There is a new awareness of the need to modify the treatment of pain with opioids or narcotics. For years, it was felt by many that opioids were safe, that people would use them only for pain relief, and that most people would not get addicted. We now know that opioids are not magic, and a major problem is that the manufacturers deceived the medical community and the FDA. In addition many pain clinics sprouted up that were basically “pill mills."
Opioids, while important, can be dangerous for several reasons. First, everyone who takes opioids over time gets a dependency (this does not mean someone who is dependent is bad or doing anything wrong; millions are “dependent” on insulin to manage diabetes or blood pressure pills to manage hypertension and this does not make them “addicts”). However, there is a fine red line where pain control with opioids is less effective (and in my experience that occurs when the doses go over 60 mg oxycodone or 90 mg “morphine equivalents” per day). That condition is called opioid induced hyperalgesia or OIH. It is paradoxical because patients actually develop more pain with higher doses of opioids. This is paradoxical; imagine if you step on the gas and your car slows down! Once OIH occurs, patients tend to believe that the solution is higher doses of pain medication when, in fact, the most effective treatment is to taper back down to lower doses and/or to weaker opioids like buprenorphine or tramadaol. In some cases it is necessary to stop them completely and treat the underlying cause of pain with surgery, a spinal cord stimulator or even less invasive methods. In some cases, we have used ketamine infusions or certification for medical marijuana. Of course, those with failed surgery have already tried surgery and fall into a different category that cannot be easily explained here.
Thus, good people can, and do, become “addicted to” or misuse opioids.
The use of the term addiction is no longer favored, unless the drug was used just to get high and not for pain treatment. The terms “opioid misuse disorder” or “opioid dependency” are preferred. Even good people cannot just stop using opioids, as the brain has been reprogrammed to adapt to the high doses and the cycle of reward/withdrawal.
As sales of opioids have increased, so have deaths from prescription opioids, emergency room visits from prescription opioid problems and admissions to drug treatment programs for prescription opioid abuse.
We now realize that opioids are both very useful and very dangerous. We offer treatment options for those who find themselves in the grip of opioid misuse problems whether from long term pain or for those who experimented with street opioids and got “hooked.”
Important medical therapies for opioid dependency include Suboxone® or Zubsolv® which are brand name drugs in a film or disintegrating tablet, or even generic tablets which are a mixture of buprenorphine and naloxone.
Suboxone, Zubsolv or buprenorphine tablets are approved for office-based detoxification from opioid misuse, opioid dependency or for maintenance of sobriety for those who abused them. If you have a craving or desire for opioids, the best treatment for you is to stay on Suboxone long-term, as Suboxone can control your cravings, allowing you to live a normal life. If you decide to go off Suboxone, we also support that, but the choice is yours.
If you need or want in-patient detoxification for opioid abuse, we have access to high-quality inpatient substance abuse programs that we are glad to refer you to and then provide follow up.
Getting off of opioids is scary. Psychological counseling is critical for the successful treatment of the disorder and to help you get off and stay off opioids. You will not successfully get off opioids unless you want to and will most likely need psychological services. Counseling is important because it is hard to do this alone. Although we are a pain management clinic, many of our patients have both misuse and pain issues, and counseling is important to help treat both. For this reason, some insurers require that patients have counseling in order to get Suboxone or Zubsolv.
One of our greatest challenges in treatment is dual diagnosis. Dual diagnosis usually means that a patient has both a psychological and a misuse diagnosis. We expand that to include a legitimate medical reason to have chronic pain. We know that opioids are not a one-decision answer to pain. We also know that some patients use the language of pain to describe or try to treat their psychological issues. Opioids can be effective in treating pain, but as discussed above they can also be very ineffective in treating pain as the doses increase. Opioids are not effective in treating the underlying cause of pain or psychological issues: they don’t numb whatever the individual is trying to numb; thus sometimes seeing a psychologist is crucial.
Opioid misuse and addiction have reached epidemic proportions. Almost everyone knows or has heard of someone who has died from an overdose of a prescription medication. It is not just rock stars anymore. While statistically, the greatest number of deaths are in the 35-55 age group, it is the death of teenagers that really seems to hold everyone’s attention. Many people are realizing that they or their family members have issues with prescription medications. There is a growing awareness among those with substance misuse or addiction issues that they want to change their lives.
I have treated patients with substance misuse and chronic pain issues for over 15 years. The important thing is to find the cause of the pain and realize that many times opioids just perpetuate the existence of chronic pain.