Opioids for Chronic Pain Management

What are opioids?

Opioids are chemicals – natural or synthetic – that interact with nerve cells to reduce pain. A class of drugs, opioids include:

  • Codeine
  • Fentanyl
  • Heroin
  • Hydrocodone
  • Morphine
  • Oxycodone

Typically prescribed, opioids can become addictive because they not only dull pain, but produce euphoria in the user. Healthcare professionals have modified their prescribing practices to reduce the length and strength of opioids prescribed to patients.

Adults are not the only ones impacted by opioid use disorders. More children are being born with neonatal abstinence syndrome (NAS) because their mothers misused opioids while pregnant. Because injection is a common delivery method for opioid misuse, HIV and Hepatitis C are also on the rise.

What is the opioid epidemic and how did it start?

The opioid epidemic is a nation-wide pattern of prescription opioid misuse. According to the U.S. Department of Health and Human Services, 12.5 million people misused prescription opioids in 2015.

The opioid epidemic started in the 1990s when healthcare professionals began prescribing opioids in larger quantities. In the recent past, it became apparent that there were many negative consequences linked to long-term, high-dose use of opioids. Because of that, prescribing practices have shifted to shorter lengths of prescriptions and smaller doses.

What are the criteria for diagnosing an opioid use disorder?

When an opioid use disorder is being diagnosed, several factors are considered. These factors include:

  • Withdrawal when use of the opioid stops
  • Use of more and more opioids
  • Attempts to cut down or control use are unsuccessful
  • Cravings for an opioid
  • Continued use of an opioid despite personal, social or work problems

What are the side effects of opioid use?

  • Drowsiness
  • Confusion
  • Nausea
  • Constipation
  • Respiratory depression (trouble breathing)
  • Euphoria

What is the difference between acute pain and chronic pain?

Acute pain starts suddenly and is caused by a specific reason. It can stem from a surgery or injury and your body usually heals in a few months. Chronic pain is on-going and the cause of the pain can be less clear or even unknown. This kind of pain comes from a disease, condition, injury or other long-term medical reason. Chronic pain will last for a prolonged period of time.

How is opioid abuse disorder treated?

An opioid abuse disorder can be treated through psychological counseling and medically-assisted therapies. Counseling involves shifting the person’s unhealthy behaviors regarding opioid misuse and changing the way they think about opioid use. Medication assisted treatment compliments counseling. Three medications typically come up when discussing medication assisted treatment. Methadone, buprenorphine/naloxone and naltrexone can be used to help lessen symptoms of withdrawal and cravings.

  • Methadone: This opioid agonist—a drug that fully activates the receptors—works to eliminate symptoms of withdrawal. Methadone reduces cravings by influencing the same opioid receptors in the brain as drugs like heroin, morphine and opioid pain medications. Methadone acts slowly, allowing the patient to feel the effects for a longer stretch of time.
  • Buprenorphine: Buprenorphine is a prescription medication that can be used to treat pain and is sometimes used in a combination product with naloxone as part of a medication assisted treatment program for opioid use disorder. Buprenorphine is an opioid agonist, which has high affinity (a strong bond to the cell) for the opioid receptor, but low intrinsic activity (lower ability to make cellular change). It is associated with less opioid-induced hyperalgesia (higher sensitivity to pain) and less respiratory depression (trouble breathing) than other long-acting opioids. This medication produces some feelings of euphoria, but they tend to plateau (level out) as the dose is increased.
  • Naltrexone: This medication is an opioid antagonist—a drug that stops opioids by attaching to the receptors and preventing activation. Where Methadone and Buprenorphine still allow some levels of euphoria to be felt by the user, naltrexone does not allow any rewarding euphoria. Because this drug does not produce the rewarding euphoria of other opioids, patients do not always stay on it for a long period of time. However, the FDA approved a long-lasting injectable version of the medication (Vivitrol®) that lasts for weeks. This option can help those without easy access to healthcare or those who have trouble regularly taking their medications.

Treatment through medications alone is typically not enough. Behavioral and psychological counseling are usually integrated into the therapy.

How is an opioid abuse disorder treated during pregnancy?

The treatment of an opioid use disorder during pregnancy can be difficult. Just as nutrients taken in by the mother influence the growth of a fetus, drug usage can impact the pregnancy. Neonatal abstinence syndrome (NAS) can happen when a pregnant women is abusing opioids while pregnant. As a result, the baby is born with NAS. Some symptoms of NAS include:

  • Fetal growth restriction
  • Placental abruption
  • Preterm labor
  • Fetal convulsions
  • Fetal death
  • Untreated maternal infections like HIV
  • Malnutrition

Similarly to medication assisted treatment for opioid use disorders listed above, pregnant women can be treated with medications like methadone, buprenorphine and naltrexone to decrease the dependence of the fetus on opioids. Utilizing these medications can lessen the impact of the opioid on the fetus. Buprenorphine in particular can produce lower instances of NAS by 10 percent, according to the National Institute on Drug Abuse. Use of these medications can stabilize opioid levels in the fetus, improve neonatal results, and are linked to higher weight and gestational age.

Despite using these medications for treatment during pregnancy, NAS can still occur. However, the effects may be decreased when treatment is pursued.

How much do these treatments cost?

The cost of treatment can vary depending on the region, type of treatment needed, frequency of treatment and many other factors. The U.S. Department of Defense estimates that treatment by methadone with counseling can cost about $126 per week and $6,552 per year. Treatment utilizing buprenorphine is estimated to cost about $115 per week and $5,980 per year. Treatment with naltrexone is estimated to cost about $1,176 per month and $14,112 per year.

How are overdoses treated?

An overdose occurs when too much of a substance is taken, harming the body. When too many prescription opioids are taken, breathing can slow and stop. Overdoses can be nonfatal or they can result in death. Immediate action is needed to help someone experiencing an overdose. Naloxone (commonly known by the brand name Narcan®) is a drug that treats the overdose immediately. Naloxone can reverse the effects of an opioid overdose if it is given to the person quickly. Medical attention is still needed after Naloxone is administered.

The chance of an overdose increases when opioids are taken in combination with other drugs. Benzodiazepines—sedatives commonly used to treat anxiety or insomnia—act as a depressant to the central nervous system. They greatly increase the risk of overdose death when taken with a prescription opioid.

Does everyone who is prescribed an opioid become addicted?

No, not everyone taking a prescription opioid becomes an addict. When prescription instructions are followed, the chances of becoming addicted are decreased. Opioids are useful for treating acute pain through short-term use. However, when a prescription drug is used outside of the instructions or for chronic pain, the risk of developing an opioid use disorder increases.

What is being done to stop the opioid epidemic?

New rules for prescribing opioid medications were issued by the Ohio State Medical Board in December 2018. These rules detail the importance of prescribing lower dosages for shorter periods of time when an opioid is the appropriate medication. When possible, other medications should be explored. The regulation discusses patient education about the prescribed opioid, the risk of addiction and documentation of those conversations by healthcare providers. In addition, there are requirements for additional review at the level of 50, 80 and 120 MED (morphine equivalent daily dose).

Abuse-deterrent opioids are a form of the drugs with safety measures built-in. These medications are developed to help prevent misuse. Some have very hard exteriors to make crushing them difficult, while others have naltrexone integrated into the capsules so that if it is crushed and taken orally or injected, the additional drug will halt the effects of the opioid. However, even abuse-deterrent medications are not abuse-proof. The determination of a user can overcome these safety measures.

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