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Fighting Opioid Addiction in Bellevue, Washington: Higher Doses and Fewer Refills?

Opioid addiction in Bellevue, King County, and the rest of Washington State presents a major public health concern. But a brand-new study just published in the British Medical Journal is suggesting a starling new option: dispense painkillers in higher doses, but prescribe them for shorter periods of time.

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Refills Increase the Potential for Opioid Abuse

“Overall rates of misuse were low, but rates grew rapidly with increasing opioid use. The rate of misuse more than doubled among those with one refill … versus those with no refills…Patients who require subsequent refills of opioid drugs are statistically more likely to have an episode of misuse, even years after the index surgery.” ~ Study authors After examining the data from over one million American patients who had surgery between 2008 and 2016, researchers found:

  • 56% of patients filled a prescription for an opioid pain medication.
  • 5906 of those given opioids misused their prescription.
  • The rate of opioid misuse increased the longer the drug was taken.
    • 2009: 183 cases of misuse per 100,000 person-years
    • 2016: 269 cases of misuse per 100,000 person-years

This was somewhat confusing and counterintuitive because of how the opioid drugs were prescribed over the long. For instance, the rate at which the pain medications were prescribed was highest early on. They then remained relatively stable for several years before decreasing. But the study found that for every week a patient takes a painkiller such as OxyContin, their risk of misusing that drug increases by 20%.  Similarly, each time they refilled that prescription, their risk of opioid misuse jumped 44%

It’s Not the Dose – It’s the Duration

Furthermore, as time went on, the dosages went down and were more spread out. This is significant, because it indicates that how much of an opioid drug is taken may not matter as much as how often. For example, when patients were given opioids for less than two weeks, the rate of opioid drug abuse among patients receiving the daily equivalent of 40-50 milligrams of morphine was roughly the same as those patients who were prescribed triple that amount.

Pseudoaddiction is a Real Possibility

“Under-treatment of acute pain increases the risk of pseudoaddiction, chronic pain, and, potentially, overdose.” ~ Study authors Patients whose pain is not being treated effectively will of course seek more medication, initially in the hope that their pain level will improve.  This is known as pseudoaddiction, a condition marked by abnormal behaviors closely resembling those seen with a true addiction. Pseudoaddiction progresses through three distinct phases:

  • The patient is given insufficient medication to meet their pain needs.
  • The patient increasingly requests more or stronger medication.  These requests are accompanied by behavioral changes born from a need to convey the severity of pain.
  • Mistrust grows between the patient and the doctor. The patient feels that their doctor indifferent to their suffering, while the doctor worries that their patient is drug-seeking for abuse purposes.

But when opioids—even ineffective ones—are taken long-term, a true addiction can develop.  Then, instead of seeking opioids simply to relieve pain, the person will feel an uncontrollable compulsion to use, regardless of any negative consequences.

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Effectively Managing Pain is Critical

“In light of the national opioid abuse epidemic, these new results underscore the importance of developing effective, multimodal approaches to managing common painful medical conditions.” ~ Mark Olfson, Dr. MD, MPH, Professor of Psychiatry, Columbia University Medical Center It seems one of the best ways to guard against the development of an opioid addiction is to give the patient enough medication to ease their pain at the beginning of treatment, even if that means giving higher doses. In other words, when their pain is alleviated, most people will not seek out more opioid painkillers, thereby negating the possibility of progress into dependence, misuse, and addiction. This ties in closely with another recent study that uncovered a direct link between severe pain and the risks of becoming addicted to opioid painkillers. Per researchers at Columbia University, patients experiencing moderate-to-severe pain are 41% more likely to develop an addictive disorder involving prescription opioids than those who are without pain. Of special relevance, people suffering pain are more likely to have:

  • A recent personal history of alcohol or drug use
  • A family history that includes an Alcohol Use Disorder
  • Mood/Anxiety disorders

Different demographic groups also have different vulnerabilities. For example, males and young adults are more likely to abuse prescription painkillers, while females and older adults are more susceptible to pain. “In evaluating patients who present with pain, physicians should also be attentive to addiction risk factors, such as age, sex and personal or family history of drug abuse. If opioids are prescribed, it is important for clinicians to monitor their patients carefully for warning signs of opioid addiction,” advises Dr. Olfson. This study analyzed data from more than 34,000 adult patients of both sexes and varying ages.  It was published in 2016 in the American Journal of Psychiatry.

Opioid Abuse in the Bellevue Area

According to a June 2017 bulletin from the Seattle Field Division office of the Drug Enforcement Administration, drug overdose deaths in King County are at their highest levels ever.  Significantly, 63% of those deaths are because of opioids.  In fact, for the past seven years, opioids have accounted for two-thirds of all fatal overdoses in the area. While prescription opioid deaths in Washington State are down from their peak of a decade ago, they remain high and have plateaued over the past few years. But what many people fail to realize is that prescription painkillers such as OxyContin and Vicodin presents another danger—they are gateway drugs leading to even deadlier opioids like heroin, fentanyl, and other illicit drugs. As regulations tighten and anti-abuse measures increase, legitimate pain medication prescriptions are becoming harder and harder to obtain.  This in turn drives up the street prices within the illicit drug market. OxyContin pills can cost close to $100 apiece when purchased illegally. Heroin, on the other hand is plentiful and cheap in Washington State.  Huge quantities of “smack” are produced in Mexico and smuggled north. A single dose of heroin can be purchased for less than $10 in and around Bellevue. 4 out of 5 people in treatment for heroin addiction report that they started out by abusing their prescription pain medication.  Over 90% of addicts admit to switching to heroin because prescription opioids are “far more expensive and hard to obtain.” That scenario is playing out in Bellevue and in the rest of King County right now.  Between 2009 and 2014, overdose deaths involving prescription painkillers have decreased significantly, but during that same timeframe, heroin fatalities have more than tripled. Over 70% of IV drug addicts use heroin.  Consider that when you learn that almost seven million needles were exchanged in King County in 2015.

What About Fentanyl and Other Synthetic Opioids in Bellevue?

But as bad as heroin is, fentanyl and its analogues are potentially even deadlier.  Fentanyl, a completely synthetic opioid, is at least 50 times more potent than heroin. At that strength, a dose as small as 3 mg could kill a full-grown man. But here’s the real issue—low-grade heroin is often cut with or even completely replaced with fentanyl, and there is no easy way to tell the difference.  This means that when someone buys what they mistakenly think is heroin and they take their “normal” amount, the can easily overdose and die. It is potentially even more dangerous when fentanyl is used to make counterfeit pills resembling other legitimate opioids. This is exactly what happened in the case of the overdose death of musical legend Prince. In fact, fentanyl is so powerful that it can take multiple administrations of the emergency overdose reversal drug Narcan to revive the victim. Other synthetic analogues of heroin are even worse. Carfentanil, U-47700. Pink, and the Grey Death are much more powerful than heroin—in some cases, thousands of time stronger. Rocker Tom Petty had both fentanyl and a number of analogues in his system when he died recently. This is already happening in the Bellevue area. In October 2017, King County Public Health alerted residents by saying, “The risk of overdose from fentanyl and this latest batch of fake pills reinforces the need for users to be aware that fentanyl is circulating in our community and may be hidden in pills and other illicit drugs.”

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The Bottom Line about Opioid Abuse in Bellevue

There are a few takeaways from this information. FIRST, opioids should only be prescribed as a last resort, after other methods of pain relief have proven ineffective. Options may include any combination of:

  • Weight loss
  • Diet
  • Exercise
  • Physical therapy
  • Massage
  • Heat and ice therapy
  • Meditation
  • Yoga
  • Acupuncture
  • Hypnosis
  • Over-the-counter analgesics

SECOND, when opioid painkillers absolutely MUST be prescribed, it should be for the shortest duration possible and at the lowest dose that alleviates pain.  There should be frequent follow-ups. THIRD, always have an honest and open conversation with your healthcare provider about any personal or family histories involving substance abuse or mental illness. FOURTH, if you or someone you care about is dependent on or is misusing an opioid prescription, the best time to get specialized professional care is always RIGHT NOW.  Addiction is a progressive disease that only gets worse when left alone, and that can lead to worsen consequences such as incarceration, insanity, overdose, and death.