Lesson 8: The Opiate Epidemic


Attention

Click HERE to view this directly in YouTube

Elliot Krane: The Mystery of Chronic Pain

The current opiate epidemic is 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

  • 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

Chapters 1,2 and 3 in Tip # 43

Read PAIN

That's the thing about pain, it demands to be felt by Augustus Waters (The Fault in our Stars)

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 and the discovery of a synthetic opiate, morphine, that was seen as cutting edge technology at the time.

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 (Freud, for example, refused any pain medication during the terminal stage of his nasopharyngeal cancer even though the pain was excruciating; however, he finally did commit physician assisted suicide with morphine).

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 the 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 the emotional response to 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.

Definitions:  

  • allodynia --- a perception of pain from a stimulus that is not normally painful  
  • hyperalgesia---an increased perception of pain from a stimulus that is normally painful
  • neuropathic pain---a continuing perception of pain when there is not a painful stimulus due to damage to the pain receptors

PAIN AND ADDICTION

Researchers have previously emphasized that opiate use is safe for most patients who don’t have a history of addiction.

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. 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). Opiate prescriptions enable millions of people to go about their daily activities, to clean their houses, go to work and keep on functioning. Opiates do have side effects especially constipation but now there’s a medication for that called naloxogel.  Use of opiates has health risks and here is an article on those health risks.

Other analgesics such as aspirin, naproxen, ibuprofen, celecoxib and even acetaminophen also have risks (especially GI bleeding for the first four and liver damage for acetaminophen). The first four are riskier for cardiovascular issues (especially for adults over the age of 60) increased risk of stroke and heart attack.

Acetaminophen is risky for liver damage especially because people consider it so safe they lose track of how much they are taking (liver risk when daily dose exceeds 4000mg or 8 500mg pills)

This concept of increased functionality, that this is the main consideration in prescribing any pain medication after taking the risks into account, is also the bottom line when we come to consider Medication Assisted Treatment for opiate use disorder.

A NOTE ON REGIONAL DIFFERENCES IN OPIATE USE:

The opiate epidemic struck first, hit hardest and has persisted longest on the East Coast and especially in the Northeast. This may be because there are older people in this region of the country who are more likely to be prescribed pain meds.

But it may reflect a more basic difference in how addiction works. Generally speaking alcoholism rates increase with geographic latitude. The further north you go, the higher the rate of AUDs. Reasons for this are poorly understood but it may have to do with the seasons and changes in mood in some people correlated with seasonal changes. DSM 5 talks about Seasonal Affective Disorder. In any case it may be generally true that sedating substances (alcohol, opiates, benzodiazepenes) are more popular the further north you go.

At the same time, it also seems to be true that at least in this country, stimulant use and especially methamphetamine use is more prevalent in the South and especially in the Southwest.

One implication for treatment is to look for underlying mood issues (and especially depression) in all cases of OUD (and also with alcohol and tranquilizers) and to treat those issues with appropriate medications and CBT).

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 for thousands of years 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 of opiates it is difficult for some people to return to non-use. The endogenous opiate system may remain disturbed for months or even years after last use. People may relapse after months or even years of abstinence because they never feel quite right again. This may be why conventional addiction treatment (abstinence based) has not worked as well for OUD as for other SUDs.

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.). 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.

People taking methadone are still addicted. But the dynamics of the addiction have changed in a positive direction that allows the person to be more functional. Here are the changes: 1) Like the nicotine patch, methadone is delivered on a schedule, thus breaking the link between craving and dosing; 2) After the first few days, there may no longer be a high associated with the dose so that the patient is neither intoxicated nor impaired; 3) Daily attendance at the clinic introduces a prosocial effect in the previously chaotic life of the patient (this is especially effective when accompanied by group and individual counseling).

Picture of a typical Methadone Clinic

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-occurring addictions which do not go away just with a methadone prescription. Cognitive behavioral therapy and relapse prevention are helpful in OUD clients who need to learn how to enjoy life and handle stress without substances and to make lifestyle changes that support return to normal life function while taking their medication.

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.  The key is to understand why they are taking their medication and to support them as long as they need it.

SUBOXONE

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. Although some poeple with chronic pain may be prescribed 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. Suboxone overdoses only occur when the medication is combined with alcohol or some other sedating substance such as benzodiazepenes.

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 (unless there are underlying medical conditions, pregnancy, or other drugs invlolved.)

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. Treatment involves working with the family and the client to learn how to function without substances. New learning involves stress management, contingency management (learning how to reward non-addictive behavior in healthful, helpful ways, e.g. relaxing with a handful of peanuts or a piece of fruit after work), and dealing with conflict, distress and other normal parts of daily life. Also important is relapse prevention.

Here is an article about Suboxone treatment from PsychCentral

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 keep in touch with resources for relapse prevention. Whether the client chooses MAT or abstinence, the task of the MHRT/C is to support the client in doing the best with their choice

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 desired opiate 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. Research (documented in TIP 43) clearly shows that patients forced off MAT before they are ready lose the gains they have made and often relapse.  The decision to discontinue MAT, as with all other medical decisions, should be made by doctor and patient depending on the patient's readiness.

It is an indication that we do not really conceptualize opiate addiction as a medical problem when we impose legislative limits on treatment. What other medical issue is subject to this kind of political interference? There would be justifiable public outrage if diabetes patients were cut off from insulin after two years because they were still obese of if cardiac patients were cut off from their meds because they did not make needed changes in diet and exercise and stress management.

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 counseling and case management (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. Rather than criticizing clinics for poor treatment outcomes when these are due to inadequate resources, we should be advocating for increased funding so that they can do their job.


Assessment

In this section you will find a list of the required Assessments that accompany this Lesson. The Lesson Discussions are designed for the ONLINE and HYBRID versions of this course. If you are not in an ONLINE or HYBRID version of this course you can ignore these instructions unless otherwise guided by your instructor.

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).
  3. The main alternative to Medication Assisted Treatment is abstinence oriented treatment. State the reason given in the Lesson about why abstinence-based treatment hasn't worked too well (20 points). Describe what the Lesson says about what does work when the client is ready for abstinence (20 points).

Lesson 8 Discussion (for online class only)

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.