In this series of articles about addiction, sponsored by the organization Chayeinu, we have been discussing paths toward opioid addiction and opioid overdose. In the last article, I wrote about the problem of teenagers progressing from alcohol or marijuana use to opioids. Often, they start with prescribed opioid medications (found in the family medicine cabinet, perhaps) and transition to illegal drugs. This is the most common path to opioid addiction. In this article, we will consider an alternate path to opioid addiction that might occur as a result of opioids prescribed to treat pain.
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Opioid analgesics like oxycodone and hydrocodone, and to a lesser extent codeine and tramadol (a synthetic analgesic), are considered frontline treatments for moderate to severe pain, including some chronic pain conditions. It is interesting to consider that over any two-year period, about a third of all adults in this country receive an opioid prescription. Physicians in the United States seem to be more open to prescribing opioids than doctors from other countries.
Many of us are familiar with the horror stories publicized in the media during the opioid crisis: A person with a diagnosed pain condition is prescribed an opioid analgesic and remains unaware of its abuse potential. No longer receiving the desired effect from the prescribed medication, or forced by the doctor to stop using the medicine before the pain has subsided, the patient takes to the streets to find heroin or fentanyl, ultimately suffering an overdose.
Thankfully, this narrative is highly uncommon. For those prescribed an opioid medication, only about five percent engage in any type of misuse, and less than one percent will ever develop an opioid use disorder. Most doctors are careful in their prescribing practices, and most patients are careful to take the medication as prescribed. People generally do not like the sluggish feeling of opioid intoxication, despite the enormous pain relief.
Yet some people prescribed opioids will have trouble managing their use. Opioids are very effective analgesics. They can also cause people to feel relaxed and happy. The misuse of prescription opioids is a strong predictor of transitioning to heroin or fentanyl use, developing an opioid use disorder, or suffering an opioid overdose. Here are some points to consider and discuss with your doctor if you or a family member is prescribed an opioid:
1) Any opioid prescription increases the risk for opioid misuse. In fact, higher doses of opioids and longer prescriptions are associated with a greater risk of opioid misuse. Especially for acute pain, opioid prescriptions should be limited to only a few days or until the next doctor’s appointment. You should worry about a doctor who is willing to prescribe opioid analgesics without establishing regular appointments to monitor use and misuse.
2) You should ask your doctor to provide some basic education about opioids. One point that is sometimes misunderstood is that physical dependence on opioids is not the same as having an opioid use disorder. Physical dependence is defined as tolerance (needing more of the drug to attain the desired effect) and/or withdrawal difficulties (an uncomfortable physical response to stopping drug use). These are normal responses to repeated opioid ingestion, which can occur in a relatively short period of time.
Physical dependence is not a disorder, however. While some people develop mild tolerance or withdrawal symptoms with short-term prescriptions of opioids, most can safely taper from the medication with few to no side effects. Physical dependence typically transitions to a disorder when the patient starts to take the opioid prescription in a non-prescribed manner, acquires opioid medications from others, or seeks doctors who will prescribe additional opioids.
3) Some people are more vulnerable than others to developing opioid use disorder after being prescribed opioids. If you have a family history of addiction, a personal history of addiction (including nicotine), a current psychiatric condition, or trauma experience, you are at higher risk for misusing opioids. People with these conditions tend to find opioids more pleasurable, as they provide short-term relief for physical pain and emotional symptoms. A good doctor will screen for these co-occurring conditions, and a good patient will be open about his or her medical history.
For parents with teenagers who require an opioid analgesic, it is important to share with the doctor if your child has vulnerabilities toward addiction. This is not a good time to hide the fact that he or she is vaping or drinking illegally. Most doctors have access to a prescription monitoring data base to check one’s history of taking opioids.
4) If you require opioids over an extended time period (e.g., for chronic pain conditions), you should ask about non-drug approaches to supplement medication. There are many evidence-based pain management strategies for chronic pain conditions, such as physical therapy, exercise, biofeedback, and/or psychotherapy. We should remember that the goal of these therapies is to tolerate, not necessarily eliminate, the pain. Because chronic pain frequently co-occurs with psychiatric concerns (like major depression), a psychiatric evaluation may also be recommended, with the understanding that treatment of the psychiatric disorder can improve pain tolerance and functioning.
5) Misuse of opioids may impact other medications that you are prescribed. On the one hand, people who misuse drugs often neglect their routine prescribed medications for such common chronic disorders as blood pressure or diabetes. On the other hand, opioid medications can interact with other prescription medications to increase drowsiness or trigger other health concerns.
Obviously, the use of opioids together with other illicit drugs or alcohol highly increases overdose risk.
6) Those who require opioids should consider including at least one family member as part of the treatment process. The family member should receive education on opioid medications, treatment goals, the importance of attending appointments, how to recognize the signs of non-prescribed opioid use, how to safely store medications, and how to manage an overdose.
7) One of the reasons for emphasizing safe storage of opioid medications is that most people who are prescribed opioids do not take the full prescription. While this practice reduces risk of overdose, it also increases the presence of extra medication stored unsafely in the medicine cabinet. These opioids could be used by children, other family members, or even workers in your house who have access to the bathroom, which occurs more often than you want to think about.
8) We have mentioned previously the benefits of keeping the overdose-reversing drug Narcan in the house, and knowing how to use it. Administering Narcan should always be done in connection with calling 911 (or Hatzalah). There is a statewide standing order that allows anyone in Maryland to receive Narcan at the pharmacy without a prescription.
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Even with these common sense precautions, there will be a small subset of people who develop an opioid use disorder after taking prescription opioids. If you suspect that a family member is misusing opioids, feel free to contact the doctor who prescribed it to voice your concerns. While the prescriber may not be able to speak to you without consent, knowing that a patient is having trouble will often be enough to change prescription patterns.
Nevertheless, once a family member has developed an opioid use disorder, it is usually not enough to simply have the doctor take the patient off of the medication gradually, referred to as opioid detoxification or taper. It is unfortunate that for people who have developed an opioid use disorder, opioid detoxification alone is rarely successful. Instead, the opioid detoxification, usually accomplished on an outpatient basis, should commence in strong connection with other therapies. These might include addiction counseling, mental health counseling, and/or alternate approaches for pain relief.
For those who chronically return to opioids, opioid-agonist medications like buprenorphine (suboxone) or methadone, together with counseling and a pain management plan, can be helpful to provide stability. These matters can be discussed with the prescribing physician or with your primary care doctor. The point here is that, although opioid use disorder is relatively rare, once it emerges, it is often chronic and severe in nature, and generally requires long-term treatment and monitoring.
Dr. Kidorf is Associate Director of Addiction Treatment Services and Associate Professor, Psychiatry and Behavioral Sciences, at Johns Hopkins University School of Medicine.
