Posts Tagged ‘pain pill addiction’

Am I Addicted to Prescription Pain Pills?

I am a guest blogger on addictionblog.org, and recently had a well-received article published on that site about how to know if you are addicted. I thought I’d repeat a version of that column here.

 There’s so much confusion about the differences between the disease of addiction to opioid pain pills and mere physical dependency on pain pills. Even some doctors don’t understand the differences, regretfully. Any person who regularly takes opioid pain pills for a period of weeks to months, for whatever reason, will develop a physical dependency to these drugs. That’s a biologic event. But addiction is much more than just the physical process. With addiction, there’s also a psychological component. People with addiction think about the drug often, spend time using and recovering from the drug, and continue to use the drug even though bad things happen. In physical dependency alone, this doesn’t happen.

 Here are a few specific questions that I ask patients, that help me decide if they have the disease of addiction:

  • Do I take more medication than prescribed? Do I take early doses, or extra doses?
  • Do I take medication in ways it’s not intended? For example, do I snort it, or chew it for faster onset? Do I inject it?
  • Do I get medication from friends, family, or acquaintances because I run out of my prescription pills early?
  • Do I become intoxicated, or high, from my medication? Without telling my doctor?
  • Do I drink alcohol with medication, even though the pharmacist advised against this?
  • Do I look forward to my next dose of medication?
  • Do I get impaired from my medication, to the point I’m unable to function normally?
  • Do I take pain medication to treat bad moods, anxiety, or to get to sleep?
  • Do I use street drugs like cocaine, marijuana, or others?
  • Have I driven when under the influence of pills, when I know I shouldn’t be driving?
  • Do I get prescriptions from more than one doctor, without telling them about each other?
  • Do I spend a great deal of time worrying about running out of medication?
  • Do I spend a great deal of time thinking about my medication, and how it makes me feel? 

One “yes” answer to any of these questions is worrisome, though not necessarily diagnostic of addiction. I think of addiction as a continuum, and it’s easier to diagnose with multiple “yes” answers. For example, people taking prescriptions may have a few worrisome symptoms, like taking an extra pill occasionally. Perhaps they did this because of a temporary increase in pain. Without any other symptoms, I probably wouldn’t diagnose addiction. At the other end of the spectrum, if a patient is crushing pills to inject or snort, I feel confident making the diagnosis of addiction.

 Sometimes addiction only becomes apparent over time. This is why doctors need to see patients frequently who are prescribed potentially addicting medication, like pain pill, stimulant, and benzodiazepines.

 If you had one or more “yes” answers to the above questions, please see a doctor who knows something about addiction, because untreated addiction usually gets worse. In fact, it can even be fatal.

Which is better, Suboxone or methadone?

 

Patients often ask which medication is better to treat opioid addiction: methadone or Suboxone? My answer is…it depends.

 First of all, the active drug in Suboxone is buprenorphine, and I’ll refer to the drug by its generic name, since a generic has entered the market. We’re no longer just talking about one name brand.

 The principle behind both methadone and buprenorphine is the same: both are long-acting opioids, meaning they can be dosed once per day. At the proper dose, both medications will keep an opioid addict out of withdrawal for 24 hours or more. This means instead of having to find pain pills or heroin to swallow, snort, or shoot three or four times per day, the addict only has to take one dose of medication. Addicts can get back to a normal lifestyle relatively quickly on either of these medications. Both methadone and buprenorphine are approved by the FDA for the treatment of opioid addiction, and are the only opioids approved for this purpose.

Buprenorphine is safer then methadone, since it’s only a partial opioid. A partial opioid attaches to the opioid receptors in the brain, but only partially activates them. In contrast, methadone attaches to opioid receptors and fully stimulates them, making it a stronger opioid. Because buprenorphine is a partial opioid, it has a ceiling on its opioid effects. Once the dose is raised to around 24mg, more of the medication won’t have any additional effect, due to this ceiling. But with methadone, the full opioid, the higher the dose, the more opioid effect.

 Because buprenorphine is a safer medication, the government allows it to be prescribed in doctors’ offices, but only if the doctor has taken a special training course in opioid addiction and how to prescribe buprenorphine, or can demonstrate experience with the drug. This office-based treatment of addiction has a huge advantage over treatment at a traditional methadone clinic. Treatment in a doctor’s office doesn’t have to follow the strict governmental regulations that a methadone clinic must follow. Methadone clinics have federal, state, and even local regulations they must follow, and patients have to come to the clinic every day for dosing, until a period of months, when take home doses can be started for weekends.

 The law allowing buprenorphine to be prescribed for opioid addicts from offices instead of clinics was passed in 2000. It was hoped that relatively stable opioid addicts would get treatment at doctors’ offices, and addicts with higher severity of addiction would still be treated at methadone clinics.

 But it hasn’t worked out quite like that. Because buprenorphine is relatively much more expensive than methadone, addicts with insurance or money go to buprenorphine doctors’ offices, and poor addicts without insurance go to methadone clinics. Rather than form of treatment being decided by severity of disease, it’s decided by economic circumstance. This means that some of the opioid addicts being treated through doctors’ offices really aren’t that stable, and have been selling their medication, making it a desirable black market drug. Most of the addicts buying illicit buprenorphine have been trying to avoid withdrawal or trying the drug before paying the expense of starting it.

 Treating opioid addicts for the last nine years, I’m continually surprised at how people’s physical reactions to replacement medications are dissimilar. Some patients don’t feel well on buprenorphine, but feel normal on methadone. For other patients, it’s just the opposite. For many, either medication works well.

 Addicts (and their doctors) tend to assume that all opioid addicts will be the same in their physical reactions to these replacement medications, but they aren’t. For example, last week I saw a lady who insisted she’s never had physical withdrawal symptoms from methadone. But most patients find methadone withdrawal to be the worst of all opioids.

 And sometimes I have a patient I expect will do very well on buprenorphine, but they don’t. they feel lousy.

 So the answer to question of which medication is best – buprenorphine is safer, and not as strong an opioid, so it’s the preferred medication. It’s also more convenient, but much more expensive at present. But a great deal depends on the patient, and how she reacts to medications.

 Neither medication is meant to be the only treatment for opioid addiction. Best results are seen when these medications are used along with counseling, to help the addict make necessary life changes.

Excerpt from my upcoming book: Pain Pill Addiction: Prescription for Hope

 One doctor makes work for another.  ~English Proverb

 The increase in opioid addiction coincided not only with the movement toward aggressive treatment of chronic pain with opioids, but also with the release of OxyContin by its manufacturer, Purdue Pharma, in 1996. Their other drug for pain, MS Contin, had become well-established in the treatment of severe cancer pain, but this drug was due to come off patent. This meant the other drug companies could then manufacture and sell a generic version of the same drug at a cheaper price. Purdue obviously wanted physicians to switch to their new drug, still under their patent, to maintain their share of this market.

 OxyContin was marketed aggressively to small town family doctors who didn’t have much experience treating chronic pain with powerful opioids, or with identifying and treating pain pill addiction. In rural areas, family doctors had few places they could refer patients who developed problems with their opioid pain medications.  (1)

 The drug company marketed OxyContin as an appropriate treatment for chronic, moderate to severe, non-cancer pain. In the past, such strong opioids were used only for intractable, severe pain. OxyContin was marketed as the pain medicine to “start with and stay with.” OxyContin was even prescribed for such ailments as menstrual cramps, oddly mirroring the misuse of opioids like laudanum and morphine a century earlier.

 Purdue Pharma believed OxyContin was tamper-resistant and less likely to be abused, due to its time release coating. The drug company was still touting this as a selling point in 2001, when addiction medicine doctors all over the country were seeing hundreds of OxyContin addicts. These addicts described how easy it was to moisten the pill, crush it, snort it, inject it, or just file off the coating and chew it.

 Purdue Pharma didn’t do pre-release testing of their new drug, to assess its desirability to addicts seeking to get high. At first, they didn’t have a post-market release system to monitor for signs of abuse and diversion, as other companies have done.  In fact, Purdue Pharma seemed to go out of their way to ignore early warnings and complaints about the drug. Doctors, who tried to warn the drug company about the patients they were seeing who were addicted to OxyContin, were ignored and discounted. (1)

 Purdue Pharma trained its sales representatives to make deceptive statements. Besides telling doctors that the drug was less likely to be abused, the sales representatives also gave false information about the risks of opioid withdrawal after stopping the pill. (2)

 OxyContin became such a commonly known drug to both abusers and the media that the U.S. General Accounting Office (GAO) asked for a report about the promotion of OxyContin by Purdue Pharma, information on factors affecting its abuse and diversion, and recommendations of how to curtail its misuse. This report, released in 2003, stated that by 2001, the sales of OxyContin were over 1 billion dollars per year, making it the most commonly prescribed brand of opioid medication for moderate to severe pain. (2)

 By 2002, prescriptions written for OxyContin for non-cancer pain constituted eighty-five percent of its total sales. The type of non-cancer pain for which it was prescribed included both acute pain, like kidney stones, broken bones, and post-operative pain, and chronic pain like arthritis and fibromyalgia. By 2003, primary care doctors, with little or no experience or training in the treatment of long-term pain, were prescribing about half of all the OxyContin prescriptions written in the country. By 2003, the FDA had cited Purdue Pharma twice, for using misleading information in its promotional advertisements to these doctors. (2)

 The GAO’s report recognized the unique timing of the release of OxyContin. “Fortuitous timing may have contributed to this growth, as the launching of the drug occurred during the national focus on the inadequacy of patient pain treatment and management.” (2, Page 9)

 Purdue Pharma could have re-formulated their pill, to reduce the risk of abuse and addiction. Sterling Drug, manufacturer of the pain medication Talwin, re-formulated their medication, to make it less likely to be abused. The active drug in Talwin is pentazocine, an opioid that had a brief rise in abuse when it was first released in the 1980s. To prevent intravenous injection of their drug, Sterling re-formulated Talwin within a year, adding naloxone, a drug that reverses the effects of opioids. This is the same medication used by doctors to treat opioid overdoses. Naloxone is not absorbed when taken by mouth, because it is inactivated by stomach acid. But when the pentazocine/naloxone pill is ground and injected, it puts addicts into immediate withdrawal, thus making it a much less desirable drug for intravenous addicts. This action by Sterling curtailed the abuse of Talwin/NX, their new product.

 Other manufacturers have taken different precautions, when concerned about the abuse of a prescription drug. For example, the drug Rohypnol, commonly called the date rape drug, is illegal in the U.S., but is legally prescribed in Europe and Latin America. Because they were concerned that the drug was being used illicitly, to facilitate rapes, the manufacturer, Hoffman-LaRoche, re-formulated Rohypnol so that instead of being clear, colorless and tasteless, it becomes milky white when added to any other liquid. This can warn unsuspecting people that something has been added to their drink.

 A Purdue Pharma representative testified before congress in 2002, saying that the company was working on a re-formulation of OxyContin, to make it harder to use intravenously, and that they expected to have the re-formulated pill on the market within a few years. (3)  Eight years later, there still is no such re-formulation of OxyContin. Purdue Pharma said it would take three or four years to reformulate the drug, though Sterling, with Talwin, managed to accomplish this within a year, more than a decade earlier.

 In May of 2007, three officers of Purdue Pharma, a privately held company, pled guilty to misleading the public about the drug’s safety. Their chief executive officer, general counsel, and chief scientific officer pled guilty, as individuals, to misbranding a pharmaceutical. The executives did not serve jail time. Though they plead guilty, they claimed they personally had done nothing wrong, but accepted blame under the premise that an executive is responsible for the acts of the employees working under him. (4) The three executives’ fines totaled 34.5 million dollars, to be paid to Virginia, the state that brought the lawsuit.

 The Purdue Pharma company agreed to pay a fine of $600 million. Though this is one of the largest amounts paid by a drug company for illegal marketing, Purdue made 2.8 billion dollars in sales revenue, from the time of its release in 1996 until 2001 alone.

 To be fair, the drug company and addiction specialists had data that showed the most common opioid to be abused is actually hydrocodone, a short acting opioid, often marketed under the brand names of Vicodin or Lortab. While this is technically correct, the strength of a single hydrocodone pill is usually 5, 7.5, or 10 mg, while OxyContin came in 10, 20, 40, 80, and, for a brief time, 160mg. In addition, hydrocodone is slightly weaker, milligram per milligram, than oxycodone. In other words, the opioid firepower in one OxyContin is much higher than in one hydrocodone, so they are hardly comparable. An addict would need more than eight hydrocodone 5mg pills to equal one OxyContin 40mg.

 This much opioid, packed into one pill, produces a powerful high when it’s released all at once, as it is when the time release coating is removed. Many patients I’ve talked to have said they knew OxyContin would cause problems from the first use. “After that first high, I knew I would keep using. I wanted that feeling,” is an example of a typical quote.

 Since the debacle of OxyContin, Purdue Pharma has donated money towards helping communities treat opioid addicts, and has paid money as ordered by the court. Much of the $600 million award will go to states heavily afflicted by OxyContin addiction. This money will help to establish programs to help prevent and treat opioid addiction.

 OxyContin isn’t a bad or evil drug. It’s just a drug, capable giving great benefit and relief of suffering to those people in serious pain. And it’s also capable of being misused, and can cause great suffering and even death, if not used in the right way.

 1. Barry Meier, Pain Killer: A “Wonder” Drug’s Trail of Addiction and Death (Rodale Books, 2003)

2. General Accounting Office OxyContin Abuse and Diversion report GAO-04-110, 2003.

3. United States Senate. Congressional hearing of the Committee on Health, Education, Labor, and Pensions, on Examining the Effects of the Painkiller OxyContin, 107th Congress, Second Session, February, 2002.

4. Washington Times, “Company Admits Painkiller Deceit,” May 11, 2007, accessed online at http://washingtontimes.com/news/2007/may/10/20070510-103237-4952r/prinnt/ on 12/18/2008.