Sunday, April 16, 2017

Bad Solution #2: Aversion Therapy

Another flawed solution to this "opioid epidemic" is born out of good intentions, and it is the one at the top of the FDA's list of solutions to the problem. It involves making prescription opioids "unappealing" to those solely interested in the euphoric component and "getting high."

Naltrexone and naloxone are two medications that are used in addiction recovery. Both of these drugs work in the body to directly counteract the effects of opioids. These and other similar medications are now often being paired and manufactured with opioids. They can be formulated so that, when the opioids are taken "properly" they will pass through the individual and eventually be harmlessly purged through urination and perspiration. These are prescribed for those feeling pain and work just as effectively as the traditional opioid-only prescription medications. If, however, the medication is misused--like when a pill is crushed for snorting or for processing into an "injectable" form--the opioid-blocker part of the medication kicks in. Although manipulating the medication in this way would normally increase the speed at which the opioid is metabolized and increase the speed and intensity of the euphoria experienced by the user, the "partner" in this medication tandem prevents the opioid from working altogether, and can actually induce the unpleasantness of withdrawal effects.

The downside here is that the medication must be inappropriately manipulated in order for the opioid blocker to activate. There is nothing to stop someone from keeping the medication in tact and then still overdosing on the medication in its natural form. This idea is, however, being touted as the best solution to this opioid epidemic as though any attempt to abuse the medication will prevent it from working, but it must be misused in a very specific way for this solution to work. In short, it prevents misuse, but not abuse, of the medication.

The alternative would be to find a way to manufacture a drug that prevents abuse which is a far greater problem than the misuse I was just describing. "Antabuse" (not kidding, that's its name, but the generic drug is called Disulfiram) is a drug that has successfully been used to help alcoholics shake off any "desire" they might have to drinking. This medication creates the nauseating effects of binge drinking every single time a person drinks. The premise is simple, have the brain either associate something negative (like nausea, vomiting, and a headache) with the intake of certain substances. It is a very effective program, and certainly, something similar could be developed to pair with opioids, like ipecac that would make a person violently ill every time they took the opioid. However, the downside with this tandem is that you have to take it voluntarily and only a person who wants to avoid the euphoria and break their own desires for that "high." Obviously, it would have no appeal for those legitimately taking opioids for pain relief. It would only serve those who have made a conscious choice to associate the effects of opioids with something negative.

Neither of these options are good options in the sense that one (the first) operates completely on a principle of distrust and the other only works in an environment of total trust.

The net result of these approaches, and, to repeat, the first one is being touted by the FDA as the best solution to this current societal problem, is that it treats all opioid users, including the predominant users who are in genuine pain, as the criminals responsible for causing the problem. And yet, the worst of it is the reality is that anyone intent on abusing opioids can still freely do so.

Next post "Bad Solution #3: Just Deal with It," will be published on or about April 30, 2017.

Sunday, April 2, 2017

Bad Solution #1: Association Theory

There are several ideas for how to best handle the "Opioid Epidemic." One of the approaches focus on demonizing the individuals who are "contributing" to the problem--those who are originally prescribed the medication. Some of these are people who were at some point in their lives experiencing a significant amount of pain and for whom, the usual methods of quelling that pain were insufficient. They did exactly what they should do in such circumstances: seek help from their local family doctor if they can get in quickly enough or the more likely case of seeing whichever doctor happened to be on-call at the local Urgent Care center.

These doctors, in response to the expectations and limitations of what insurance companies have deemed acceptable practice, gave these individuals the narcotic of the day. Why some doctors favor hydrocodone (Vicodin) over oxycodone (Percocet) over codeine (Tylenol #3 or #4) is anyone's guess since most general practice or family practice doctors know very little about the difference between those medications other than they are part of what has become standard issue. However, in whichever the case, doctors are allowed to prescribe up to a month of medication and since the likelihood of seeing that patient again is small, they have to gauge what is an appropriate amount to tide the patient over based on their assessment of the patient's pain level with a recommendation to seek assistance from their family doctor who will then be able to make a referral to a pain management doctor if they feel that is warranted and the pain continues to persist beyond the 30 days of script.

Of course, pain that does persist beyond 30 days of opioid relief would technically be considered chronic pain and require the intervention of a pain management doctor. However, getting in to see a pain management doctor will likely take a few additional months at a minimum and leave the regular non-specialist in charge of managing the patient's opioid scripts.

Well from the very first script administered, there is no telling how effective the original opioid will be. There are subtle differences between the different opioids out there (beyond potency) and those differences will mean that while some will work fantastically well for relieving an individual's pain, others will have almost no pain-relieving effects and still others will have direct effects or side effects that are unpleasant in the least and nearly fatal at most.

One of the most significant consequences of this, very typical, situation is that people end up with an abundance of prescribed opioids that they are adverse to taking, yet fearful enough of the pain to not want to simply dispose of them. Never having had the need to secure their medication in a locked encasement or at least hide it from anyone, most individuals new to taking opioids will treat them no differently than any other medications they have been taking at various times in their lives. Then, the local and national media puts out stories about how enticing these drugs are and rather than risking getting caught in some salacious drug deal, everyone from innocent and ignorant teenagers to genuinely malevolent drug seekers find that they suddenly have easy access to either easy money or an easy high or both.

Meanwhile, there is an important, but smaller subgroup of chronic pain survivors who are doing what they need to--safeguarding their opioid medications because without them, they are living in extreme and incessant pain, or as I refer to it: relentless agony. They are not responsible for the influx of opioids on the street and in the local schools. However, the reaction by legislators and the media is to lump everyone who picks up a script from their local pharmacy as someone who is responsible for the idiot kid "with the bright future, who never did drugs before this incident" dies from an overdose because he didn't seem to understand that a person who isn't in pain and hasn't been issued a prescription shouldn't take three times the daily maximum of that opioid at one sitting.

Sorry, but the real demons here are the ones committing the felony by selling and dealing the drugs, and the ones who are taking those drugs deliberately intent on getting high, and the idiot legislators and media reporters. Before society can understand what the best solution to this problem--this "opioid epidemic"--is, they need to understand that associating chronic pain survivors with drug dealers and drug addicts is unfair and, itself, contributing to the ongoing problem.

Apologies for getting this post out a week late. Beginning with this post, I will be back on a two-week schedule. Next post, "Bad Solution #2: Aversion Therapy," will be published on or about Sunday, April 16, 2017.