substances avoid addiction and to deter diversion of these medicines. Tese same chemicals produce brain reward in laboratory animals, like rats and monkeys, especially, but not only, among those with a genetic predisposition. Tose genetically vulnerable animals will work hard to have access to them just like genetically vulnerable humans do. Many of these addictive chemicals stimulate brain reward many times more intensely than natural rewards such as food and sex. When taken as directed—orally and
at stable doses over time and without simultaneous use of other addicting substances—the opioid pain medicines in most people seldom produce brain reward. However, a small but important segment of medical patients prescribed opioids for pain do experience intense brain reward sometimes from their first dose of an opioid, even when it is taken orally, in the prescribed dose and without simultaneous use of other addicting drugs. Tis reaction is unusual but it is not rare. Most patients who have this reaction have had earlier experiences with alcohol and other addictive drugs and have had similar strong positive reactions to their prior drug use. Teir brains have been primed to this effect by their earlier chemical simulation of brain reward and perhaps for other reasons including genetic vulnerability to addiction. It is important to recognize that genetic
factors account for between 40–60% of an individual’s vulnerability to addiction “including environmental factors on the function and expression of a person’s genes.”19
does in all animals regardless of their specific genetic vulnerability. Medical patients prescribed
opioids need to be warned about the serious health risks of misusing these drugs, of using in combination with benzodiazepines (tranquilizers) and/ or alcohol, and they need to be warned of the possibility of intensified brain reward because misuse can trigger long- lasting addiction to opioids. But even if patients are not warned of this risk by their prescribing physicians, or if they fail to heed this warning, there is another clear bright line that must be crossed to produce addiction: Patients must use the opioids at doses higher than prescribed, use alcohol and other drugs with the opioids, and/or use the opioids by routes of administration other than oral. In other words, when patients use the opioids against medical advice and in the face of mounting adverse reactions—this is addictive opioid use.
Risk is accentuated in those with
genetic vulnerability; of particular relevance is common family history of addiction. It is also important to recognize that there is no genetic invulnerability to addiction. Without any genetic predisposition, the repeated, high-dose use of opioids and other drugs addictively risks addiction in all people, as it
10 datia focus
Informing Medical Prescribing Practices Tere are two important take-away messages from this discussion of the transition from non-addicted pain patients to active opioid addiction. First, prescribing physicians and patients as well as families need to be aware that histories of early and heavy substance use or addiction are danger signs for patients prescribed opioids for pain. To turn back the opioid overdose death epidemic, it is necessary to broaden the target beyond pain management. Parents and educators need to clarify the prevention and/or early intervention message to adolescents regarding the dangers of any early drug use. Te prevention goal for youth is no use of alcohol, tobacco, marijuana or other drugs for reasons of health.20
is an important reinforcement of this essential health message.21
Second, there are stark differences in the
frequency, amount and circumstances of use between medically prescribed opioid use and opioid addiction. Prescribers and families need to monitor opioid use by patients regularly to assure that there is no transition to addictive use. Remember that the signs of addiction are not just larger amounts of medication, which can be appropriate medically in certain situations, but rather when patients use higher doses than recommended, use with other addictive drugs, shop for other doctors to prescribe opioids and are dishonest about their drug use. Nevertheless, it is possible for any patient prescribed opioids to transition into active opioid addiction, even if they have not been actively using alcohol or other drugs for some time, even for many years. Physicians have an important role to play
in the future of opioid-prescribing practices. Tere are steps that can help prescribing physicians reduce the supply of prescription opioids and opioid addiction.22
Tis begins Te opioid epidemic
with following the CDC guideline for prescribing opioids for chronic pain.23 Patients should be screened for substance use, misuse and related problems and searched within their state Prescription Drug Monitoring Program (PDMP) to identify “doctor shopping”—i.e., geting controlled substances from multiple physicians. Physicians can also administer drug tests to identify the use of other drugs because many opioid-addicted individuals use multiple drugs simultaneously. Physicians prescribing opioids can look for red-flag behaviors like “losing” prescriptions and needing early refills and they can talk with family members, with a patient’s permission, to get their opinions about the patient’s behavior including alcohol and other drug use. Tese practical steps are too-seldom taken now. Physicians oſten do not want to address the problems of addiction because the addicted patients do not want help, addicted patients lie about their drug
winter 2018
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