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.

Why Chronic Pain Patients Feel Targeted By Opioid Crackdowns

March 28, 2017 / Thomas Cohn, MD

As opioid overdoses continue to rise in the US, the government, lawmakers and medical personnel are all trying to figure out the best way to reduce these unnecessary deaths. Obviously restricting access to opioids would reduce the number of people who can get their hands on them, and in turn reduce overdose deaths, but it would also unfairly target people who need the pills. People like those suffering from chronic pain. So it’s understandable to see why when lawmakers propose strict rules for who can access these medications that chronic pain sufferers feel like they are being targeted and singled out.

It’s a tough balance to strike, and unfortunately it seems that as a nation we are more focused on what is easy and cheap instead of what will really address the root problem. Putting a band-aid over a large gash might stop some bleeding, but the wound won’t close correctly without stitches. Simply restricting access opioids and painkillers might stop some abusers from getting the pills, but it won’t solve the whole problem. We need to put some stitches in place.

Solving The Opioid Crisis

We’re not going to sit here and pretend we have all the answers for solving the problem of opioid addiction and overdose, but like we said above, simply restricting access is not going to solve the problem, and many innocent people who rely on those medications may no longer be able to access them. Instead, here are some steps that will help address the root problem.

1. Doctor Education – The vast majority of doctors understand that opioids do not address the root problem, but sometimes they are confused by a diagnosis or have seen other treatments fail and they fall back on them. Other doctors cut corners and prescribe pills freely and dangerously. We need to provide better understanding at the top level of how these drugs should be used, how to spot signs of abuse and how to ensure patients are safely taking their medications so that overdoses don’t occur.

2. Systemic Pressure – This problem will be harder to solve, but in many cases doctors are told to see as many patients as possible. If a doctor is feeling overwhelmed or rushed to see a number of patients, they can sometimes fall back on easy solutions like opioids. Doctors need to take their time with each and every patient and ensure they are giving them the best care possible. It’s possible the best care will involve opioids, but it should also involve therapy, exercise and regular abuse checks.

3. Patient Education – Patients also lack understanding of opioids and their abuse potential. Opioids are not a magic pill that will cure your pain, but they can provide temporary relief so other rehab techniques like exercise, swimming or physical therapy are more bearable. Opioids are a passive treatment, and they need to be paired with an active treatment option for best results. Patients also need to learn the warning signs of abuse for themselves and for loved ones who may have access to their pills.

4. Pill Technology – Medical researchers are looking into new abuse-deterrent opioids. They are creating pills that can’t be crushed or that become gooey if a user tries to extract the solution for injection. Other pills come in an extended release form and can’t be manipulated to give an elevated or intense high. More research into abuse deterrent options could prove useful.

Simply saying we need to restrict access to opioids will not solve the problem, and many chronic pain sufferers will be affected instead of those who are actually abusing the pills. That’s why so many patients feel targeted by these proposals. It won’t be easy to reverse this trend, but if we put in the time and money, it can be done.

Opioid-Related Deaths Increase in Minnesota

January 10, 2017January 25, 2017 / Thomas Cohn, MD

Although we’re still waiting on the numbers from 2016, it’s clear that there is a growing problem with opioid overdoses in Minnesota.

According to new data from the U.S. Centers for Disease Control and Prevention, deaths from opioid overdoses rose in Minnesota in 2015, especially among young adults. The data suggests that 338 people died from opioid overdoses in Minnesota in 2015, up from 319 in 2014. A closer look at the data suggests that the highest number of deaths occurred in individuals in their late 20s and early 30s rather than older individuals for the first time since the 1990s. The problem isn’t contained to the big cities, either.

“It’s hitting rural areas harder than it is cities,” said Rural Aids Action Network program manage Maggie Kazel. “I think that’s a hard concept for a lot of people to grasp because we have a historic setup in our brains of drugs equal big cities. What we see in Duluth is horrible, what they see in Iron Range is pure tragic.

Synthetic Drugs On The Rise

Pain pill abuse has been a problem for a while now, as the number of people killed by opioid overdoses in Minnesota has risen steadily since 1999. The CDC recently awarded Minnesota more than a half million dollars to develop more opioid overdose prevention plans, but it’s not just normal opioids that health officials need to be aware of. According to Dana Farley, the Minnesota Department of Health’s alcohol and drug prevention policy director, synthetic drugs are popping up in Minnesota more frequently. He said synthetic drugs have become more accessible recently, which tend to be more popular in younger crowds. He believes synthetic drugs played a big part in why younger people were dying at such a higher rate in 2015.

Pain Management in Minnesota

We need to develop better opioid management programs here in Minnesota. Doctors and medical professionals can’t keep handing these pills out like candy. Opioids certainly have numerous benefits and they truly help some people, but we need to have better management of how these drugs are administered to ensure they aren’t abused. Too many people are dying, and there’s little sign for optimism based on the trends of the last decade. We need to make preventing opioid abuse a priority in Minnesota.

Pain Care – When Correlation Doesn’t Equal Causation

October 13, 2016 / Thomas Cohn, MD

It seems that there are new articles being published almost every day on the dangers of opioid pain medications. Unfortunately a lot of the studies are not very enlightening. Worse yet, some are just sensational, dumb correlations without causation.

For instance, saying obesity is correlated to eating is a great example of poor research. If you eat, of course could run the risk of being obese, but if you do not eat you could die, so obviously these findings are not very meaningful.

The latest was an article stating that a third of all adults in the United States in the last year received a prescription of opioid medication, and this is larger than the number of people who smoke cigarettes. The reason this is absolutely meaningless is this number has no real meaning. If you add up all the prescriptions for opioids written in one year and divide by the adult population, this is very likely.

Another interpretation would be that 1 in 3 people had a serious medical issue in the last year and were prescribed pain medication. Most people who have been in the hospital or emergency room for a surgery or injury may get a short-term prescription for pain medications. This is one of the very legitimate uses of these drugs, and should not be demonized. Treating acute pain aggressively at the outset has been shown to reduce the incidence of chronic pain problems. Several days of pain medications after a surgery or serious injury is appropriate but it should not be an ongoing use once the acute episode has healed.

Making Bad Connections

A third of the world population also suffers from chronic pain. A small percentage of those people are helped only by opioid medication and use these appropriately to maintain function and ability. There are many who use these medications extremely sparingly and thus continue to be highly productive in society since then they can control their symptoms. These people are dependent on these medications, they are not addicted, and oftentimes other conservative treatments have failed them. If there were better legal treatments available, many of these people would never use opioids.

Taking a prescription pain medication for a legitimate medical problem is not a significant issue or statistic. Smoking cigarettes for most is a daily addiction, affecting 25 percent of adults. It is voluntary, it causes multiple health problems, and has a huge cost to society. Comparing pain medication use to smoking is a useless correlation with no meaning.

The Dangers of Mixing Pain Medication

September 12, 2016 / Thomas Cohn, MD

The 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.