The pain meds are not working: The slippery slope of physical dependency on prescription opioids
By Harold Clifton Urschel III, M.D., M.M.A.
Chief Medical Strategist, Enterhealth
Q: When do pain medicines become a problem?
Find out here! More on the difference between drug DEPENDENCE and drug ADDICTION and its treatment from thought leader and Enterthealth Chief Medical Strategist, Dr. Urschel. Then, we invite your questions and comments about using opioids safely at the end.
Pain pill statistics in America
The United States uses approximately 80 percent of all opiates prescribed in the world, though we only have about 5 percent of the global population. According to the American Society of Addiction Medicine (ASAM), approximately 1.9 million Americans live with prescription opioid abuse or dependence, of which 17,000 fatally overdose each year. That’s an average of 46 people per day that die from a prescription drug overdose, or about two per hour—and many of these individuals will have developed a problem unwittingly.
Prescribers must understand the risks
We, both prescribers and patients, are fortunate to have effective prescription opiates like hydrocodone and OxyContin, and benzodiazepines like Valium and Xanax available for the treatment of pain and anxiety. However, whereas patients may not understand the risks widely associated with these drugs, prescribers must—given their authoritative role in providing firsthand medical or psychiatric treatment to those at risk for addiction. The burden for stemming the growing opiate epidemic lies heavily on those providers who are currently overprescribing.
Over-prescription often starts somewhere as innocuous as a dentist’s office after a routine procedure. Following oral surgery, the patient is handed a prescription for a bottle of 30 hydrocodone with instructions to take them every four hours as needed for pain. Her pain is gone in two days, but she still has 23 pills left, and so she finishes off the bottle because she sure feels good when she takes them.
When those pills run out in 10 days, not only does she have to face the psychological angst of not having anymore, but in many cases, she also feels physical symptoms from the sudden absence of the medication in her system. This significant “uncomfortable condition” moment, we have found, presents a widespread misunderstanding in terms of how our bodies rebalance under normal circumstances.
Pain medication: When do you become physically dependent?
Physical dependence can occur when you take opiates every day for longer than four weeks. When you then stop taking the medication, you experience physical withdrawal symptoms. This condition is your body, and mainly your brain, working to rebalance itself without the opiate medication.
You can experience physical withdrawal from other non-addictive medications when you stop them abruptly as well. These include antidepressants, blood pressure medicines, or even insulin, because your body gets used to them and has to recalibrate. This recalibration can take from three to seven days for opiates depending on the length and amount of use, and the level of the body’s dependency.
Physical withdrawal DOES NOT indicate addiction
Many people think that because they have physical withdrawal symptoms, they are addicted. Given the stigma and lack of understanding of alcohol and drug addiction as the chronic brain disease it is, this erroneous belief can spark an emotional fear of being addicted that can easily descend into an ongoing prescription opiate problem.
Opiate withdrawal is very uncomfortable, and depends on how long the drug lasts in the body. The shorter the opiate lasts, the quicker the withdrawal, which usually peaks around day three as your body simply readjusts. Despite widespread discussions of the difficulty of opiate withdrawal, it is in fact a very temporary process that can be treated symptomatically, as you would the flu. Symptoms can include:
- Goosebumps and chills
- Runny nose
- Teary eyes
- Agitation and irritability
- Nausea, stomach pain, vomiting, diarrhea
- General muscle aches
Additionally, because you feel like you have a really bad case of the flu, another temporary symptom many report is, “I feel like I’m going to die.”
Day #1 of discomfort can draw people back to pain meds
We know the flu will run its course, just like recovery from physical dependence. However, that patient mistakenly assumes her first day of discomfort means she is addicted, and instead of enduring the difficult 3-4 days in order to get over the short-term hump, seeks aid from more quickly available “relief” in terms of relapsing back to opiates.
This process is where we see escalation of both the dose of opiates and the addictive-type behaviors. It is important to note that the latest scientific research has provided several medical treatments that can make opiate withdrawal more comfortable.
When use goes from normal prescription to drug seeking …
It is illegal to obtain any prescription drugs except by way of a prescription written for you from your doctor, which means first, escalation is reckless. Some patients will start buying these drugs off the Internet, which is also expensive. Others will steal them from the medicine cabinets of friends, family, even strangers, which is both immoral and illegal. So where the patient may have had a couple of days of a temporary sickness, their desire for more opiates has immediately presented them with three more risks:
The short jump from pain pills to heroin
The patient that may not have been initially addicted will likely become addicted through escalation of the dose, as the body adjusts to higher levels of opioids, meaning larger doses are needed and greater risk incurred. Given the government restrictions on these prescription drugs as controlled substances, many who are addicted to prescription opiates will start buying heroin because it is cheap and it is available.
The addictive properties of opiates, combined with the high cost of maintaining a prescription drug habit, lead a large number of those who become addicted to prescription opioids to switch to heroin as a cheaper opioid source. In fact, another recent study found that among self-reported heroin users, 75 percent started down the path of addiction by abusing prescription opioids.
Heroin is a street drug, uncontrolled by FDA regulations, which means users do not know the potency of the opioids it contains, or what other substances are included in its composition. There is a semblance of control when you can regulate milligrams in pill form, unlike heroin which can be so potent that accidental fatal overdose is common. Additionally, very few people will stop at using just opiates once they are abusing a street drug like heroin, so the addictive behavior becomes more expensive and dangerous on many levels.
259 million prescriptions written in 2012
The ASAM reports that in 2012, American doctors wrote 259 million prescriptions for opioid pain medications, essentially one bottle of pills for every adult in the country. Most prescriptions come from a small number of prescribers, who are most likely to be:
- General practitioners
- Family medicine MDs
- Internal medicine MDs
- Mid-level practitioners
Adding to that fact, certain patients obtain drugs for nonmedical use or resale by obtaining overlapping prescriptions from multiple prescribers, a behavior for which the patient can be arrested.
Recent studies have found that adults age 50-69 with health insurance are the fastest-growing segment of opioid addicts, and the rates of addiction for women have doubled in the period from 2002-2013. The higher prescribing rates for women and all adults age 50-69 years old can be explained by the prevalence of certain common types of pain for these demographics, such as recovery from childbirth or lower back pain for women, and chronic age-related pain in the older population.
We need to prevent dependence AND treat addiction
Currently, the government and medical societies are working to better educate physicians to change their prescribing habits, which will hopefully stem the tide of new prescription opiate abuse cases. But for those already experiencing physical dependence, it’s important to not see a hopeless fight against an inevitable addiction, but rather an illness that can be treated effectively and immediately with medication.
As I mentioned, there are anti-addiction medications such as Suboxone and Naltrexone to treat opiate addiction and withdrawal that will help the brain recover from the intense opioid cravings and discomfort associated with withdrawal. With my oversight, this approach, which is gaining broader appeal nationally, is the method used at the Enterhealth Ranch, an exclusive treatment facility just 30 minutes north of Dallas/Fort Worth, and the Enterhealth Outpatient Center of Excellence located in the Park Cities, just north of downtown Dallas.
In addition, I expand on how they chemically work with the brain’s receptors in terms of addiction in my book Healing the Addicted Brain. But, to know that there is something to help you feel normal and diminish cravings on the physical front, while you can battle recovery on the psychological front, may help more choose the successful road to recovery.
Be honest about the signs of opiate abuse
But before we or our loved ones have to start that road to recovery, let’s first recognize and stop abuse where we can. Get rid of unused pills once you don’t need them, removing temptation for you or others that might have access, like your children or their friends. And, be honest with yourself about the signs that you are abusing opiates, such as:
- You’re taking more than a doctor prescribes when your pain does not demand it;
- You’re going to multiple physicians because you’re running out early and want more, and not telling anyone; or
- You’re accepting opiates from somebody else, buying, gifting or getting them online.
Being vigilant about what many perceive as an innocuous short-term abuse will help others avoid the slippery slope of America’s current prescription opioid epidemic.