John M. Talmadge, M.D.

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Painkillers, Narcotic Abuse, and Addiction

The Texas Medical Association sent an alert today about a new study: About 25% Of Chronic Pain Patients May Abuse Prescriptions. Forbes (4/2) Contributor C.J. Arlotta writes that a new report, published in the journal PAIN, found that “20-30% of opioids prescribed for chronic pain are being misused,” and further concluded “that the rate of addiction is approximately 10%.” The opioid epidemic in the US, he writes, “puts chronic pain front and center,” and physicians and health experts “are routinely looking for ways to” lower the “risk of patients becoming dependent on” prescription medicines. An independent panel convened by the NIH came to the conclusion that “individualized, patient-centric care,” despite its challenges, “is one way to control opioid tolerance development in chronic pain patients.” Additionally, state governments have continued investing in prescription monitoring programs (PMP), even though “only 53% of primary care physicians” utilize PMPs.

Over the past twenty years, drugs like hydrocodone, oxycontin, and similar narcotics have become an epidemic problem.

Opioids -- also called opiates or narcotics -- are pain relievers made from opium, which comes from the poppy plant. Morphine and codeine are the two natural products of opium. Synthetic modifications or imitations of morphine produce the other opioids:

Heroin (street drug)
Dilaudid (hydromorphone)
Percocet, Percodan, OxyContin (oxycodone)
Vicodin, Lorcet, Lortab (hydrocodone)
Demerol (pethidine)
Methadone
Duragesic (fentanyl)
When people use narcotics only to control pain, they are unlikely to become addicted to the drugs. However, opioids provide an intoxicating high when injected or taken orally in high doses. Opioids are also powerful anxiety relievers. For these reasons, narcotic abuse is one of the most common forms of drug abuse in the U.S.

Terms like opioid abuse, drug abuse, drug dependence, and drug addiction are often used interchangeably, but experts define them as follows:

Drug abuse, including opioid abuse, is the deliberate use of a medicine beyond a doctor's prescription. In the case of opiates, the intention is generally to get high or to relieve anxiety.
Dependence occurs when the body develops tolerance to the drug, meaning higher doses are needed for the same effect. In addition, stopping the drug produces drug withdrawal symptoms.
Drug addiction occurs when the person has drug dependence, but also displays psychological effects. These include compulsive behavior to get the drug; craving for the drug; and continued use despite negative consequences, like legal problems or losing a job.

Symptoms of Narcotic Abuse
Signs and symptoms of opioid abuse include:
  • Analgesia (feeling no pain)
  • Sedation
  • Euphoria (feeling high)
  • Respiratory depression (shallow or slow breathing)
  • Small pupils
  • Nausea, vomiting
  • Itching or flushed skin
  • Constipation
  • Slurred speech
  • Confusion or poor judgment

Symptoms of Opioid Drug Withdrawal
If a person uses opioids for a long time, they develop physical dependence and tolerance. Usually, opioid abusers will then take more of the drug, to continue to get high. If a person stops using opioids after they become physically dependent on the drug, they will experience drug withdrawal symptoms which can include:
Anxiety
Irritability
Craving for the drug
Rapid breathing
Yawning
Runny nose
Salivation
Gooseflesh
Nasal stuffiness
Muscle aches
Vomiting
Abdominal cramping
Diarrhea
Sweating
Confusion
Enlarged pupils
Tremors
Loss of appetite

I tell patients that withdrawal from drugs like painkillers and heroin is like the worst case of the flu you've ever experienced. The symptoms of opioid drug withdrawal can be agonizing and intolerable, contributing to continued drug abuse. In general, how severe opioid drug withdrawal symptoms are, and how long they last, depends on how long the person has been abusing opioids and how much they have been taking.

Medicines like methadone, buprenorphine (sometimes combined with naloxone), and naltrexone can be taken in various forms and are used to prevent withdrawal symptoms after a person stops using, a process called detoxification ("detox"). After drug withdrawal is complete, the person is no longer physically dependent on the drug. But psychological dependence can continue. Some people with drug addiction may relapse in response to stress or other powerful triggers.

Dependence vs. Addiction

Controlling pain is the goal when opioids are used medically. Patients or health care professionals should not let fear of addiction prevent them from using opioids for effective pain relief. Knowing the difference between dependence and addiction is important.

People who take opioids for pain relief for extended periods of time may need higher doses to ease their pain. They may develop tolerance to the drug and experience withdrawal symptoms if the medication is abruptly stopped. They become physically dependent on the drug.
Addiction occurs when narcotic abuse becomes compulsive and self-destructive, especially concerning an opioid user's need to use the drug for reasons other than pain relief.
To prevent withdrawal symptoms in people who have become physically dependent on opioids for pain relief, the dose may be slowly lowered over a few weeks. People who are weaned off opioids and are pain free usually don't start taking the drug again or become abusers of narcotics. Opioids used for short-term medical conditions rarely require weaning. In those cases, stopping the medication after a brief period usually doesn't cause withdrawal symptoms.
Other Abused Drugs
Strictly speaking, most drugs referred to informally as narcotics really aren't. However, two drug classes have some similar effects to opioids, when abused:

Benzodiazepines include Valium, Ativan, and Xanax. Benzodiazepine abuse results in sedation and calm, but tolerance develops rapidly. Withdrawal can result in seizures, unlike opioid withdrawal.
Barbiturates include Seconal, Amytal, Nembutal, and Luminal. Barbiturates are also sedating and calming. Withdrawal after continued barbiturate abuse, like benzodiazepine abuse, is medically serious.
In general, benzodiazepines and barbiturates have less pain-relieving effects than opioids. All three drug classes are sedating and anxiety-relieving. Benzodiazepine abuse, barbiturate abuse, and narcotic abuse all produce tolerance and physical dependence over time, and withdrawal symptoms after sudden discontinuation.

This post includes material from WebMD Medical Reference.
SOURCES:
Van den Brink, W. Canadian Journal of Psychiatry, 2006.
WebMD Medical Reference: "Narcotic Abuse."
Bateson, A.N. Current Pharmaceutical Design, January 2002.
eMedicine.com: "Toxicity, Barbiturate."
Reviewed by Arefa Cassoobhoy, MD, MPH on August 01, 2013