Archive for the ‘Pain Pill Addiction’ Category

The Genetics of Opioid Addiction

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The American Society of Addiction Medicine defines addiction like this: “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.” [1]

Like other chronic disorders, risks for developing the disease of addiction are complex, and include genetic and environmental factors.

Opioid addiction is highly heritable, which means the genes we inherit play a strong role in determining who develops this disease. Experts estimate opioid addiction heritability at about 70%, meaning more than half the risk of getting this disease is genetic.

Now let’s talk specifics.

We all have genes that code for the structure and function of the mu opioid receptor. This receptor, when acted upon by an opioid medication, activates cellular events that create pain relief and euphoria. One gene for the opioid receptor is called OPRM1. This gene varies a little bit between people, and the varieties are called polymorphisms, from the Greek for “many forms.” In other words, my gene for the opioid receptor may be different from another person’s gene for this same receptor. Plus, each person has two copies of each gene, so I inherited one polymorphism from my dad and one from my mom, and they could be the same form of the gene or slightly different forms of this same gene. These two forms of the same gene are called “alleles.””

We know that one polymorphism of the OPRM1 gene, called 118A>G, found in around 15% of whites, causes a three-fold increase in binding of endorphins, our bodies’ natural opioids. This gene is associated with an increased risk of addiction to opioids, and variations of responses to opioids.

This means that someone with the AG variety of the OPRM1 gene is more likely to become addicted to opioids, and the sensation that person gets when taking opioids is different from people with other forms of this gene.

Still, association doesn’t necessarily mean causation. We still don’t have enough evidence to say this gene causes opioid addiction, though the gene’s presence is at least associated with opioid addiction.

Let’s turn now to the COMT gene. This gene codes for catechol-o-methyltransferase, which is an enzyme which metabolizes catecholamines in the nervous system.

Catecholamines are the chemicals in the body that are all made from the amino acid tyrosine, and the most common are epinephrine, norepinephrine, and …our old friend dopamine, the pleasure chemical.

Epi- and norepinephrine are the fight or flight chemicals released when we are stressed. Dopamine is the chemical released in the pleasure centers of the brain when we do pleasurable things like eat or have sex. Or use addicting drugs like opioids, nicotine, alcohol, benzodiazepines, cocaine, methamphetamine, or marijuana.

This COMT enzyme inactivates catecholamines including dopamine. Just like the gene coding for the opioid receptor, this gene has different varieties, or polymorphisms. At least one polymorphism is associated with upregulation of mu opioid receptors. Past studies have shown people with this polymorphism need more morphine to treat pain than people without this polymorphism. This difference may also influence the risk of opioid addiction.

Our genetics are not our destiny, however. Certain genes make addiction more likely, but there are others factors that influence risk.

For example, let’s say Jane Doe inherited all of the genes that are associated with increased risk for opioid addiction. Let’s say she got a genetic double whammy, and inherited risky genes from both sides of the family. But Jane grew up in an area where illicit opioids can’t be found. Jane remained healthy, and never had to take opioids in her whole life. Now at age 80, she’s never developed opioid addiction, even though she’s always been at much increased risk than the average person.

Let’s say Jane has a friend named Mary, who inherited all the genes that put her at low risk for addiction. But she was plagued with painful medical problems that required prescription opioids for a few years as a teenager. She also grew up in an area where adolescents had access to a wide variety of drugs including opioids. Because she missed high school often due to her medical condition, she made low grades in school. As a result, she became discouraged with school and started hanging out with drug -using peers. Eventually, Jane started misusing opioids and eventually she developed opioid addiction.

This example illustrates how environmental factors interact with genetic factors to influence risk of addiction, as ASAM pointed out in their definition of addiction.

Let’s remember people face all kinds of environmental and genetic challenges. Stress and negative life experiences increase the risk of addiction. Before we judge someone for having an addiction, let’s remember we don’t know what genetics that person has, or what challenges they’ve faced.

Anyone can become addicted to opioids, given the right circumstances.

1. http://www.asam.org/advocacy/find-a-policy-statement/view-policy-statement/public-policy-statements/2011/12/15/the-definition-of-addiction
2. http://www.ncbi.nlm.nih.gov/gene/4988

New Health Care Laws: How Will They Affect Office-based Treatment with Suboxone?

Last week, one of my office-based buprenorphine patients asked me how I thought the new healthcare laws would affect my business. I’ve considered this question with a mix of anxiety and hope. Until we have more details, I’m not certain I’ll like the new changes. And of course since I’m a healthcare provider, I’ll look at changes differently than if I were an insurance executive.

I told my patient that it will be excellent for my patients in buprenorphine (Suboxone, Subutex) treatment who don’t have insurance now, and are paying out of pocket. My patient then remarked that I’ll be much busier, because more pain pill addicts will be able to afford treatment.

“No,” I said, “I can still only have one hundred Suboxone patients at any one time, so I can’t add any new patients.”

My patient was quiet for a moment and said, “So if an addict calls you because he just got insurance to pay for his treatment, you couldn’t see him anyway?”

“That’s right, unless I lost a patient for some reason, and had an open spot for him.”

“So even if addicts get insurance, they can’t use it? That’s crazy. Why does the government have that law?”

I explained to him about the newness of the DATA 2000 Act, and that some lawmakers were skittish about this program from the beginning. They were worried Suboxone “mills” would open, where hundreds of addicts were treated with little physician oversight or precautions.

Lifting that limit would be the easiest way to get more opioid addicts into treatment.

My private practice, where I treat opioid addicts with buprenorphine (Suboxone, Subutex), is a bare bones operation. Because of the one hundred patient limit, I have enough patients to keep me busy for one day per week. On the other days, I work at opioid treatment programs. I enjoy my own office practice because of the autonomy, and because I have some great patients that I’ve known for years. But at my own office, I make far less than half what I make at the opioid treatment programs.

I have the usual fixed overhead of rent, utilities, answering service, internet, etc., and most of the money I take in goes towards that. I have a part-time health care coordinator, who makes appointments for patients, calls them to remind them of appointments, does most of my office drug screens, screens my after-hours calls, handles the filing, copying and other record-keeping tasks, and deals with those pesky pre-authorization requests that insurance companies make. (She and the counselor have decided I ought not to be allowed to talk with the insurance companies, since I often erupt into profanity).Then I have the best LCAS (Licensed Clinical Addiction Specialist) counselor in the world who works with me on Fridays, doing individual counseling (he’s my fiancé). Since I don’t file insurance, but rather give the patient a receipt so they can file it themselves, I avoid that personnel expense.

And I don’t accept Medicaid or Medicare as payment for treatment. I feel guilty for admitting that, but I don’t think I could stay in practice if I accepted what these government programs pay for treatment. When I first opened my own office in 2010, I saw a handful of these patients for free, since trying to file and going through the necessary red tape isn’t worth the pittance these programs pay for an office visit.

So if my uninsured patients get Medicaid, I’ll have to decide how to deal with that problem.

It’s not legal for me to ask patients with Medicaid and/or Medicare to pay for treatment out of their pocket unless I opt out of those programs completely for a period of years. I can’t do that because some of the other treatment facilities that I work for do bill Medicaid.

So do I start taking Medicaid, with all its headaches, red tape and low re-imbursement? I don’t know. I don’t like the thought of it, but it will perhaps become a necessity. It will depend on reimbursement rates. Plus, I’ll be paid even less since I don’t have electronic medical records. Government programs have decreed that doctors without meaningful use electronic medical records will receive less money for Medicaid/Medicare patients than doctors with these programs.

I’m not against electronic medical records. I use them effectively at both of the opioid treatment programs. One program is completely paperless, and I like that much more than I ever thought. But in my small, one hundred patient office, I can’t afford any software for medical records. It’s not practical or feasible

Since I was trained and still am board-certified as an Internal Medicine doctor, I could fill my other days with primary care patients. I was talking to another doctor who was starting her own Suboxone practice, and she was wondering how to get by financially, only practicing Addiction Medicine. She too is a former Internal Medicine doctor. I suggested she could always do some primary care.

“Just shoot me in the head,” she said, summarizing my feeling exactly. I’ve never liked primary care as much as addiction medicine, to put it mildly.

Addicts are easier to deal with, and are often nicer people than the average soccer mom, demanding an antibiotic to treat her viral upper respiratory infection. But my biggest reason for preferring addiction medicine is that addicts get better. I never saw the big changes in health when I worked in primary care, like I do in people treated for addiction. Primary care feels like a step backwards. I don’t want to go back to treating non-compliant diabetics, and overweight people who won’t exercise. I’d prefer to keep my present patients, in whom I see an intense desire to get well.

I’m addicted to seeing the big changes that I see when I work in addiction medicine. I hope the new changes in healthcare will allow me to stay in the business of helping people change. Like the rest of the U.S., I’ll have to wait and see.

Officially an Epidemic

 

It’s official. Prescription drug abuse in the U.S. is now called an epidemic by the Centers for Disease Control and Prevention. In November, CDC officials released a new report of prescription drug addiction. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm?s_cid=mm6043a4_w

It’s really interesting reading.

The CDC points out that prescription opioid overdose deaths now outnumber heroin and cocaine overdose deaths combined and prescription opioids were involved in 74% of all prescription drug overdose deaths.

The breakdown of their data by state is particularly interesting. The states with the highest rates of opioid overdose deaths are, in descending order: New Mexico, with a rate of 27 deaths per 100,000 people, then West Virginia, Nevada, Utah, Alaska, Kentucky, Rhode Island, Florida, Oklahoma, and Ohio. Tennessee missed the top ten, but was still 13th highest in overdose deaths, with a rate of 14.8. North Carolina’s rate was 12.9 per 100,000 people, which put North Carolina 24th out of 50 for prescription overdose deaths. That’s too high, but much improved since 2005, when North Carolina was in the top five states for prescription opioid overdose deaths. The lowest opioid overdose death rate was seen in Nebraska, with 5.5 deaths per 100,000 people.

The CDC also analyzed information about the amount of opioids prescribed in each state. They measured kilograms of opioid pain relievers prescribed per 10,000 people in each state. The state with the highest rate had over three times the rate of the state with the lowest rate. It’s no surprise that Florida had the highest amount, at 12.6 kilograms per every 10,000. Illinois had the lowest amount, at 3.7 kilograms per 10,000 people.

The big surprise: Tennessee has the second highest amount of opioids prescribed, adjusted by population. (OK, they tied for second place with Oregon). Yep. Tennessee, the state that refuses to allow more opioid treatment centers to be built within its borders, has 11.8 kilograms of opioids prescribed per every 10,000 people.  But since I want to devote an entire blog entry to Tennessee’s backward outlook on addiction and its treatment, I’ll defer further comments about that state.

Sales of prescription opioid quadrupled from 1999 to 2010. According to the CDC, enough opioids were sold last year to provide a month of hydrocodone, dosed 5mg every four hours, for each adult in the U.S.

The CDC estimates that for every prescription overdose death, there are at least 130 more people who are addicted or abuse these medications, and 825 who are “nonmedical users” of opioids. (I’m still not sure how nonmedical users differ from abusers. To me, if it’s nonmedical, that’s abuse.) Not all of the 825 are addicted or will become addicted – but they are certainly at risk.

Just like what was found in other studies, people who abuse opioids are most likely to get them for free from a friend or relative. So if you are giving pain pills to your friends or family members, you are part of this large problem.

In 2008, 36,450 people died from prescription overdose deaths. That was nearly equal to the number of people who died in auto accidents, at 39,973. In fact, in seventeen states, the number of overdose deaths did exceed auto accident deaths.

The CDC authors conclude that the prescription opioid addiction isn’t getting any better, and in measurable ways, it’s worsened, with some states worse than others. The worst areas, not surprisingly, have higher rates of opioid prescribing that can’t be explained by differences in the population. To me, this means doctors in some states are overprescribing, or at least aren’t taking proper precautions when they do prescribe opioids.

In my next blog entry, I’ll explain how people and organizations in North Carolina have been working hard to deal with the prescription pain pill addiction problem. Based on information from the CDC, it appears my state has made some major progress, at least compared to one of our neighboring states.

Tapering off Methadone or Buprenorphine (Suboxone): Pain and Relapse

Physical pain is a relapse trigger for recovering opioid addicts, especially after they’ve tapered off maintenance medications. While on maintenance medications, most patients can no longer get high from opioids, and so are less likely to take prescribed opioid medication in destructive ways. Once off maintenance medications, patients can again feel euphoria from opioids, even when taking opioid medications as prescribed. This can lead to medication misuse and eventual relapse back into active addiction.

Pain can be acute (think broken bones or a kidney stone), or more chronic and persistent, as in chronic back pain. Acute pain by definition resolves within a short time, and there are ways to reduce the risk of relapse for the relatively short time opioids are necessary. Before a patient on maintenance medications (methadone or Suboxone) even begins a taper, he should have a clear plan for handling an acutely painful event.

Here are some ideas:

  • Tell the prescribing physician that you’ve had problems with addiction to opioids in the past. Try to use a non-opioid pain medication if possible
  • If you have to take opioids, ask the doctor to prescribe fewer pills at a time, and have more frequent follow up visits, for more accountability
  • Have a dependable non-addict hold your pill bottle and dispense to you as prescribed.
  • Tell your circle of supporters, whether that’s friends, family, and/or your 12-step group members that you need to take pain pills, and could use extra support and accountability.
  • Read the booklet published by Narcotics Anonymous, “In Times of Illness”
  • Ask a dependable friend or family member to do daily pill counts for more accountability, if you don’t have someone that can hold your pill bottle

A patient with chronic pain obviously has a more complicated situation. Preferably, the recovering opioid addict can find some way to manage the chronic pain without opioids. If that’s possible, then the patient can slowly bring down their dose of methadone or buprenorphine, knowing that if pain returns, there’s a non-opioid way to managing it.

For a patient who can’t find an adequate non-opioid way to relieve chronic pain, staying on maintenance medications may be the best option. Methadone and buprenorphine (Suboxone) prevent opioid withdrawal symptoms for longer than 24 hours in most patients, which is why we use them to treat addiction. But the anti-pain effect wears off at about six hours after dosing. Therefore, methadone and buprenorphine may not be ideal for pain management, but may be enough to bring the patient’s pain to manageable levels. For this reason, a patient with both pain and addiction may reasonably decide to stay on maintenance medications. If such a patient does taper off maintenance medications, every flare of pain is a potential relapse trigger.

For more on management of pain on maintenance medications like Suboxone and methadone, please see my blog entry of 10/16/11.

Great Book About Opioid Addiction!!!

I orginally started this blog to promote the book I wrote about pain pill addiction. As it’s turned out, the blog has been much more popular than the book (it isn’t exactly flying off the shelves), so I’d like to remind blog readers – again – that if you like the blog, you’ll love my book.

You can order it from Barnes & Noble, or Amazon. But I’m selling it for a much-discounted rate of $13.95 on EBay. That’s with shipping included.

http://shop.ebay.com/i.html_from=R40&_trksid=p5197.m570.l1313&_nkw=pain+pill+addiction&_sacat=See-All-Categories

National Prescription Drug Action Plan

Yesterday, government officials proclaimed the formation of collaborative plan to address this nation’s problem with prescription opioid abuse and addiction. Speakers included Mr. Gil Kerlikowske, the director of the ONDCP (Office of National Drug Control Policy), Dr. Howard Koh, from the department of Health and Human Services (DHHS), Dr. Margaret Hamburg from the Food and Drug Administration ( FDA), and Ms. Michele Leonhart, administrator of the Drug Enforcement Administration (DEA).

 Speakers recited pertinent statistics regarding the state of opioid addiction and abuse in the U.S.  It’s now the faster growing public health problem in our country. Around 28,000 citizens died from unintentional drug overdose in 2007, the latest year for which data is available.  More people in the U.S. now die of unintentional drug overdose than gunshot wounds. In seventeen states and Washington D.C., unintentional overdose deaths outnumber deaths from motor vehicle accidents.

 The plan has four main points. First, both patients and prescribers of controlled substances will be provided with better education about these potentially dangerous medications. The drug manufacturers will be asked to develop educational products for both patients and providers for education, which will be reviewed by the FDA before approved for release. The medications included will likely include sustained-release oxycodone, oxymorphone, hydromorphone, and methadone. Fentanyl patches will also be included. The ONDCP is seeking to introduce legislation that will change the Controlled Substances Act in order to make training mandatory for doctors who prescribe long-acting opioids.

 Second, the national government will push the few remaining states that don’t have function prescription monitoring programs to put them in place, and to be able to share data with adjacent states.

 Third, the government will support more medication “take back” days in communities across the U.S. Citizens will be encouraged to bring old medication to community sites in order for proper disposal. Previous take back days have been very successful, with tons of pills collected and disposed. This will reduce the number of prescription opioid pills available for diversion. Surveys reveal that round 70% of the pills obtained by people misusing prescription medication for the first time are obtained from friends and family members, often without permission, from old prescription bottles.

 Fourth, state and federal agencies plan to crack down further on rogue doctors and clinics that are “pill mills.” This will require participation from state medical boards, law enforcement, and the DEA.

 At the end of this presentation, Karen Perry, founder of NOPE, told the story of her son, a bright young college student who died of an unintentional drug overdose. She described how his death affected her and his siblings. Her face was etched with the grief that can only come from such a profound loss

 The goal of this plan is to achieve a 15% reduction in prescription opioid misuse in this country by at within the next five years.

 I’m so pleased to see this announcement. Back in 2001, when I first started treating prescription opioid addiction, I was amazed at the numbers of people seeking treatment for this disorder. Studies since then have shown the situation has gotten much worse.

 There will be problems with this plan. Many doctors will not be happy they must have mandatory training in order to be able to prescribe some controlled substances (probably schedule II). Some will stand up on their hind legs and protest this new regulation, if it is passed by congress. But after seeing the prescribing habits of some of my brethren and sistren, it’s obvious we need this. We don’t get much education about appropriate prescribing of opioids, recognizing addiction, and referral for treatment. I’ve blogged before about this (see February 10th’s entry)

 I’ve been blathering on to anyone who will listen about the need for prescription monitoring plans (see prior blog entries for March 6, 8, and 31), so I’m delighted more attention is being paid to this. But I still worry about how states will communicate with each other. For example, my practice is close to South Carolina, yet that state has denied me access to their database. The only allow access to doctors licensed in South Carolina. I use the prescription monitoring program in my state both at the two Opioid Treatment Programs where I work and in my own office, where I see Suboxone patients. I’ve been using it since 2007.

I support the pill “take back” programs. While such events probably won’t do much for those with established addiction, they can help reduce the number of new users and experimental users. Remember, opioid overdose deaths don’t just happen to addicts. Youngsters experimenting with opioids can die from overdoses. In fact, new users dabbling with these pills, because they think they’re safer than “street” drugs, may be more likely to die because they don’t have any tolerance to opioids.

 We need good judgment and balance when shutting down pill mills. How can the DEA tell a pill mill from a legitimate pain treatment practice? I believe this is best done by other doctors. In this state, the medical board does investigations, which I feel is more appropriate than having investigations done by law enforcement. Law enforcement personnel just don’t have the training to tell the difference between appropriate care and careless prescribing with disregard for patients. Let other doctors do that. Granted, a few places will be so obvious that little investigation is needed.

 We don’t want the opioid pendulum to swing to the opposite side again, and become completely opioiphobic. These pain medications are addictive, but are also godsends in the right setting and used in the right way. Let’s take care not to throw out the good with the bad. The best people to set policy in this area are well-trained doctors who approach this issue with common sense and balance.

 Coming as late as it does in this epidemic, I could be negative and say the government has had an epiphany of the obvious. But I do know it takes time for all of these agencies to come together in a cooperative manner and form a plan of action. I’m just thankful that action is finally being taken.

Tramadol, AKA Ultram, Ultracet

I just returned from the American Society of Addiction Medicine’s spring conference, held in Washington, D.C. I go to at least one of their meetings every year, to stay current with the latest research and developments in Addiction Medicine. It was impossible to attend all of the sessions, since four or five meetings are often conducted at the same time. This makes it the intellectual equivalent of a three ring circus. I think I learned some new stuff, and will share some of this in my blog over the coming weeks.

The first day, I went to a day-long course called “Pain and Addiction: Common Threads.” I think this is the fourth time I’ve attended that particular seminar over the last eight years. I hear something new every year.

 It’s striking how much this meeting has changed. The first year I went was 2005. At that time, pain medicine specialists still debated with the addiction medicine specialists about the risk of addiction in patients who were prescribed opioids long-term for chronic non-cancer pain. By 2010, I didn’t hear any debates about the risk of addiction. I heard lectures about how to manage chronic pain without opioids, and about the risk of hyperalgesia in patients on long-term opioids. Hyperalgesia is an increased sensitivity to pain, sometimes seen in patients prescribed opioids for months or years. The human body accommodates to the presence of these prescribed opioids, which adjusts the pain threshold, making a patient on opioids paradoxically more sensitive to pain.

This year, the Pain and Addiction conference had lectures on several interesting topics, but one that captured my interest was about the not-so-safe “safe” medications. Included were carisoprodol (Soma), zolpidem (Ambien), butalbital (found in Fioricet and Fiorinal), and tramadol (Ultram). These are all medications that many doctors think are safe for addicts, but really aren’t all that safe.

I’ve seen many patients develop problems with tramadol, so the rest of this blog is about this medication.

Tramadol is a messy drug. It’s a pain reliever that has actions on several types of brain receptors: the mu opioid, serotonin, norepinephrine, NMDA, and other receptors. Because it stimulates the mu opioid receptors, it can cause feelings of pleasure as well as pain relief. Tramadol is far less active at the mu opioid receptors than its metabolite, and it takes time for the tramadol to be metabolized in the liver to its first metabolite. Because of this delay, some experts thought it wouldn’t appeal to addicts, who prefer an immediate high. Overall this is probably true, and tramadol has a much lower rate of addiction than other opioids, but it still causes addiction in some patients.

Some of tramadol’s pain relieving properties may also be produced by its actions on serotonin and norepinephrine receptors, since tramadol’s pain relieving capability is only partially reversed by a pure opioid antagonist like naloxone.

When this medication was first released, it wasn’t a controlled substance. That is, the DEA didn’t control it strictly like medications that can cause addiction. Now, it’s a Schedule IV drug, thought to have benefit but also some risk of addiction, though lower than that of hydrocodone, for example.

Tramadol is usually dosed in 50mg pills, one or two every six hours, giving the maximum dose of 400mg per day. Recreational use of this medication (to get high) is dangerous, since it causes seizures at doses higher than 400mg. In susceptible patients, it can even cause seizures at lower prescribed doses.

I’ve seen patients in tramadol withdrawal who were so sick it frightened me. This drug can produce a severe withdrawal. When it’s stopped suddenly, patients have opioid withdrawal symptoms like sweating, nausea, diarrhea, high blood pressure and heart rate, and severe muscle and joint pains. The sickest patient I’ve ever seen in opioid withdrawal had been using only tramadol, in doses of around 600mg per day. She had fever to 103 degrees, and dehydration from the diarrhea and vomiting. That patient needed hospitalization.

Besides the opioid-withdrawal symptoms, some of these patients also have withdrawal symptoms similar to those seen when certain serotonin-affecting antidepressants, like Paxil and Celexa, are stopped suddenly. They can have fairly severe anxiety, depression, mood swings, and restlessness. Many times they have weird sensory experiences, often called “brain zaps,” or the sensation of electric shocks throughout the body. They can have seizures during this withdrawal.

If the patient had only physical dependency and no addiction, the dose of tramadol can usually be tapered slowly over a few weeks to months, as an outpatient. But if the patient has not only physical dependency but also the disease of addiction, the obsession and craving for the medication will usually prevent a successful outpatient taper, unless a dependable non-addict holds the pill bottle, and dispenses it as prescribed.

Traditional treatment for tramadol addiction starts with detoxification. As above, that can rarely be done as an outpatient, so medical inpatient detoxification admissions for five to seven days can be helpful. However, since tramadol acts so much like an opioid, patients ready to leave detox probably need to go on to an inpatient residential treatment center for at least thirty days.  Intensive outpatient treatment probably isn’t enough support for these addicts. But that’s only my opinion, since I haven’t found any studies describing success rates with tramadol addicts.

Opioid maintenance medications like methadone and buprenorphine do stop the opioid-type withdrawal symptoms from tramadol, and patients probably benefit from medication-assisted therapy just like any other opioid addicts. Using these medications, they can be successfully treated as outpatients. However, as above, I can’t find any long-term studies of tramadol addicts on replacement medications. One of the addictionologists with whom I work doesn’t think it’s wise to put an addict who is addicted only to tramadol on methadone, given the lack of data. However, usually these addicts are using other opioids too, and physically addicted to them as well as tramadol.

Often, methadone patients at the opioid treatment centers where I work are given tramadol by their primary care doctors who think it’s a low risk medication for opioid addicts. It probably is lower in its risk for abuse, but it can cause withdrawal in patients on stable, blocking doses of methadone. (1)

Tramadol is a synthetic, pared-down version of codeine. Interestingly, a structurally similar medication, tapentadol, has just been released, and is now being sold under the brand name Nucynta. That medication is a schedule II drug, presumably because of a higher abuse potential than we’ve seen with tramadol. Tapentadol stimulates opioid mu receptors, and also acts as a norepinephrine re-uptake inhibitor, like some antidepressants. It will be interesting to follow abuse and addiction patterns with this medication.

The bottom line is this: if you are in recovery from addiction (alcohol or drugs) this medication should be used with caution. Let your doctor know that you’re in recovery from addiction. If you must take a potentially addicting medication, talk to your sponsor and your support network. Go to extra meetings. Let a dependable non-addict hold the pill bottle and dispense as prescribed. If you have to take the medication for more than a few weeks, have your doctor taper your dose instead of stopping suddenly.

I’ll have upcoming blog entries concerning Soma, Ambien, and Fioricet.

  1. Leavitt, MA, PhD, “Methadone-Drug Interactions,” Pain Treatment Topics, Addiction Treatment Forum, January 2006
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