Just a few day ago, sitting across from one of my therapy patients, a former opioid addict now 10 years into recovery, I was reminded, in the midst of all of the bad news about the opioid overdose epidemic, that if the same level of determination that fuels an addict's pathological pursuit of opioids can be channeled into recovering from the devastating impact of addiction, a life can be transformed -- and even the sickest of addicts can be restored to health. This patient, who suffered a severe sports-related back injury in his early 20s and underwent two surgeries to repair the damage, was handed handfuls of prescriptions for opioids to chase his seemingly unending pain after surgery. He tried them all -- Vicodin, Norco, Fentanyl and Darvocet -- and when they failed, he began supplementing them with Oxycontin he bought on the street. After mixing opioids with downers, he overdosed, just two days prior to his scheduled qualifying exams for graduate school.
Having survived the overdose, with recovery or death as his remaining choices, he seized control over his life, seeking out treatment with a medicine known as suboxone for his opioid addiction. Other healthy behaviors and choices followed, including a couple stints in inpatient rehab, treatment by a psychiatrist, involvement in self-help groups and outpatient therapy. Recovery has not been easy, and he continues to work at it, but the payoff has been well worth the struggle. Now, a decade later, with a doctoral degree, a steady job, a wife he loves and plans to start a family, no one would ever guess that he is a former painkiller addict.
In the addiction community, many would say that he "hit rock bottom" before he was able to change. But we know so much more now about the risks of opioid treatments for pain and the potential for fatal overdose. Waiting for a loved one to hit bottom, we risk missing a chance to save a life. As knowledgeable consumers of medicine in the Digital Era, we have the power to make safer and more informed choices about pain treatment, and we can recognize the signs of a plan of pain management that is headed towards addiction and destructive consequences in a loved one.
Addiction Medicine: a Tough Pill to Swallow, for Some
The staggering statistics are all over the media. Drug overdoses are claiming more lives than auto accidents, with opioids as the main driver of the climbing death toll. The Centers for Disease Control and Prevention estimate that 78 people die every day from an opioid overdose, an unprecedented toll in the history of the health impact of drug abuse. With proper treatment, however, many recover from opioid addiction. With as much public awareness that has developed about the potential for opioid addiction and overdose, the rates of treatment initiation and recovery ought to increase dramatically, if this information is put to use by consumers of medical care.
Research studies have found medication-assisted treatments for opioid addiction, such as suboxone and methadone, to be highly effective in helping people recover from addiction and preventing overdose deaths. There are many reasons these medication-assisted treatments are underutilized, including limited availability of the medicines and trained prescribers. Perhaps equally problematic is the skepticism that patients and health care providers have about the use of these medicines in treating addiction. Concerns about replacing one addiction with another are all too common, and usually stem from misunderstandings about how these medicines work.
Medicines like suboxone and methadone eliminate the vicious cycle of using increasing doses of opioids and then going into withdrawal when they wear off, a cycle that fuels escalating use of opioids to get rid of the terrible discomfort in withdrawal. The desperation to avoid withdrawal can then contribute to excessive use, overdose and even criminal activities in the pursuit of more of the drug. Medicines that are used to treat opioid addiction stop the cycle of highs and withdrawals by providing a stable dose of a replacement drug that acts on the same area of the brain. This restores the stability of the addict's brain chemistry, relieves cravings and helps the person become functional again, and to be productive and have meaningful relationships.
If Your Doctor Prescribes Opioids, Ask Why
While once considered a secondary concern in medicine, the idea that pain could be thought of as a "fifth vital sign" to avoid undertreating it emerged over a decade ago, prior to the surge in painkiller prescriptions. Curbing inappropriate and excessive use of opioid treatment while avoiding jeopardizing opioid therapy for individuals who clearly need it is a balancing act that will continue to challenge physicians.
As scientific data concerning chronic pain treatment has accumulated, the benefits of opioids when prescribed for pain that extends beyond three months have been called into question. What's more, the repeated use of opioids has been found to worsen pain in a sizable group of patients, a condition known as "hyperalgesia." This can create a vicious cycle in which the pain sufferer takes larger doses of opioids to try and eliminate a pain condition that was itself worsened by opioids in the first place. As the pain progressively intensifies in response to escalating doses of opioids, the risk of addiction and overdose worsens.
More critically, because opioids also affect the respiratory centers in the brain, which regulate breathing, at too high a dose, or when combined with other sedatives, respiratory depression and death can occur. This is now the too-often heard story of a fatal overdose.
New guidelines for opioid prescribers who are treating chronic pain, released in March by the Centers for Disease Control, recommend consideration of alternative treatments to opioids rather than starting with opioids as a "go-to" pain management strategy. As these guidelines are being implemented, we are not powerless against the devastating disease of opioid addiction. If a doctor prescribes opioids for your pain management, make sure you ask questions about the risks -- and alternative treatments.
If you have a history of addiction, even if unrelated to controlled substances, or if you suffer from a mental health condition like depression, you are more vulnerable to becoming addicted to opioids. Adolescents also have an increased risk. But even those who are not at especially high risk can develop an opioid addiction; no one is immune. As an informed patient, you can ask your doctor to try non-opioid pain treatment strategies first and see how they work before considering a plan of care that could include opioid medications.
As the fight against opioid addiction continues in this nation, spreading awareness of an opioid antidote that is now available for reversing an overdose is critical. The treatment is easy to use, available as an injection into the muscle or a spray into the nose that can and should be carried by individuals who are taking opioids and by their family members. It's called naloxone, and while a victim of an overdose likely won't be able to administer it, a bystander can, quickly restoring the victim's ability to breathe within 2 to 5 minutes.
Recovery from both chronic pain and addiction can be achieved through a combination of behavioral therapies and effective medicines. Studies support the use of non-medicinal approaches including psychotherapy, exercise, biofeedback and complementary medicine such as yoga, meditation and acupuncture, to treat certain types of pain. In addition, non-opioid medications may also be useful and can include nonsteroidal anti-inflammatory drugs, anticonvulsants and certain antidepressants.
Addictive behavior can be recognized as a progressive loss of control over drug use, and can be reflected in behaviors such as "doctor shopping," or seeking multiple prescriptions for opioids from different doctors, difficulty functioning in important life areas such as at work or in important relationships, and escalating use of opioids despite the devastating impacts, both physical and psychological. If you or someone you are close to is suffering from these signs and symptoms, seeking a prompt evaluation by an addiction treatment professional is a good place to start.
Addiction is not a simple problem with a simple solution. My colleagues and I at UCLA Integrated Substance Abuse Programs are conducting ongoing research to better understand and treat this devastating illness. Many have tragically lost the fight, yet I have worked with and heard powerful stories from those who not only survived, but have created rewarding and meaningful lives in the aftermath of their battle with this disease. It is true: Physicians have an essential role in ending the opioid overdose epidemic, by shifting their prescribing practices to avoid unnecessary and excessive use of opioids in pain management. Equally true, however, is the fact that we can be empowered by all that we have learned about pain control, opioid abuse and addiction, and have the courage to face the pain with alternative and safe methods of treatment, or recognize when a loved one needs help. There is help available, and it works.
Suzette Glasner-Edwards, Ph.D., is an associate professor at UCLA Department of Psychiatry and author of "The Addiction Recovery Skills Workbook."