The Kaiser Family Foundation and the Washington Post have released a survey of prescription opioid users to the general public. Reading through this survey and the accompanying explanations does not seem to match a few realities about the ongoing opioid epidemic. Some important dimensions of addictive drugs are left out. It is not clear to me who designed the survey. My only intent here is to critique it from the standpoint of an addiction psychiatrist and the current literature on what may have been more comprehensive questions. The key dimension with opioids and any other potentially addictive drug is that a drug is being prescribed and a certain part of the population will over administer as a result of their biology. The exact percentage of people with that tendency is unknown. After reading through the survey results, this survey suggests the number of people is about a 30% - but there are some red flags. Other literature suggests that the number is lower. The current opioid epidemic correlates with wider availability of these medications.
In order to understand the right questions to ask in a survey to detect problems with opioid use a brief review of the reinforcing effects of opioids are in order. On the positive reinforcing side many people feel and intense euphoria with first use. Many report increased energy and a sense of well being. In some cases people feel that they are thinking more clearly and in the extreme that their personality has been transformed. Many people report that they feel like they have been transformed into the person they thought that they could always be. All of these perceptions of the effect of opioids are highly reinforcing of future use. It also highlights the problem when opioids are given for minor injuries in that a susceptible population is being exposed to these effects. Another area of concern is post operative use. A significant number of people continue to take opioids long after surgical procedures are done and wound healing is accomplished.
Another source of positive reinforcement is what has been considered self medication. When a medication has the properties noted in the previous paragraph, it can take on magical qualities. In American culture illicit drugs and opioids in particular take on magical qualities. They are seen as the silver bullet for acute and chronic pain - when neither case is true. When that belief is widespread and the medication reinforces its own use - people begin to use it for insomnia, anxiety, depression, and as a general solution to stress. Some people will report that they just "don't want to feel anything" and will take enough of the drug to do that. Taking the medication for these secondary effects can also reinforce use and lead to escalation of the dose.
Negative reinforcement is another aspect of addictive drugs. In the case of negative reinforcement, the frequency of any behavior to decrease the response to an aversive stimulus increases. With opioids the aversive stimulus is opioid withdrawal and the early symptoms are associated with cravings to use opioids and continue the addiction. During that phase of addiction there is typically a tolerance to the euphorigenic and other positive reinforcing effects of opioids. People are using opioids at this time primarily to prevent withdrawal but now the withdrawal has a host of associated effects like insomnia. anxiety, and depression that also must be avoided.
That landscape of addiction, tolerance, withdrawal, positive reinforcement and negative reinforcement does not make this an easy problem to study. There is an even larger problem and that is that decision-making is compromised in the direction of continuing the addiction. That translates to dishonesty about use and in many cases dishonest behavior necessary to acquire and use drugs. That dishonesty in the service of addiction is a major problem in studying addiction and providing clinical services. It is the reason for toxicological testing, collateral information, and establishing sober environments with no access to intoxicants. Any survey of patients with potential addictions should address how this issue has been handled in the sample. Studies have been done on the predictive value of specific behaviors with opioids like purposeful oversedation, lost prescriptions, mixing alcohol with opioids, early prescription renewals, etc. but many of these stuides also depend on self report.
How does the KFF/Washington Post survey do? First off the random sample is a combination of people using prescription opioids (N=807) or in the household where a person uses opioids (N=187). The indication for opioid use is chronic noncancer pain. The threshold was using for two months in the past 2 years. Only 55% of the respondents were currently taking opioids. The study was all done by telephone interview. The respondents ranked prescription painkiller abuse as a serious problem (84%) and only slightly less serious than obesity, cancer, heart disease, alcohol abuse or heroin abuse (89-95%). The lowest ranking of seriousness in that category was heroin abuse at 89%. 25% of the respondents began taking opioids for postoperative pain and 44% for chronic pain.
The section on motivation for using opioids indicated that pain relief was the major reason people were taking opioids and 92% or people ranked pain relief as either "very well or somewhat well". Secondary reasons included dealing with stress, to get high, or to relieve tension (12-34%). Of the secondary reasons getting high has the highest ranking of 34%. There are several chronic pain studies that suggest that for chronic neuropathic pain - the relief from opioids is on par with pain relief from non-opioid medications for the same application.
Physicians did not get rated very highly in the survey with only 2/3 of them warning patients about the addictive potential of opioids or talking about non-opioid strategies for treating pain. Only 1/3 of physicians had a plan to get people off opioids. Physicians did better in terms of warning patients not to use alcohol concurrently with opioids and discussing side effects but only slightly better in terms of advising patients on keeping opioids out of the hands of others.
In medical practice, especially with electronic health record systems there is often an emphasis on pre-existing alcohol or substance use disorders. The closest this survey comes is to ask about the number of alcohol drinks per week. About 22% of respondents had more than one drink per day. There is a lot of room on the high side. There is also a dissociation between known addictive disorders and opioid prescriptions. Many physicians believe that people with a known addictive disorder to a non-opioid including alcohol can control their use of opioids for pain. They are often reassured by these patients who tell them that they have never had a problem with opioids.
Only 18% of respondents had difficulty getting their prescriptions refilled. That contrasts with the 1/3 of patients taking the medication to get high.
The degree of polypharmacy in the sample was striking with 32% taking 7 or more prescription drugs and 25% taking 4-6 prescription drugs. Slightly over half of the sample were taking medications for insomnia, depression or anxiety. Benzodiazepines and z-drugs were not specified. The survey did ask about alcohol use while taking opioids and it is a clear problem. In addition practice it is common to see patients who are using benzodiazepines and z-drugs with opioids. It is also common to see people taking one, both and both in combination with alcohol. In addiction practice it is important to determine if anxiety, depression, and insomnia are primary, caused by the addiction, or associated with chronic intoxication or withdrawal states.
On the specific question of risk of addiction 2/3 of respondents said that "The benefits of pain relief outweigh the risk of addiction." One third of the sample said they were dependent on the drugs and would find them hard to stop. When that question was rephrased with the description "addicted" 23% thought they were addicted to the painkillers. Of the respondents who thought they were dependent or addicted - 1/3 sought treatment and 2/3 did not. An interesting study might look at videotapes of the informed consent procedure and what information the patient recalls after that procedure. My experience suggests that a large percentage of people who are actively using opioids and alcohol do not recall what was said in the initial consultation by comparison with the documentation.
The survey attempts to parse blame for the prescription painkiller epidemic and in that series of questions the groups ranging from most to least blame (61% to 15%) were ranked the patients themselves > doctors > drug companies > government > hospitals > law enforcement > pharmacies and pharmacists. The key elements here are wider access to opioid medications as a result of an initiative to treat chronic pain and a movement away from gatekeepers.
Given the limitations of a survey, I thought that the self assessment of the number of people who though they were dependent or addicted to painkillers was striking. The number of people seeking treatment though low is much higher than what has been estimated using other methodologies like the NSDUH survey. It may suggest that survey technologies alone or in combination with other corroborative methods may be useful in further studies of this phenomenon. One of the real questions out there is the number of people in the wild who are at high risk for the initial highly reinforcing properties of opioids. If I had to guess, I would put that number at about 40% of the population. There is a significant and slightly smaller group who get immediate negative effects and do not tolerate opioids at all. By definition, there may be a safe third portion of the population who can benefit from opioids with very low addiction risk. Clearly defining that population, hopefully with biological markers would have a significant impact on the problem of addiction to opioids. It would also have implications for a more elaborate diagram of the neurobiology of opioid addiction.
For physicians the problem is as clear as ever. The vast majority of this sample (95%) got prescription pain relievers to alleviate their acute or chronic pain and 1/3 end up using the drug for other reasons including getting high. That is due to the inherent properties of addictive compounds. The practical problem is how to address that risk in medical practice.
George Dawson, MD, DFAPA
References:
1: Drew Altman. Understanding Who Opioid Users Are Underscores Challenges. December 19, 2016. KFF.org
2: The Washington Post/Kaiser Survey: 1 in 3 Long-Term Prescription Painkiller Users Think They’re Addicted or Dependent. KFF.org
I think you may be leaving out a few additional factors that patients also frequently lie about (in addition to how much they are using and why they are using). I believe that people are not as stupid as they act, and I have found that addicts know as well or better than anyone the risks and dangers of their drug use, and yet they do it anyway. Even when they no longer experience a pleasant high from it.
ReplyDeleteI also know they can control their intake when they want to because they do that all the time. For example, most addicts will choose not to purchase or take a street drug right in front of someone they know might call a nearby cop - unless they want to get arrested for some reason. Misuse of drugs is on some level purposeful, self-destructive behavior, and that is usually caused primarily by ongoing and repetitive disturbed family relationships combined with a history of trauma, enabling, neglect, and/or chaos growing up. Nobody even asks these folks about that sort of thing! Or if a doctor does ask, they accept the first answer they get, as if people were all gung ho to talk about shameful family issues.
Any addict can control their intake to a point. Koob's longstanding observation that addiction transitions from positive reinforcement (euphoria) to negative reinforcement (withdrawal avoidance) can be observed in a detailed interview of any addict. These days there are more options than ever for drug substitution - even diversion of legally prescribed buprenorphine.
ReplyDeleteThere is also the issue of how addiction is defined. Volkow's current definition is that it is only severe DSM5 use disorder (the max criteria). It is well known for example that DSM-IV studies of male college student drinking patterns shows that a large number of these men meet criteria for alcohol use problems but that fades over time and the majority stop using. The same is true for cannabis use. These people are much different from the person who is in residential care because they absolutely cannot stop using even with the real or threatened loss of a spouse and a job. They are much different from person drinking 1/5 of vodka or whiskey a day for years or decades.
In doing the suicide assessment of people with addictions a useful question I have found is: "Have you ever found yourself at the point where you knew your drug consumption was dangerous but you didn't care? You were so determined to try to get high - you didn't care if it killed you?" A significant number of people will endorse this even though they deny any conscious intention of killing themselves.
The pathways to addiction are varied. There are now second and third generations of opioid and stimulant users and many more generations of alcoholics. There are substantial numbers of people who are casualties of the "pain as a fifth vital sign" movement as well as the "ADHD with no clear impairment" movement. There are shocking numbers of 20 year olds who start using opioids as teenagers from the family medicine cabinet, from friends with opioids, or from prescriptions for what used to be considered routine injuries. I don't ever recall getting oxycodone or hydrocodone for a sprained ankle in high school sports. Many (most) of these young people come from privileged backgrounds and no childhood adversity.