Anna Lembke, MD, professor of psychiatry and behavioral sciences, Stanford University, California, and author of Dopamine Nation: Finding Balance in the Age of Indulgence. AnnaLembke.com
With all the alarming headlines warning us against the full-blown opioid epidemic that is gripping the US, you’d think that patients and doctors would be on high alert for possible misuse of these drugs. Yet the problem continues…
Shocking statistics: More than 91 Americans die every day from an opioid overdose, according to the Centers for Disease Control and Prevention (CDC).
Surprisingly, only 7% of people who misuse or are addicted to these powerful painkillers get them from strangers or dealers—the vast majority are obtained with legitimate prescriptions or from friends or relatives who presumably obtained them from their doctors.
Why do doctors continue to prescribe drugs that are known to cause addiction—and why do so many patients demand drugs that are not effective for long-term pain?
To learn more, Bottom Line Health spoke with Anna Lembke, MD, a psychiatrist and addiction specialist who has extensively studied the misuse of prescription drugs.
Which drugs are most likely to cause addiction? The opioid painkillers—morphine, hydrocodone (Vicodin), oxycodone (OxyContin, Percocet), fentanyl (Sublimaze, Duragesic), etc.—are the main offenders. They’re classified by the FDA as Schedule II drugs, meaning they carry a high risk for addiction.
Some stimulant drugs, including methylphenidate (Ritalin) and other medications used to treat attention deficit hyperactivity disorder, can also be addictive, particularly when they’re used by patients who are also taking opioid painkillers or other mood-altering drugs.
Are prescription medications more addictive than street drugs? They may not be inherently more addictive (this would depend on the different chemical properties), but they’re more readily available—and that’s a big part of addiction. In the 1960s, 80% of heroin (an illicit opioid) users started out with heroin. Today, most heroin users begin with prescription opioid painkillers before moving on to heroin.
Opioids are routinely prescribed by pain specialists, surgeons and family doctors. Patients acquire the drugs from emergency rooms, walk-in clinics and online pharmacies. They’re everywhere.
Who is most likely to get addicted? Patients with a previous history of addiction—to alcohol and/or drugs—have the highest risk. Addiction is also common in those with a family history of addiction or a personal history of depression or other psychiatric disorders. Before prescribing opioids, doctors should ask if a patient has any history of addiction or mental illness as well as if there is any family history of addiction. If a doctor does not ask about this (many don’t), a patient should be sure to alert his/her doctor regarding these issues.
However, we’ve also found that patients with no history of addiction/drug use are also at risk. Studies have shown that about 25% of patients who use these drugs for legitimate medical reasons for three months or more will begin to misuse these medications—meaning they take more than prescribed or don’t take the medication as prescribed (for example, they binge or hoard medication). This is a first step on the road to addiction.
Why do doctors keep prescribing opioids? Many believe, mistakenly, that patients who take these drugs for pain—as opposed to using them recreationally—are unlikely to become addicted. There’s an old (and flawed) statistic that pain patients have less than a 1% chance of becoming addicted. We now know that this is not true. Other factors: Doctors want to ease pain…pleasing patients is part of their DNA. Prescribing a powerful painkiller can feel like a better alternative than possibly letting someone suffer.
How do patients get more medication than they need? Many of them “doctor shop”—they exaggerate their symptoms while collecting prescriptions from many different doctors. Some patients claim to have lost or misplaced their prescriptions before the refill date. Others create so much disruption in doctors’ offices—begging for drugs, threatening lawsuits, intimidating the staff, etc.—that they’re given prescriptions just to be rid of them.
Note: Some insurance companies are now closely monitoring claims and alerting prescribers about suspicious activity, so some patients pay out of pocket to avoid getting caught.
Don’t patients know that they’re becoming addicted? Surprisingly, they don’t. Addictive drugs work on the brain’s reward pathways. Patients feel so good when they take the drugs that they lose insight into all the negative consequences—lost jobs, damaged relationships, etc.
Who should take these drugs? Opioids are very effective painkillers. Anyone who’s suffered a severe, acute injury—a broken leg, for example—will clearly benefit in the short term. Those who have had major surgery almost always need them. They’re also a good choice for those with acute pain related to cancer, such as metastatic cancer lesions on the bone. And opioids are an essential tool in the last few hours of life to help ease the passage to death.
But for chronic pain, opioids should be the very last choice. Nonmedication alternatives, such as psychotherapy, physical therapy, acupuncture, massage, meditation, etc., should be tried first, followed by nonopioid medications, such as ibuprofen (Motrin) or acetaminophen (Tylenol). These approaches can also be tried in combination.
For people who don’t respond to the approaches above, opioids may be required, but doctors need to proceed with caution. I advise intermittent dosing—say, using the drugs three days a week, without using them in between. This will still reduce pain but with less risk for addiction. Patients don’t take the drug regularly enough to build up a tolerance and dependence, so they shouldn’t have withdrawal symptoms.
Can anything else be done to help? Doctors who prescribe these drugs should take advantage of prescription drug monitoring programs. These state-by-state databases (available in every state except Missouri) allow doctors to see every prescription (for opioids and other scheduled drugs) that a patient has received within a certain time. They’ll know how many prescriptions a patient has received…how many doctors they’re getting them from…the doses they’re taking, etc. This information goes into the database when a patient picks up the prescription at the pharmacy.