The Landscape of Addiction in 2017

addiction opioidsOne of my favorite activities is reading. I read a wide variety of things, some of the most interesting things come from magazines that are not medical. Time magazine regularly has interesting stories of health.  Science, a bi-weekly publication, routinely has articles on a wide range of subjects that challenge the core of what one thought was fact. National Geographic regularly throws in medical stories. A couple years ago they had a great summary on marijuana, and recently now they had a great article on addiction. Medical journals are often a somewhat dry and boring read, but they do allow one to keep up-to-date with current research. Sometimes these other magazines have extremely valuable information as well.

The September 2017 National Geographic lead story is on The Science of Addiction. The problem is more than just opioids, it is a vast variety of problems from smoking to gambling and including all kinds of drugs. Addiction is a very complex process in the brain, and is definitely a disease and not a moral failing. Different types of addictions may affect a variety of brain regions. The processes involve disruptions in pathways responsible for learning, emotion, desire, regulation, and cognition among many neural events. It can change chemical, hormonal, and electrical paths in the brain. Addiction becomes abnormal learning in the brain with the reward being the addictive activity.

Addiction And Our Brains

All addiction has its roots in the primitive regions of the brain. They have to do with our need to survive, and they all involve our senses like sight, smell and taste. Critical in addiction is the neurotransmitter dopamine and that stimulates brain motivation. Those lacking dopamine often are depressed. Further, Parkinson’s disease has a lack of dopamine, and when given to some patients, it causes problems with an addiction like gambling. When something is addictive, it stimulates the dopamine pathways in the brain and is a very positive reward. The dopamine reward is so strong in the brain, people lose the control of impulses and the ability to inhibit behavior even if it is self-destructive.  

Since there are many things that are now considered true addictions, it is likely there are many different strategies to treat them. For drugs, often there are medications that can block the pleasure from the drug and prevent withdrawals. For alcohol, there are drugs that make drinking nauseating. There are also numerous counseling strategies and psychological-type interventions to deal with the behavioral components of addiction. There are also some new novel strategies including electrical and magnetic stimulation of specific areas of the brain to treat addiction.

The problem of drug addiction or any type of addictive behavior is caused by abnormal function and rewards in the brain. Pain and the problems associated with the medications taken can cause addiction, but this isn’t always the case. Taking opioid medications does lead to dependence and tolerance of the drugs that cause them to lose effectiveness. Opioids can also change a person’s sensitivity to pain and make a person perceive pain sensations more intensively. Therefore, in general, opioid medications have many downsides.

Lastly, opioids can be addictive and cause typical addiction issues in pain patients, but it is in only in a small percentage, somewhere between 5-20%. In most chronic pain patients, addiction and problems with opioids are generally not a typical problem. Treatment in pain patients is the same as with any other person who has opioid problems, and is often best handled by a pain care specialist.  If you are a pain patient on opioids, and taking your medication has become the focus of your life, then it is probably time for one to be treated for addiction and be off of these medications.

The Dangers of Mixing Pain Medication

Pill Mixing Minnesota painThe Food and Drug Administration came out with a new warning this week, stating that mixing drugs that are opioids and either benzodiazepines or barbituates (anti-anxiety) can be especially dangerous and may result in coma or death. The recognition of the dangers of mixing these two classes of drugs is becoming increasingly evident. Both types of drugs – opioids and anti-anxiety drugs – have addictive natures. The use of these drugs is additive, and both can suppress the respiratory drive. When used together, one could easily “pass out” and stop breathing.

The FDA is ordering that some 400 products now carry a “black box warning.” This is one of the most severe categories of risk, indicating that these products have serious health risks and are potentially fatal. The products of concern are anxiety medications such as Valium (diazepam), Ativan (lorezepam), Xanax (alprazolam), Klonipin (clonazepam), Restoril (temazepam), Soma (carisoprodol), and phenobarbital. All these drugs make one relax and often fall asleep. Drugs in this class are also used as part of anesthesia to control anxiety during procedures. All these medications can decrease the ability to breathe. However, in a medical setting, they can be reversed with an IV medication flumazenil, but they can not be easily reversed often when taken orally or outside of medical settings. These are the same type of medications that are part of the cocktail used for putting a person to death with drugs for the death penalty.

Why Mixing Medications Is Dangerous

Opioid addiction and abuse has been a major problem, becoming worse over the last ten years. Death rates have skyrocketed and now are about 30,000 people each year in the US, putting it in the same range as the number of people killed in motor vehicle accidents. A person can die just from overdosing on an opioid. The illegal use of narcotics makes death especially easy since the dose of drug is often uncontrolled. Prince died due to such an illegal mixture of oxycodone and fentanyl. The only good thing is that the drug naloxone (Narcan) can reverse most opioids rapidly and prevent death. Examination of those dying from opioid overdoses has found a disturbing trend that many of those people have had both opioids and benzodiazepines in their bodies. Furthermore, just giving naloxone may not rescue an overdose victim.

Patients with chronic pain are often dependent on medications to control symptoms. When pain is not well managed, and there is no successful treatment, many doctors resort to the use of opioid medications. For select patients, these drugs may be very helpful to manage symptoms. With chronic pain, the brain also tends to show changes, and the central receptors for painful sensations become overly active. These regions in the brain are right next to the same regions responsible for depression and anxiety. Patients with chronic pain often develop depression and anxiety, possibly related to the fact that the centers in the brain involved in pain and anxiety are next to each other. Treating chronic pain patients who have anxiety with both opioids and benzodiazepines now has become especially dangerous, and potentially fatal.

The bottom line for chronic pain patients is that if you have pain and anxiety, do not mix opioids and anxiety medications. If as a patient, opioids are felt to be necessary, try to find an alternative treatment. Long-term management with opioids for pain is often unsuccessful, and using other options may be more beneficial. Anxiety is a form of depression. If you also have pain, do not use an anxiety drug. Instead, work with a professional to treat the symptoms and the depression. There are many anti-depressant medications that may help along with working with a psychology management team.

The mixing of medications when one has pain can be highly dangerous. A good pain provider will want to know all the medications a patient is taking such that they can reduce the risks of serious interactions.