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.

Let’s Focus On The Pain Epidemic, Not The Opioid Epidemic

pain opioid epidemicA recent article in the Star-Tribune noted that every three weeks, the death toll from opioid overdoses matches the death toll from the attacks on the World Trade Center on September 11, 2001. Not only is this a concerning number, but trends show that the death toll from opioid overdoses is continuing to skyrocket. The government and even President Trump have stated that the opioid epidemic is a problem that needs to be solved, but are they looking at the problem in the right way?

The opioid crisis is a huge issue, but it’s only a symptom of a larger problem, which is the pain epidemic in America. More people are turning to opioids in the United States because more of them are fighting a losing battle against pain. We need to be finding solutions to the pain problem, because the opioid crisis is a symptom of the problem of pain.

Stopping Pain

Think of it this way. Let’s say you’re in your house and you see smoke. You run to the kitchen and notice a fire behind the stove. You quickly fill up some water from the sink and douse the flames with water, stopping the fire in its tracks. It’s great that you stopped the fire, but you wouldn’t just go back into your living room without investigating what caused the fire to start in the first place. If you don’t fix the faulty wiring that caused the fire, you’re prone to another fire in the future.

In the above instance, throwing water on the fire is like trying to treat the opioid epidemic. It is a problem that needs to be addressed, but unless we also focus on the root problem, which is pain (or faulty wiring in this case), then the problem is only going to continue to be cyclical. Eliminating opioids may reduce the number of overdose deaths, but it will also hurt patients who use them responsibly to manage their pain, and severely cutting back on opioids will do NOTHING to solve the pain problem.

What We Need To Do

Enough about what’s wrong with the current system – here’s a definitive list of what we as a nation need to do in order to fix the opioid crisis and the pain problem in America.

  • We need to educate both patients and doctors about how opioids work in conjunction with a multi-faceted approach to pain management.
  • Opioids can play a role in pain care, but they can’t be the only treatment option. They can help manage pain, but they are not a long term solution to treat pain. Anybody who is only taking pain medications for their condition is at a high risk for dependency and has a low chance of ever recovering from their pain.
  • We need to open up insurance coverage to other non-traditional methods of pain management. Let’s get creative with pain management, because what works for some will not work for others.
  • We have to pound home the message that there is no magic pill for pain, but tangible solutions are within your reach.
  • Doctors need to do a better job of pushing people towards tangible solutions instead of quick fixes. Things like physical therapy, aqua therapy, cognitive behavioral therapy, yoga, etc. over writing a quick prescription.
  • We need to invest research funding into pain treatments, whether it’s medical marijuana or new diagnostic tools, we need to spend money on solving the problem of pain. Invest in pain solutions like we’re investing in treating cancer or diabetes.

If we can check off all the items on this list, I’m confident we can find new ways to treat pain, and in turn combat the opioid crisis in America.

Doctor Killed For Not Prescribing Pain Pills To Patient

pills doctor killedLast week one of my colleagues in the Pain Medicine community was shot and killed for not writing an opioid prescription to a patient. I was sent an email from a manager who came across the information in passing, and I was shocked at the incident.

The worst part of this incident was that the victim and colleague was once a medical student and then a medical resident with me while I was in training. I have not kept in touch with him but he was an excellent doctor and a caring individual. Unfortunately, that did not matter to the person who killed him. The only thing they understood was he did not feel it was indicated to prescribe opioids, which in retrospect was clearly the right choice.

Addictions and Opioid Dependence

Pain management and treating pain has always been more than prescribing medications like opioids. Anyone who has read this blog knows my field is all about how complex treating pain has become. If you as a patient believe that the only thing you can do for your pain is taking opioids, you likely have an issue with addiction that is far beyond just managing pain.

Addiction is a psychological problem and one does irrational things to obtain whatever substance you want for the dopamine support. The things one would do are beyond societal norms and are often illegal. The problem is not only about pain; it is about how to manage the addiction. There are countless ways to manage pain and unfortunately there often is not a cure. Pain management clinics are faced with the problems of opioid use every day and one of the most important jobs we have is to find other options beyond these medications to help patients. There is a shortage of professionals who have the training and ability to work in this challenging area, and it is tragic that someone has lost their life doing the right thing.

Alternatives To Opioids

Having pain is a common occurrence in this world. Worldwide about 30 percent of the population has problems with pain on a regular basis. The use of opioids to solve pain problems has become an American solution. The United States uses 95 percent of the narcotics produced in the world, yet we are only 5 percent of the world’s population. If your doctor is saying no to opioids, there usually is a good reason, and working with a specialist to find a better solution is indicated.  Most people, once they develop significant neck or back issues, will not be pain free, but one needs to make some life changes to control the symptoms. Pain is a tough medical issue and the United States does have an opioid epidemic.  

If it is upsetting that there are not better treatments for pain, become vocal about this problem. Start with your insurance company and with your legislators and make it known you want money to be spent on paying for more treatments for pain. Money is being spent on addiction but one of the more important issues is spending money on treating the pain problem before it becomes an addiction. Pain is a grueling and depressing part of life. There are hundreds of pain professionals trying to make life better for those suffering with pain, please do not let your anger out on them.

Cutting Back On Opioids Could Reduce Pain

opioids cutting backIt may sound counterintuitive, but new research suggests that reducing long-term opioid intake could actually lead to lower pain levels in patients with chronic pain.

More than 10 million Americans are currently prescribed a long-term opioid to deal with a chronic pain condition. The number of people who get these prescriptions continues to grow, and not surprisingly so too do opioid overdose deaths. Used correctly, opioids can work wonders for individuals who have been struggling to find a way to take control of their chronic pain, but far too often they are overprescribed and knowingly or unknowingly abused.

Long-term opioids should only continue to be used if you’re still seeking active treatment options to address the painful condition. Since opioids are a passive treatment option, they are only masking the pain, and they aren’t actively working to correct the problem. They can work wonders when paired with active solutions like physical therapy or exercise because it can lessen pain during these crucial strengthening times, but if you’re not actively working towards a solution, long-term opioids are just dulling the pain while your body begins to crave larger doses of the drug to be effective, which can lead patients down the path of addiction.

Reducing Long-Term Opioid Intake

Researchers conducted a systematic review of 67 published studies in order to determine the effects of discontinuing long-term opioid therapy for patients with chronic pain conditions. Although they admit that the overall quality of evidence was not superb, they found an association between long-term opioid dose reduction and improvements in pain, function and quality of life.

“It’s counterintuitive that pain and well-being could be improved when you decrease pain medication…but patients felt better when dosages were reduced,” said Dr. Erin Krebs, medical director of the Women Veterans Comprehensive Health Center, part of the Minneapolis Veterans Affairs Health Care System, and an author of the study.

However, study authors echoed what we’ve been saying in this blog, that long-term opioid reduction shouldn’t be done by itself. It should be reduced with the oversight of a licensed physician and paired with other multidisciplinary approaches and behavioral interventions to continue actively pursuing pain reduction and function improvement. Hopefully future studies can take a closer look at this idea and provide some clearer solutions with stronger evidence so we can continue doing everything in our power to help patients fight back against their chronic pain conditions.

Overprescribing Opioids Is A Problem In Our Own Backyard

opioid problems mnNew findings published in the Annals of Surgery suggests that clinicians at the Mayo Clinic in Rochester were routinely writing opioid prescriptions for surgical patients that exceeded regulatory guidelines currently being drafted by the state of Minnesota. The findings also uncovered significant differences in opioid prescribing among the Mayo clinics in Rochester, Arizona and Florida, as well as within surgical procedures.

Study senior author Elizabeth Habermann, who also serves as the scientific director of surgical outcomes research at Mayo, said the findings help highlight where improvements can be made.

“In light of the opioid epidemic, physicians across the country know overprescribing is a problem, and they know there is an opportunity to improve,” said senior author Elizabeth Habermann, scientific director of surgical outcomes research at Mayo. “This is the first step in determining what is optimal for certain surgeries and, eventually, the individual patient.”

Opioid Overdoses In America

According to the Centers for Disease Control and Prevention, the number of deaths involving prescription opioid overdoses have nearly quadrupled since 2000. In fact, more than 90 people died each day from either a prescription opioid or heroin overdose in 2015 alone.

Study co-author Dr. Robert Cima said doctors have been so focused on ensuring patients have their pain minimized as much as possible after surgery that they often don’t consider the possible long-term side effects of the prescriptions they’re filling.

“For the last two decades, there had been such a focus at the national level on ensuring patients have no pain,” said Dr. Cima, a colorectal surgeon and chair of surgical quality at Mayo Clinic’s Rochester campus. “That causes overprescribing, and, now, we’re seeing the negative effects of that.”

I have no doubt that the Mayo Clinic will adhere to the new guidelines being drafted at the state level in short order, but this story speaks to the larger issue of just how unregulated opioids are at some of the nation’s best hospitals. And if it’s happening there, you can bet it’s happening to a larger degree at lesser care centers.

However, these findings do cast light on the problem and should help push us towards a solution, but it’s not necessarily going to come from the top down. It needs to start with doctors. We need take time with each patient and push them towards active treatment techniques instead of passive treatments like opioids. Opioids certainly have their role in pain management, but they shouldn’t be over-relied on, as it appears they are.