has stabilized their life and is doing well and abstaining from all other substances, the clinic will assist in a taper. The problem with methadone is that it is a hard med to come off of and many people report deep bone pain months after the last use.

Suboxone (buprenorphine) is easier to taper off and typically clients are advised that they can try a taper after a couple of years of therapy providing their life is stable and they are abstinent from all other substances

JUSTIFYING METHADONE

Asking clients to automatically stop MAT after 2 years (current MaineCare policy) is not advised. This decision should be made by doctor and patient depending on the patient's readiness.

From a cost effectiveness standpoint, MAT is much less costly than continued addiction or incarceration. Also, especially with Suboxone, there is abundant evidence of lives changed for the better  

The effectiveness of methadone clinic treatment could be improved with more substance abuse treatment (The Discovery House clinics tend to be lite on this aspect) and better supervision of cases. But these are not achievable with current reimbursement levels. 

Assessment

Lesson 8 Quiz

1. A "complex approach" to pain management is described in this Lesson. List (for 10 points each) the different elements of this strategy and give an example of each. (Worth up to 40 points)
2. List the medications used in Medication Assisted Treatment and describe the risks and benefits with each (20 points for each medication).
3. The main alternative to Medication Assisted Treatment is abstinence oriented treatment. State the reason given in the Lesson about why this hasn't worked too well (20 points). Describe what the Lesson says about what does work when the client is motivated and ready for abstinence (20 points)

Lesson 8 Discussion

Given what the Lesson says about the relation of pain to the current opiate epidemic, what do you think would be an effective solution. State your solution and tell us why it would work.

Remember, you mist post TWICE in EVERY discussion board. Your first post should address the topic of the discussion (like the one above) and your second post must be a reply to ANOTHER students' post...your reply should be MORE than just a "I agree!" or "Very cool!" It should be "substantive" by expanding on the students post, asking a questions, adding your own thoughts to what they have said, etc.