How Unregulated Opioid Use Can Lead To Heroin Addiction

April 12, 2017 / Thomas Cohn, MD

In the 1960s, the drug culture was known for psychedelics, LSD and marijuana. Eventually, some of those users sought a stronger high, and that led them down the path to heroin. At least that was the message pushed by the government in its fight against drugs.

Heroin was actually not that common and it was often a drug of addiction found in Vietnam veterans due to its availability in that region. Intense drug programs and interventions to rid production significantly reduced heroin use in the U.S. from the 1970’s through about 2000. In the 1990’s, the era of everyone needing opioid pain management began and along came Oxycontin. The quick and easy option for most doctors to treat pain was to write a prescription for the magical opioid pill. For the last ten years, we now have discovered the rising tide of opioid addiction and now deaths from overdoses is catching up to the number from auto accidents.

Link Between Pills and Heroin

Oxycontin first came on the market in the 1990’s and was extensively marketed as a safe drug for management of pain. The manufacturer would fly physicians to resorts, wine and dine them, and then try to hire them to lecture other doctors on the wonder of their drug. By about 2005, some of the problems with addiction were becoming evident. The government convinced the manufacturer to develop a formulation that would deter abuse by making anti-crush pills, and these came on the market around 2010. It was still a potent drug, but it was not as fun to take and the pills became expensive on the black market. However, the damage had been done and now the main way to treat pain was with opioids, any many people had become addicted to the powerful medication.

A study recently done by the University of Pennsylvania and the Rand Corporation explains why heroin has now become a problem. The development of the new formulation of Oxycontin made this drug more expensive and harder to abuse. Heroin has become cheap, more pure, and once you’re hooked on opioids, it is now easier and less expensive to obtain. So once a person is addicted to pain pills, the cheaper route to get high and prevent drug withdrawal is to use heroin.

Now the latest trick for those with an opioid addiction to get high is to use heroin or oxycodone that is mixed with another synthetic opioid like fentanyl or cor-fentanyl which are a hundred to over a thousand times stronger. These drugs are often been manufactured in China or India, and they can be easily mailed anonymously without much suspicion into the U.S. If mixed wrong, these newer synthetic opioids are often deadly.

Takeaway Points

The message from the opioid crisis is that pain has many ways to be treated, and left unregulated the use of opioids is often more dangerous then helpful. Addiction is a disease; without treatment, some resort to the use of heroin since it is cheap, and many cut that drug with other potent drugs that are deadly.

Stopping the opioid crisis will take time and effort. Treating pain is not just about taking opioids – that has led to the addiction crisis. Money needs to be spent on pain research and the development of better pain management strategies. A third of the population has issues with pain, making it more prevalent than heart disease, cancer and diabetes combined. To solve the problem of pain and drug abuse, a concerted government investment into pain research and better medical management is needed.

Opioid Dependency and Prescription Length

April 10, 2017 / Thomas Cohn, MD

A new study conducted by the University of Arkansas on opioid use has been recently published by the Centers for Disease Control. It is somewhat of a curious study since it was based on record analysis of prescription records for opioids. The results will likely be twisted by the press soon to announce how bad these drugs are and how addictive they can be.

The question the study sought to answer was – “If a patient gets a certain amount of drug prescribed on a first visit, will they still be taking that drug a year later?” The numbers are somewhat surprising, but in reality it does not really say anything about opioids, addiction or pain. All it really says is that for some people there may be limited options to treat pain, and maybe it is very effective for some people.

Continued Opioid Use

The patients studied were all 18 and over, cancer free, studied June 2006 through September 2015 and did not have a history of opioid abuse. Here’s a look at the results:

A person who received 1-day supply of medication had a 6% chance of being on opioids for a year or longer.

With a 5-day supply, they had a 10% chance of being on opioids in a year.

With a 10-day supply the odds go to a 20% that they will be still using opioids in a year.

A 30-day supply had about 30% chance of being on the medications a year later.

So if you start on opioids, and have it for over 10 days, 1 in 5 of those people may still be on those medications. However, it also means that 80 percent will not still be on those drugs.

Interpreting The Results

Several messages can be inferred from this data. First, acute pain should be treated with the least amount of medication for the shortest length of time. If at all possible, avoid the use of opioids for acute pain and find other less addictive and dependency causing medications. Second, many people do not use these medications long-term and can use them responsibly. Lastly, pain is very complex, and since some medications are highly addictive, try to avoid them and use the multiple other ways to treat pain including everything from chiropractors, to physical therapy, to exercise, and to injections.

The study also may be an analysis of the treatments available for severe pain. Some of the most effective treatments sometimes are the least healthy and can cause dependency. Opioids have been around for hundreds of years. Our knowledge of pain is limited, as are the solutions. Since it is such a huge medical problem, we really need to spend more on research and solutions. We know there is an opioid crisis with addiction. We need research solutions and new treatments. Now is the time to spend on research, as it may provide better solutions for more people than some of the recent government spending recommendations.

How Placebo Pills Are Helping Patients With Chronic Pain

October 27, 2016 / Thomas Cohn, MD

New research suggests that knowingly taking placebo pills may help chronic pain sufferers find some pain relief.

Conventional wisdom suggests that the placebo effect should only work if the patient believes they are taking a medication with an active ingredient, but the new study suggests that may not be the case.

“These findings turn our understanding of the placebo effect on its head,” said joint senior author Ted Kaptchuk, director of the Program for Placebo Studies and the Therapeutic Encounter at Beth Israel Deaconess Medical Center and an associate professor of medicine at Harvard Medical School. “This new research demonstrates that the placebo effect is not necessarily elicited by patients’ conscious expectation that they are getting an active medicine, as long thought. Taking a pill in the context of a patient-clinician relationship — even if you know it’s a placebo — is a ritual that changes symptoms and probably activates regions of the brain that modulate symptoms.”

Placebo Study

For the study, researchers recruited 97 individuals with chronic low back pain and split them into two groups. Both groups watched a 15-minute video explaining the placebo effect, then one group continued their normal treatment, while the other group took daily placebo pills that were stored in a container marked “placebo pills” that clearly stated that they had no active ingredient. Both groups continued their specific treatment options for three weeks.

At the end of the three week period, patients in the placebo pill group reported 30 percent reductions in typical and maximum pain, while those in the treatment as usual group experienced 9 and 16 percent reductions respectively. Individuals in the placebo group also reported a 29 percent drop in pain-related disability, while those in the treatment as usual group did not report improvement in that measure.

“Our findings demonstrate the placebo effect can be elicited without deception,” said lead author, Claudia Carvalho, PhD. “Patients were interested in what would happen and enjoyed this novel approach to their pain. They felt empowered.”

However, Dr. Carvalho cautioned that the placebo effect may only provide mild relief for patients with undiagnosed chronic back pain, and that patients with specific conditions like herniated discs or pinched nerves will not experience similar results.

“You’re never going to shrink a tumor or unclog an artery with placebo intervention,” he said. “It’s not a cure-all, but it makes people feel better, for sure. Our lab is saying you can’t throw the placebo into the trash can. It has clinical meaning, it’s statically significant, and it relieves patients. It’s essential to what medicine means.”

Yoga And Acupuncture May Ease Chronic Pain Symptoms

September 6, 2016 / Thomas Cohn, MD

New research published in the journal Mayo Clinic Proceedings suggests that activities like yoga, Tai Chi and other complementary health approaches may help alleviate discomfort associated with some types of chronic pain.

Lead author Richard L. Nahin, Ph.D., of the National Center for Complementary and Integrative Health (NCCIH) at the National Institutes of Health (NIH), suggested that activity options like Tai Chi and yoga may help prevent symptoms from chronic pain, especially when paired with other treatment options like regular exercise, a healthy diet and certain pain medications.

“For many Americans who suffer from chronic pain, medications may not completely relieve pain and can produce unwanted side effects,” said Nahin. “As a result, many people may turn to non-drug approaches to help manage their pain.”

Chronic Pain, Yoga and Tai Chi

For their study, researchers identified 150 randomized, controlled U.S. clinical trials conducted over the past 50 years that examined non-drug approaches to chronic pain. Specifically, the research targeted five common sources of pain, which were:

Chronic back pain
Osteoarthritis
Neck pain
Fibromyalgia
Severe headaches and migraines

The treatment techniques analyzed were considered effective if patients reported that it led to improvements in pain severity and pain-related disability/function. After looking at the data, researchers found that both yoga and acupuncture were safe and effective for chronic back pain, while Tai Chi and acupuncture may be most beneficial for patients with osteoarthritis of the knee. Massage therapy was also somewhat beneficial for patients suffering from neck pain when it was managed with one-hour sessions 2-3 times per week.

“These data can equip providers and patients with the information they need to have informed conversations regarding nondrug approaches for treatment of specific pain conditions,” said David Shurtleff, Ph.D., deputy director of NCCIH. “It’s important that continued research explores how these approaches actually work and whether these findings apply broadly in diverse clinical settings and patient populations.”

At the end of the day, the study paints an interesting picture at some non-drug techniques that can be used in conjunction with other lifestyle interventions to provide relief. Simply getting massages or doing some yoga isn’t going to fully rid you of your pain, but it can play an important role in a total pain management plan. There is no magic pill to cure many of the above conditions, but with a multifaceted approach that involves treatment with a physical medicine pain specialist, relief can be found.

The Link Between Anxiety and Chronic Pain

September 2, 2016 / Thomas Cohn, MD

Researchers say the expression of a single peptide has been linked to both anxiety disorders and chronic pain, suggesting that we may be on the verge of a breakthrough for treating patients with both conditions.

Currently far too many patients are being prescribed a combination of drugs to treat both their anxiety and chronic pain condition, which researchers say can be dangerous. Instead, researchers say the discovery of the expression of pituitary adenylate cyclase activating polypeptide, or PACAP for short, could change the way we simultaneously treat the two conditions.

“Chronic pain and anxiety-related disorders frequently go hand-in-hand,” said Dr. Victor May, a professor of neurological sciences at the University of Vermont and study author.

Chronic Pain and Anxiety Disorders

For the study, researchers used mice to determine where the pathways for stress and pain intercept. By applying what the team called a “PACAP receptor antagonist,” researchers were able to successfully reduce both stress and pain in the rodents.

“By targeting this regulator and pathway, we have opportunities to block both chronic pain and anxiety disorders,” said May, who plans to next develop small molecule compounds that can antagonize PACAP actions. “This would be a completely different approach to using benzodiazepine and opioids — it’s another tool in the arsenal to battle chronic pain and stress-related behavioral disorders.”

The findings are intriguing because the US Food and Drug Administration recently issued a strong warning against mixing opioid painkillers and benzodiazepines, which is a current standard treatment for patients with chronic pain and anxiety. You can read more about the study here.