Tuesday, January 22, 2019

Sonoma Medicine

The magazine of the Sonoma County Medical Association

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Strategies for Reducing Opioid Use

Gary Pace, MD

Earlier this year, former FDA director Dr. David Kessler said in a CBS News interview that the aggressive expansion in use of opioid pain medications “has proved to be one of the biggest mistakes in modern medicine.”1 

The problem isn’t that doctors prescribing opioids are incompetent or foolish. Instead, they thought they were helping patients based on the newest research. Now that the tide has turned against prescribing opioids, physicians don’t have much more to offer pain patients than they did 20 years ago, when long-acting opioids hit the scene. 

New initiatives aimed at educating physicians and the public on the importance of decreasing opioid use, and of developing systems to monitor prescribing patterns, may help with the epidemic; but the initiatives employ the same strategy of the failed War on Drugs: trying to stop the supply without addressing the demand. By paying attention to the demand side—the patient perspective—we can gain a fuller understanding of opioids and learn effective strategies for reducing opioid use. Below I discuss some of the approaches that are being recommended or that we are trying at our site that can be useful when approaching patients who are struggling. 

The current push for reducing opioid prescriptions involves setting policies and guidelines to get patients below 90–120 MEDs (morphine equivalent doses) per day to minimize the side effects and the risks, and to maximize the benefit. Before the paradigm shift, our clinic had problems bringing opioid dosing down. Patients would perceive us as being withholding and punitive for making them suffer when “effective” measures were available. Now with the public education campaign and the policy changes on medication coverage, most of our patients have been able to decrease their doses with relative ease. 

In our experience, a relationship-based approach with a clear focus on the goal has proven most effective. Dose reduction strategies include:  

  • Reducing the daily dose by 5–10% every month, with some flexibility during flares or stressful times.  
  • Using our relationship with patients to get them interested and optimistic about the process.  
  • Educating patients about the long-term benefits of lower doses.  

Of course, there are exceptions where patients—sometimes labeled “legacy patients”—are unable to wean. They are stuck in limbo: they know the medications are bad, but they can’t tolerate reducing them. In our practice, these are often patients with psychiatric problems, substance-abuse histories, poor insight and tenuous living situations. One patient, schizophrenic and with chronic pain, mishandled a slow wean by regularly coming up short, and then not managing to navigate the prior authorization process. He ended up paying out of pocket for some of his meds, which led to financial difficulties, and he has now lost his housing. Essentially, the wean ended up being the straw that led to his destabilization. 

Buprenorphine (a mixed agonist-antagonist for opiate receptors) is gaining prominence as a first-line solution for replacing conventional opioid pain medications. It has a moderate pain-relieving effect, and because of its unique pharmacology, overuse or the need for increasing doses is generally avoided. I have worked with this medication for more than 10 years, for both pain patients and addicts, and have seen some dramatic results. Because of the drug’s long half-life, its strong affinity for opioid receptors (thus blocking other opioids from having much effect), and the plateau of drug effect, cravings tend to disappear quickly. 

Physicians need a special license from the DEA to prescribe buprenorphine for addiction. The license can be easily obtained by going online for several hours of specialized training. Prescribing buprenorphine for pain has no prescribing limitations separate from other opioids. 

Starting buprenorphine usually involves an initial consultation, fol-lowed by an induction period. During the induction, patients stop using opioids for a certain amount of time (usually 12 hours for short-acting opi-oids, 24 hours for long-acting opioids, sometimes longer for methadone), and come into the office when they are starting to go into withdrawal. The rationale for this approach is that if opioids are still in their system, the avid receptor affinity of the buprenorphine will knock the opioids off the receptors and the patient will go into a rapid withdrawal. If they are already withdrawing, the buprenorphine will help resolve their symptoms quickly. 

Since buprenorphine is a combination of antagonist and agonist, it avoids the hyperalgesic effects of other opioids, so dosing goes down over time. Also, since there is a plateau of effect at about 24 mg per day, taking more buprenorphine does not lead to a “high,” nor is there a risk of overdose. Buprenorphine is especially useful in early recovery, because it tends to block effects of other opioids, thus discouraging relapse. 

My experience with buprenorphine has been positive in several pain patients who continually ran out of their medications early. They switched to buprenorphine and no longer come to the clinic with one crisis after another. Clearly, there was some sort of addiction component to their earlier struggles. 

Non-opioid therapy 
The recent CDC guideline for prescribing opioids states, “Of primary importance, non-opioid therapy is preferred for treatment of chronic pain. Opioids should be used only when benefits for pain and function are expected to outweigh risks.”2 Patients can be hard to sell on this approach, especially when insurance companies won’t cover many of the strategies that seem to have some efficacy. 

The research on non-opioid therapy is complicated and somewhat ambiguous. A 2007 guideline from the American College of Physicians and the American Pain Society found that cognitive-behavioral therapy, exercise, spinal manipulation and interdisciplinary rehabilitation were moderately effective for chronic or subacute low back pain.3 The guideline also found that acupuncture, massage, yoga and functional restoration can be effective for chronic low back pain. The only non-opioid therapies with evidence of efficacy for acute low back pain were superficial heat and spinal manipulation. 

My experience is that having a variety of modalities available can help selected patients, but our ability to address chronic pain with these modalities is limited. People who are motivated and empowered in their lives tend to benefit from the lifestyle-based therapies. Cognitive approaches can be particularly helpful in getting people to change their relationship with pain. Interventional and physical medicine approaches have an extensive write-up in the medical literature. Finding the right combination of these modalities seems to be specific for each patient. 

A patient recently described to me the despair he used to feel while driving to his drug dealer’s house. The whole way, he knew he didn’t want to go, that his life would be much worse for getting the drugs. Yet, something else had control of his body, and he couldn’t stop it. He would be in tears as he turned into the driveway. Now, after years of being clean, he still worries that he could lose control and sink into addiction again. 

Neuroscience research shows that addiction is a brain disease, not an issue of willpower. The brain chemistry becomes altered because of repeated exposure to addictive substances. Receiving dopamine release from the addictive drug becomes the addict’s over-riding focus, and avoiding the withdrawal and the crash when there is no drug can become an obsession. Research on risk factors considers genetics, but recently there is increased attention on the effects of adverse childhood experiences (ACE). For instance, a male child with an ACE score of 6 (out of 8), when compared to a child with an ACE score of 0, has a 46-fold increase in the likelihood of becoming an injection drug user sometime later in life.4 

When is the line crossed from legitimate use of opioids for pain relief to use for addiction? Physicians are well aware of patients who run out of pain meds early, have various excuses and consume a lot of time in the office. Ten years ago, “experts” were saying that it was unusual for people on pain medications to slide into addiction; but experience suggests a much higher risk. Moreover, as access to prescription opioids becomes limited, patients shift to cheaper, less predictable alternatives. Heroin overdose deaths have increased more than  30% annually since 2010.5 

Opioid addiction treatment is difficult to access, and just two general models are available: abstinence-based treatments (the 12-step model) or medication-assisted treatment (MAT) with buprenorphine or at methadone treatment centers. MAT is gaining traction, and research shows that it saves lives. When Baltimore improved access to MAT in the community, drug overdoses decreased by 50%.6 MAT patients generally have longer relapse-free periods than patients aiming for complete abstinence.6 

Many of the opioid addicts that I have worked with over the years have had dramatic turnarounds in their lives with buprenorphine, and I encourage physicians to get trained and offer this service to the community. MAT allows them to step off the all-consuming treadmill of planning how to obtain drugs. They begin to be able to reenter society and to appreciate the joys of working, of re-engaging with family and friends, and of having some control over their lives again. One of the most touching stories I heard was of a young man who was finally able to go to his extended family’s Christmas gatherings after many years of being forbidden because of the outrageous and criminal behavior he had previously exhibited.  

Some unusual approaches to opioid addiction are not available in the United States. Psychoactive plants with unique properties when used in appropriate settings may have success as cures for addiction. For instance, a treatment center in Peru that uses ayahuasca, an Amazonian plant concoction, reports a cure rate greater than 50% for difficult addictions, a result that would be the envy of treatment centers in the U.S.7 Ibogaine, from a traditional African healing tradition, is said to help opioid addicts avoid withdrawal after one extended and rather intense treatment.8 Since these plant-based treatments are illegal in the U.S., research is scarce, but the treatments do raise some provocative questions and avenues for inquiry. 

Is the amount of pain that contemporary Americans claim to experience higher than what Americans experienced in earlier eras? It would be a stretch to believe that people doing physical labor in earlier times or in other cultures had less pain than we do now. The U.S. has just 5% of the world’s population, but it consumes 75% of the opioid pain-killers.9 Clearly, Americans need a cultural shift in their willingness to tolerate discomfort. 

There aren’t any easy answers to the prescription opioid epidemic, but a few suggestions seem obvious. My interest here is for the policy-makers and thought leaders to move from a punitive approach that limits medications to a broader approach that includes the patient perspective. We need to:  

  • Reduce the number of opioids prescribed; we are having some success with that.  
  • Develop comprehensive strategies that work with pain, including non-pharmacologic approaches such as acupuncture, chiropractic and cognitive-behavioral therapy. 
  • Expand addiction services and recognize the life-saving capabilities of medication-assisted treatment.  
  • Examine the relationship our society has with pain and suffering, and go beneath the surface of the quick fix. ::

Dr. Pace, a family physician, is medical director of Alexander Valley Healthcare in Cloverdale.  
Email: gpace@alexandervalleyhealthcare.org 
1. “Former FDA head: opioid epidemic one of great mistakes of modern medicine,” CBS News (May 9, 2016).
2. Dowell D, et al, “CDC guideline for prescribing opioids for chronic pain,” www.cdc.gov (2016).
3. Chou R, et al, “Diagnosis and treatment of low back pain,” Ann Int Med, 147:492-504 (2007).
4. Felitti V, “Origins of addiction,” Kaiser Permanente (2004).
5. American Society of Addiction Medicine, “Opioid addiction facts and figures,” www.asam.org (2016).
6. Cherkis J, “Dying to Be Free,” Huffington Post (Jan. 28, 2015).
7. Giove R, “Medicina tradicional Amazónica en el tratamiento de las toxicomanias,” Comision Nacional para el Desarrollo y Vida sin Drogas [Peru] (2002).
8. Mash DC, et al, “Ibogaine in the treatment of heroin withdrawal,” Alkaloids: Chem & Bio, 56:155–171 (2001).
9. National Institute on Drug Abuse, “Popping pills: prescription drug abuse in America,” www.drugabuse.gov (2014).
Further Reading
Alexander B, The Globalization of Addiction, Oxford UP (2010).
Maté G, In the Realm of the Hungry Ghosts, North Atlantic (2010).
National Center for Complementary and Integrative Health, nccih.nih.gov (2016). 

SONOMA MEDICINE  |  Summer 2016  |  Sonoma County Medical Association

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