Opioids and the Slippery Slope of Addiction

Dear Cindy:

There are 2.1 million people suffering substance use disorders related to opioid pain relievers, according to a report to Congress by Nora Volkow, M.D., director the National Institute on Drug Abuse. Opioids—prescription and illicit—are the main driver of drug overdose deaths. Opioids were involved in 33,091 deaths in 2015, and opioid overdoses have quadrupled since 1999 according to the Centers for Disease Control and Prevention (CDC). Women over fifty have been fueling this growth in prescription opioid drug use disorder.

The CDC has been clear about the cause of the crisis: overprescribing of opioids, especially for chronic non-cancer pain. Opioid prescribing began increasing sharply in the 1990s, largely in response to a pharmaceutical industry-funded campaign that minimized opioid risks and exaggerated benefits. The increased prevalence of opioid addiction, caused by overexposing the U.S. population to prescription opioids, has also led to rising rates of heroin use in non-urban communities and other health and social problems.

I can understand that you feel that it is unfair that the new state monitoring program in New York has prevented your medical team from dispensing the Percocet that you felt helped with your back pain and unexpectedly helped with mood and energy. Prescription Drug Monitoring Programs (PDMPs) are state-run electronic databases used to track the prescribing and dispensing of controlled prescription drugs to patients. They are designed to monitor this information for suspected abuse or diversion (i.e., channeling drugs into illegal use), and can give a prescriber or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help prescribers and pharmacists identify patients at high-risk who would benefit from early interventions.

The Prescription Monitoring Program used in New York State is known as I-Stop (Internet System for Tracking Over-Prescribing). Most prescribers are required to consult the Prescription Monitoring Program (PMP) Registry when writing prescriptions for Schedule II, III, and IV controlled substances. The PMP Registry provides practitioners with direct, secure access to view dispensed controlled substance prescription histories for their patients. Patient reports will include all controlled substances that were dispensed in New York State and reported by the pharmacy/dispenser for the past year. This information will allow practitioners to better evaluate their patients’ treatment with controlled substances and determine whether there may be abuse or non-medical use.

It is important, Cindy, that you understand that the Prescription Drug Monitoring Program Registry is intended as a tool for the physician to determine if a controlled substance e-prescription is appropriate. It remains up to the physician’s discretion whether to write a controlled substance e-prescription. Your impression that the doctor was afraid of being “investigated” if she wrote another prescription for Percocet is unwarranted. Physicians in New York undergo extensive training in pain management with post training testing to document that they understand the cause and extent of the opioid crisis in America and how they can better care for patients with acute and chronic pain without contributing to the national epidemic of opioid addiction. The physicians in New York State are part of the solution to this national epidemic that is a growing cause of unnecessary deaths in all age and socioeconomic groups. They understand that it is important not to be an ongoing part of the cause of inappropriate prescribing of opioid medications.

Cindy, you may not know that Percocet is the trade name for a prescription pain reliever that contains Oxycodone, an opioid analgesic—or narcotic painkiller—with similar effects as heroin and morphine. Percocet is prescribed for short-term relief of moderate to severe pain that is not typically chronic in nature . Like heroin and morphine, Percocet affects the brain and the central nervous system, changing the way the brain perceives pain.

Percocet acts on opioid receptors throughout the body to initiate a cascade of chemical events that ultimately modify pain perception and elicit a dopamine response in key regions of the brain. Dopamine is a neurotransmitter that plays an important role in the brain’s reward system circuitry—instrumental in delivering feelings of pleasure and motivation, as well as reinforcing behaviors that initiated the dopamine release to begin with.

When taken in large doses, Percocet can cause a “high” similar to heroin that is characterized by:

  1. Euphoria.
  2. Feelings of calm and relaxation.
  3. Heightened pleasure.

Percocet and other prescription drugs are often mistakenly viewed as a safer way of getting high than using illicit street drugs, like heroin and cocaine. People may think that since a doctor is prescribing the medication that it must be safe and effective for their needs. Unfortunately, however, Percocet abuse can lead to the same dangerous problems of dependence and addiction as the illicit street drugs that share its origin. There are several validated screening tools to help providers assess the risk of possible opioid misuse. It is critical that all patients be screened prior to initiating opioid therapy. Validated screening measures include the Screener and Opioid Assessment for Patients With Pain. Your doctors were right to be concerned that you may have developed an unhealthy dependence on the Oxycodone, the main ingredient in Percocet.

Cindy, recognition and acceptance of a problem like this is the first step to finding a solution for control of your pain and evaluation of your dependence on Percocet use. You will be best cared for with evaluations from both a pain management team and an addiction specialist.. It may take some time and much effort to find other ways to deal with your pain, longstanding anxiety and now the Percocet withdrawal mood issues. Much is at stake here: your health, the relationship you have with your family and adolescent daughters and your opportunity to have a productive work life.

Dr. Megan Riddle will discuss the psychological and physiological implications of overuse of opioid medication in the setting of pain management and addiction treatment.

Dr. Pat

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