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December 4, 2015
PAINKILLERS OF CHOICE
Prescription Opioid Use May Be Decreasing, but Heroin Use Is Increasing

Dr. Eric C. Strain
Dr. Eric C. Strain

One million Americans regularly use heroin. At least another million misuse or abuse prescription pain relievers. These estimates were provided by Dr. Eric C. Strain at a Contemporary Clinical Medicine: Great Teachers Grand Rounds Lecture in Lipsett Amphitheater recently.

These numbers could well be higher, but itís hard to come up with an exact estimate, said Strain, director of the Center for Substance Abuse Treatment and Research and executive vice chair of Johns Hopkins Bayview Medical Centerís department of psychiatry and behavioral sciences.

Heroin and prescription painkillers are opioids, he explained. Both decrease pain. Opioids attach to proteins called opioid receptors. These proteins can be found in the brain, spine and gastrointestinal tract. When taken as prescribed, opioid painkillers can safely and effectively manage pain. When abused, high doses of opioids can cause severe respiratory depression and death.

Opioid use may lead to addiction or physical dependence. Physical dependence is not the same as addiction, Strain said. Patients with cancer pain who take opioids, for example, may experience physical withdrawal symptoms if they forget to take their dose. These patients do not exhibit the signs of addiction, which is the compulsive use of a substance that may interfere with work and other life activities.

In the late 1990s and early 2000s, doctors began aggressively treating chronic pain with opioids, Strain said. These drugs were also aggressively marketed. As a result, more people began taking painkillers. With increased use came potential for misuse. In 2000, 2.78 million people admitted to misusing prescription painkillers within the past month. By 2012, that number had risen to 4.82 million.

According to the most recent data from the federal National Survey on Drug Use and Health (NSDUH), 4.33 million people admit to misuse. “It appears that we’re seeing some stabilization or even a decrease in prescription opioid misuse,” Strain said.

States such as Maryland require doctors to take continuing medical education courses on the prescription of opioids. Strain noted that it appears that providers are appropriately becoming more careful about prescribing opioids and noted that his own recent experience with a dental procedure provided an example of this.

However, the most recent information from NSDUH indicates what Strain called a “worrisome” rise in heroin use. He encouraged the audience to focus not on the absolute numbers when looking at NSDUH results, but rather the change over time. Between 2013 and 2014, people who admitted to heroin use within the past month increased from 681,000 to 914,000.

“This suggests to me that we’re seeing a shift from prescription painkillers to heroin,” he said.

There are four FDA-approved drugs used to treat problematic opioid use (or opioid addiction) and that help users to stop using heroin or prescription painkillers.

Strain says heroin use seems to be on the rise.
Strain says heroin use seems to be on the rise.

PHOTOS: ERNIE BRANSON

Two common medications used to treat opioid use disorders are buprenorphine and methadone. A third is LAAM (not currently marketed in the U.S.) and the fourth is naltrexone, an opioid antagonist. Buprenorphine and methadone are well-studied and offer “a great value to people who suffer from” opioid use disorders. Strain reported that at least 300,000 patients are taking buprenorphine, but said he has heard estimates that this number may be considerably higher. He added that at least 250,000 patients are taking methadone in the U.S.

Buprenorphine is usually taken once daily in tablet or film form, which resembles a mouthwash breath strip. It can be prescribed in an office setting, provided a physician has been authorized by the Drug Enforcement Agency to prescribe it.

Strain called it a partial agonist, which means buprenorphine reduces withdrawal symptoms by blocking opioid receptors without activating them. Methadone, on the other hand, is an agonist, which activates opioid receptors.

Buprenorphine tablets and the film could be dissolved and injected. However, most tablet forms typically contain naloxone (an opioid antagonist), and if dissolved, “would precipitate withdrawal.” Strain said it makes the user sick. “It’s gotten out in the [drug] culture that it’s not something to do,” he said.

Methadone has been in use since the 1960s. By law, it only can be given through an opioid treatment program, Strain said. Patients must be part of a program to receive a dose. They also receive behavioral therapy such as counseling or social support.

When used correctly, these drugs can help people stop using heroin and prescription painkillers by suppressing withdrawal symptoms and opioid cravings over time and blocking the effects of other opioids.

Contingency management therapy—a behavioral therapy that can be used as a positive incentive approach to assist in motivating patients to follow their treatment plan—is another strategy that can be “a powerful and strong incentive” when used with treatments like methadone. For example, if patients meet their treatment goals they might be able to take their dose without visiting a program.

Strain concluded that public health officials are using the strategies of providing pharmaceutical and non-pharmaceutical treatment and training for physicians who prescribe opioids in hopes of reducing heroin use and prescription painkiller misuse and abuse.

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