Sunday, February 17, 2013

OPIATE USE AND DEPENDENCE


Opiate Dependence and Withdrawal - 
The Covert Killer

     Without even realizing it's happening, people of the Boomer generation can find themselves in a situation of physical dependence and addiction to opiates. The reason is that as we advance in years, we are more prone to chronic and debilitating injuries. Let's  face it, looking sharp and aging gracefully has its price. Today, Boomers are more active than any other generation of people over 50. We run races, play tennis, bike, mountain climb, and spend our time in places like HOME DEPOT, where we buy stuff to engage in exhaustive repairs of our homes. All of these activities, of which I've only named but a few, combined with aging bodies, are too often a recipe for trouble - sprains, strains, breaks, and chronic injuries are our rewards. Sometimes we wear them like badges of honor. In a large number of cases, they lead to painful disabilities and recoveries. 

    Let’s take chronic low-back pain as our example: The spongy, donut shaped structures between our vertebrae, our discs, provide cushion and bounce to us as we perform our daily activities. As we age, they tend to lose water and naturally compress. Sometimes, an injury like a fall, sports injury, or an accident cause the vertebrae to compress the spinal nerves which go out to the body. This compression, right at the beginning of the nerve, called the nerve Root, is called a radiculopathy - an exceedingly painful condition. It shows itself mostly by a

PICTURE OF SPINAL NERVE COMPRESSION -
Fig 1. 
This shows a spinal compression in the neck region, a bulging disc causes a pressure on the nerve roots coming out of the spinal cord, and a narrowing of the cord itself. 
chronic, dull, back pain; unremitting and miserable to anyone that's had it. It can lead also to numbness of the areas of the body supplied by the nerve, or even paralysis if untreated. In severe cases, surgery is required in which the disc is removed, and the vertebral bones are fused to remove the pressure. Sometimes, a simple movement like cleaning oneself during toileting can cause a sudden, vicious acute pain requiring a trip to the ER or the neurologist, who will usually prescribe a skeletal muscle relaxant like VALIUM (diazepm), or FLEXERIL (cyclobenzaprine), along with the narcotics which the patient is already on from the orthopod or the physiatrist. 

       Sometimes people may be in so much pain that they will tend to over medicate, which can lead to a lethal chemical cocktail for the unwary subject. 
Today we will look at the case of a patient who has a nerve compression problem due to an accident, with a collapse of the vertebrae and a narrowing of the opening for the nerve. They are in severe, chronic, low-back pain, and their physician elects to treat their problem of pain with narcotics - a mixture of a long-acting one like OXYCONTIN(R) long-acting), and something like MORPHINE SULFATE, immediate-release tablets for sudden or “breakthrough pain.” Along with the medication, the patient will also undergo physical therapy 3 times weekly. 
     But first, in order to get an idea of how narcotics work in the body, there are some terms we will become familiar with: tolerance, dependence, addiction. Narcotics are really very devilish drugs because as a person becomes “used to” the pain-relieving benefits of the drug, the adverse effects of the drug like respiratory depression, and slowing of the heart rate also occur when the person increases their dosage. This is what is meant by a “tolerance” developing - you need increasing amounts of the drug to feel pain relief, and more to hurt you. Unfortunately, there comes a point where those bad effects take over, and taking more narcotics will kill you. Dependence goes right alongside of tolerance; a person who becomes tolerant to a larger dose of, say, OXYCONTIN(R), is also physically dependent on the drug as well - if they suddenly stop taking it, there will be withdrawal symptoms, which are most unpleasant!, after about 24 hours. 

How Narcotics Work In The Brain


FIG 2. The two pathways through which Narcotic Opiates work in the Brain -
From the source of Pain to the Spinal Cord via the Peripheral Nervous System, and
then in the Brain, where the Pain response is altered; in other words:
"The Pain is still there, but who cares?"  

      When someone is in withdrawal from an opiate narcotic, they will feel anxious, have sweating, chills, a runny nose. Later on, muscle contractions become apparent - they may have to keep stretching and contracting their arms or legs, and feel pressure in the chest. It’s also possible to have a heart attack as well! (Remember Jamie Lee Foxx in the Ray Charles movie?) Someone in withdrawal like this is VERY sick, and should be in an emergency room, or under a physician’s care directly. Giving a person the narcotic they have become tolerant of and dependent on, will immediately stop the withdrawal. 
      There are other ways of stopping withdrawal which I will introduce soon, other than "cold turkey." Is  a person undergoing narcotic withdrawal addicted to the drug, or are they a “drug addict?” The answer is not necessarily. Being dependent on these drugs when someone is taking them for legitimate medical reasons can be a stigma, and something that people may elect to hide from family, friends, employers and even insurance companies. This is unfortunate and more public education is needed on the subject (Like this blog!).
     Someone who takes OXYCONTIN(R) for constant, unremitting back pain, and in high doses, does not seek or take the drug for the euphoria or “the high” it produces. They don’t seek phony prescriptions, or seek to obtain the drug from illicit sources - That . . . in most definitions, this maladaptive behavior, constitutes a drug addict. So, there is a big difference between our pain patient, who is physically dependent on OXYCONTIN(R) and Morphine, and a drug addict, who is chasing the euphoriant effect of the drug.  The addict has become tolerant to the euphoria, and will often die of an overdosage while “chasing the high.” This is the case with Heroin, an illegal street drug, as well as the prescription narcotic opiate drugs, like the OXYCONTIN(R), PERCOCET(R) or the Morphine. 
     Our patient has been taking the OXYCONTIN(R) and a fast-acting very potent narcotic for "breakthrough pain" called FENTANYL lozenges on a stick, a relatively new product that dissolves slowly when held between the cheek and the gums, releasing the drug in fruit-flavored varieties for different strengths. Originally, this product, also sold under the brand name ACTIQ(R), was developed to treat the chronic pain of terminal cancer, but lately has been used for chronic back and neck pain of a severe variety as well. 
     So, its been 5 years that our patient has been on steadily increasing doses of both drugs, (tolerance and dependence can develop in as little as 2 weeks!)and they've really outlived their usefulness; increasing the doses would be dangerous for both drugs, and the doctor isn't sure they are working any longer to provide adequate pain relief - something else will have to be decided upon by both doctor and patient that would be acceptable. There are other modalities to use such as Physical Therapy, non-steroidal anti inflammatory drugs NSAIDS, such as CELEBREX(R), NAPROSYN(R), or the newer drugs that work on the nervous system like LYRICA(R) or NEURONTIN(R)
     
     Also, our patient has developed a problem of considerable tooth decay from the lozenges, and has developed low testosterone, and Type II Diabetes, which have been linked to chronic use of narcotics. So how does he come off the narcotics? Cold Turkey is a rather rough and dangerous way to come off these drugs as we have seen. METHADONE, with various manufacturers is an alternative, but again, there is a stigma associated with HEROIN addiction. Today, there is a safe, rapid, and relatively painless way to get off these drugs safely and permanently, on an out-patient basis, and no stigma attached. I will discuss that method soon, in my next installment of "BOOMER HEALTH."   
     
     

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