The Pain of Opioid Withdrawal

It is easy to blame the American opioid epidemic on doctors, pharmaceutical companies and our over reliance on prescription drugs. While all of those played a huge role in the issue becoming a full blown national crisis, the fact remains that opioid narcotics are extremely difficult to stop using for many people—especially those who experience legitimate chronic pain. Those of you in recovery for an opioid use disorder, whether prescription painkillers or heroin, know all too well just how difficult it was to break the cycle of opioid addiction.

It often takes people suffering from opioid addiction a number of attempts at abstinence to finally succeed. And those who do manage to find recovery from such drugs typically need assistance via medical detox, inpatient treatment and regular attendance at 12-Step recovery meetings.

Those who have known alcoholics who managed to sober up using Alcoholics Anonymous, may find themselves asking why opioid addicts are unable to do the same? The answer to that question usually lies in the nature of opioid withdrawal. The early days of abstinence from opioids is by all accounts an extremely painful, uncomfortable experience. Typically characterized by:

• Anxiety
• Depression
• Diarrhea
• Cramping
• Insomnia
• Irritability
• Nausea
• Pain
• Restlessness

While it is true that opioid withdrawal is painful, those who actually have a chronic pain condition which led to the use of opioids in the first place, are met with even more pain as the drugs leave their system. What’s more, it can take some time for the brain to start producing painkilling endorphins after being idle for extended periods of time. Those who cannot tolerate the pain experienced during that interim period are at great risk of relapse, HealthDay reports. Kelly Dunn, an addiction specialist who researches opioids at Johns Hopkins University School of Medicine, in Baltimore, points out that:

"When you stop taking opioids it takes time for your body to regenerate its own 'painkiller' system," she explained. "Generally, four to five days. The severity varies per patient, and it's not predictable who will react how -- but withdrawal is real." 

It for the reasons mentioned above that many prescription opioid addicts require inpatient treatment. Being in a monitored environment, closed off from the medicine cabinet at home and aided by addiction withdrawal medicines are vital to the success of recovery.

Prescription Opioid Diversion

When most people are given a prescription for an opioid painkiller, they take the medication until the pain dissipates. It is quite common for there to be leftover tablets sitting in the medicine cabinet. Patients usually forget the pills are even there and continue living their life.

The prescription opioid epidemic that has been raging since 1999 has prompted a number of actions that were previously deemed unnecessary. Leftover opioid painkillers pose a serious threat, and often end up in the wrong hands. That is why prescription drug take-back programs have become more and more common in recent years. Opioid addicts will scavenge other people's medicine cabinets for drugs like oxycodone and Percocet. More importantly, teens will also raid their parents' medication bottles as well.

Such drugs are highly addictive and carry a large risk of overdose. It is vital that those with leftover medication dispose of them properly. Many pharmacies will actually take back unused medications. Another common trend of concern is medication diversion. People with a prescription for opioids giving the drugs away to friends, family or peers. A new study sought to find out how often painkiller sharing occurs.

A team of researchers from the Johns Hopkins Bloomberg School of Public Health in Baltimore, MD, found that 50 percent of patients with prescribed opioids have leftover tablets and 20 percent share the drugs, MNT reports. The findings were published in JAMA Internal Medicine.


"The fact that people are sharing their leftover prescription painkillers at such high rates is a big concern,” said Prof. Colleen L. Barry, Ph.D., senior study author. “It's fine to give a friend a Tylenol if they're having pain, but it's not fine to give your OxyContin to someone without a prescription." 

There were some other findings of note, including:

• 14 percent of respondents said they would share with family.
• 8 percent said they would share the pills with a friend.
• Less than 50 percent were not given safe storage or proper disposal information.

Fentanyl Salesmen Arrested for Kickback to Doctors

An aspect of the prescription opioid epidemic that is often ignored is the role of pharmaceutical salesmen. These are people who are employed by pharmaceutical companies to travel around the country enticing doctors to prescribe their medical product. Now, it stands to reason that a physician's willingness to prescribe a drug should be based off of the drug's effectiveness at treating a specific condition—and in a perfect world that may be the case. However, doctors are often times given huge incentives to prescribe one medication over another, a practice which surely had a hand in the rampant over prescribing of drugs like OxyContin (oxycodone).

In the wake of the beloved pop star Prince’s death, attention has been redirected back to the powerful opioid analgesic fentanyl. Many Americans may have never heard of fentanyl as the drug is not commonly used outside of hospital settings. Those who had heard of the drug before may have been unaware that fentanyl is 100 time more potent than morphine. Fentanyl, while fast acting and highly effective, can cause severe respiratory depression that can be fatal; this is why it should be scarcely used except under the close supervision of doctors and nurses.

In an attempt to stem the tide of irresponsible prescribing practices, law enforcement has begun to set their sights on pharmaceutical salesmen. Recently, two former pharmaceutical salesmen were arrested from charges stemming from paying doctors to prescribe a form of fentanyl, USA Today reports. The two salesmen, who worked for Insys Therapeutics, allegedly paid two doctors in the New York-area $259,000 in kickbacks to prescribe Subsys.

Most fentanyl prescribed for take home use comes in the form a transdermal patch. The patches are adhered to one’s skin—slowly releasing the drug throughout the course of the day. Subsys, on the other hand, is sprayed under the tongue, according to the article. The spray version of fentanyl works quickly, relieving pain in just five minutes.

"You have this hyper-powerful drug marketed intensely, aggressively and shamelessly without any sense of the addictive and lethal power of what is being sold," said Arthur Caplan, the director of medical ethics at NYU Langone Medical Center in New York.

We will continue to follow the fentanyl story. Stay tuned. 

Naloxone Without a Prescription

In the United States, we face a grave and serious situation with regard to both prescription opioids and heroin use. For far too long an unprecedented number of Americans have been able to access prescription opioids, even in situations where an alternative treatment could be utilized. In the wake of widespread over prescribing, an old drug reemerged on the scene—heroin.

Historically, heroin was thought to be a drug found only in heavily populated urban environments—used primarily among the poor and those of ethnic descent. While there may have been some truth to that idea in the past, it is far from reality today; Americans affected the most by illicit heroin and prescription opioid abuse reside in rural parts of the country—the Appalachian region strongly considered to be the epicenter of the American opioid epidemic.

If you have been following the media reports on this subject, it is likely that you have read about the efforts being made to mitigate the crisis. Efforts include:

• Expanding Access to Addiction Treatment
• Offering Treatment Instead of Jail Time
• Utilizing Prescription Drug Monitoring Programs
• Making It Easier to Acquire Naloxone

By and large, there has been widespread support on both sides of the political spectrum for expanding access to the lifesaving opioid overdose reversal drug naloxone—sold under the brand name Narcan. Thousands of American lives have been saved by the miracle drug, prompting lawmakers, health experts and those who work in the field of addiction to call for legislation which would make it easier for the friends and families of addicts to acquire naloxone.

If you think about it, it makes perfect sense. Time is of the utmost importance when it comes to an opioid overdose. Friends and family are, more often than not, the ones who are present—having naloxone on hand can better ensure a positive outcome. The good news is that states are jumping on board, and now practically every state has some form of legislation allowing people to buy naloxone without a prescription, Fox News reports.

"This saves lives, doesn't seem to have any negative impact that we can identify, therefore it should be available," said Dr. Corey Waller of the American Society of Addiction Medicine.

Coroner's Report: Fentanyl Caused the Death of Prince

This past April, millions of people around the United States and across the globe were shocked to learn that Prince Rogers Nelson, more widely known as Prince, died at the relatively young age of 57. While it was unclear as to the cause of the pop singer's death, many were convinced that the superstar passed away from drug related issues. It probably comes as little surprise that Prince suffered from pain after decades of high energy performances, and it was widely known that he endured a hip injury that required pain medication.

Prince had been known to lead a clean life, refraining from mind altering substances over the years, which made it hard for many to believe that his death could be the result of a drug overdose. Now, two months later, the coroner's report has come out, and the cause of his death was an overdose of the powerful opioid analgesic fentanyl, CNN reports. It is likely that you have heard news reports about the drug in recent years, as fentanyl is commonly mixed with heroin to increase potency—resulting in a wave of overdoses across the united states.

Just to put the drug into perspective, fentanyl is around 80 to 100 times stronger than morphine and roughly 40 to 50 times more potent than pharmaceutical grade (100% pure) heroin. The drug is known to cause severe respiratory depression even in small doses—rife for the potential of overdose. Heroin users, more often than not, have no idea that the “dope” they are about to snort or inject is laced with fentanyl; being unaware of the presence of the powerful analgesic, users will dose themselves out as they normally would—ignorance that can prove deadly.

Authorities are still trying to determine where Prince acquired the fentanyl that led to his death, according to the article. To be sure, it could have come from only one of two places. Either a physician wrote him a prescription for fentanyl to treat his pain, or he acquired the drug through illegal channels. Fentanyl is being produced in clandestine labs, typically overseas in countries such as China where it is easy for chemists to acquire the requisite precursors. The drug is then shipped out of China, finding its way to Mexico where it is then moved north of the border.

Without a doubt it is important authorities find Prince’s source; however, where the drug came from will not bring the beloved artist back—as is the case with the thousands of Americans who lose their life in this country from prescription opioid and heroin overdoses. What’s more, Prince’s death, much like Michael Jackson's and a number of other stars' deaths in recent years, drives home the point that everyone is eligible for addiction—and all who use opioids are at risk of overdose. Every day in the United States alone, over 70 people succumb to opioid overdose deaths.

Is W-18 Too Powerful for Naloxone?

Over the last few years there have been a number of deadly cases of heroin laced with fentanyl overdoses. Fentanyl is a powerful opioid analgesic, typically used in a hospital setting for either surgery or the most severe pain. The drug is roughly 80 to 100 times more powerful than morphine and around 40 to 50 times more potent than pharmaceutical grade heroin, according to the Centers for Disease Control and Prevention (CDC). With potency like this, it is easy to see that mixing fentanyl and heroin together is a sure recipe for disaster.

Fentanyl is now being produced in clandestine labs in China, shipped to Mexico and mixed with inferior grades of heroin to increase potency. Heroin users in the United States are often times unaware of the deadly admixture when they use, so they do not adjust their dosage accordingly—overdose often ensues. You might find yourself wondering if there could be a more deadly amalgamation. The answer to that question, unfortunately, is yes.

A drug that could be as many as 10,000 times more potent than morphine is possibly being mixed with heroin in the Philadelphia area, The Philadelphia Inquirer reports. The drug, known as W-18, may be too powerful for the opioid overdose drug naloxone to reverse. The Drug Enforcement Administration (DEA) has released a bulletin warning of the dangers associated with mixing W-18 with other drugs, such as heroin. The agency pointed out that a microscopic dose of W-18 could be fatal.

Recently, anesthesiologist Anita Gupta, who works as a pharmacist and pain specialist at Drexel University College of Medicine, began seeing cases of overdose where patients didn’t have the typical response when naloxone was administered. Gupta’s suspicion for the atypical response was the presence of W-18.

“The symptoms were worse than we were used to seeing,” said Gupta. “We were getting patients with symptoms of near-death, and often required multiple doses of the antidote naloxone.”

Two Types of Alcoholics

Drugs and alcohol take their toll on the human brain, which can be measured through a number of scanning techniques. When compared to the brains of people who have not had a substance use disorder, clear differences can be seen. That being said, the brain of one alcohol user may look different than another, and new research may have found that there are two types of alcoholics. Researchers from the University of Eastern Finland found that while all alcoholics share similar brain changes, some alterations are exclusive to one type of alcoholic but not another, PsychCentral reports. The findings are published in the journal Alcohol and Alcoholism.

There are two types of alcoholics, anxiety-prone (Type I) and impulsive (Type II) based on Cloninger’s typology, according to the article. The researchers looked at post-mortem brains from both types of alcoholics and a control group.

“From the viewpoint of the study setting, this division was made in order to highlight the wide spectrum of people suffering from alcohol dependence. The reality, of course, is far more diverse, and not every alcoholic fits into one of these categories,” said Olli Kärkkäinen, M.Sc. (Pharm).

Typically, Type I alcoholics are more prone to anxiety and are more likely to become dependent on alcohol later in life, the article reports. On the other hand, Type II alcoholics usually become dependent on alcohol when they are younger and show greater impulsivity and antisocial behavior. In Type I alcoholic brains, the researchers found:

• Changes in the endocannabinoid system, which modulates stress responses.
• Increased Docosahexaenoylethanolamide levels in the amygdala, possibly linked to their anxiety prone nature.

With Type II alcoholic brains, the researchers found elevated levels of AMPA receptors in the anterior cingulate cortex, according to the article. That part of the brain has a hand in learning and the regulation of behavior, which could explain the impulsive nature of Type II alcoholics.

“These findings enhance our understanding of changes in the brain that make people prone to alcoholism and that are caused by long-term use. Such information is useful for developing new drug therapies for alcoholism, and for targeting existing treatments at patients who will benefit the most,” said Kärkkäinen, the study findings were part of his doctoral thesis.