Search for tag: "opioids"

Interviewer: We know here in the United States, the opioid crisis and the addiction to those drugs is a real concern. But when it comes to the medical side of things, what is opioid addiction?

Joining us today is Dr. Elizabeth Howell. She is an Associate Professor of Psychiatry and the Director of Addiction Psychiatry and Addiction Medicine Fellowship at University of Utah Health and Huntsman Mental Health Institute. Now, Dr. Howell, just to kind of start out, like, when it comes to your perspective, what is opioid addiction?

Dr. Howell: Well, everybody has their own thoughts about it. But if you want to look at the official definition, we would look at something called the DSM, the "Diagnostic and Statistical Manual 5th Edition" of the American Psychiatric Association, and they have 11 criteria. And if you have two or more of those criteria, you have either mild, moderate, or severe opioid use disorder or other use disorders. But I think a simpler way to think about it, because I don't think the general public goes around memorizing the DSM-5, is to think of it as loss of consistent control over use of a substance, continued use in the face of adverse consequences, compulsivity or craving. And then the other part can be denial, and it doesn't mean that you don't know there's a problem, but you're not in touch with how many ways the use of the drug is affecting your life.

Interviewer: So those are behavioral things that we're looking for.

Dr. Howell: Right.

Interviewer: But when it comes to, say, biologically, physiologically, I guess, what is going on when we get into this? Because I've heard that it's not actually the drugs that are causing the addiction.

Dr. Howell: Right. The addiction is actually in the brain. And, you know, there is no addiction without a brain, so we don't know in the field if there's something different about people who get addicted before they ever use or if the drugs cause the brain to change or both. And that's a big mystery. There's actually a really neat study that we're part of at HMHI, called the ABCD Study, that may shed some light on that. But for now, we don't have the answer to that. So what we do know, though, is once people have started using regularly is that the brain is different and it doesn't react the way that the brain of someone who doesn't use drugs reacts.

So, for example, people tell me all the time, "I don't understand why they don't just quit using because I can have a drink and then stop." But the point is that that person's brain is very different than the person's brain who is unable to stop when they start. And there are a lot of different brain changes that happen, and it's interesting because you can actually track some of these brain changes to specific behaviors. So, for example, you know, being out of touch with the consequences of your actions, or not having strong feelings about anything except drugs, those can all be traced to different parts of the brain. So it is behavioral, but behavior comes from the brain and addiction and drug use change how the brain reacts to normal things in our lives.

Interviewer: When we say that the brain is different, I guess, does that mean that there are certain people that are more susceptible to addiction? Does that mean that, you know, is it nature? Is it nurture? Or are certain people just born that way? Do people, you know, grow up leading towards addiction?

Dr. Howell: It's really both. About 40% to 60% of the risk is genetic. That's only 40% to 60%. Some of the other risk comes from life experiences or, you know, where you grow up. If you grow up in a family where everybody else is drinking, of course some of that is genetic, but it is also environment and you are exposed to that. But also, trauma is a huge risk factor for addiction. Trauma, traumatic experiences in childhood, especially, can change the brain in a way that you're much more susceptible to either wanting to use, or when you do use, losing control over your use.

Interviewer: Thinking of those patients, you know, or maybe a loved one is listening right now and they have someone in mind, what kind of treatments are available? Because, I guess, one of the things I want to ask first before you get fully into the treatments is, is there a cure for opioid addiction?

Dr. Howell: There's no cure, as I think of a cure. There is treatment. And this is very similar to other illnesses that we treat in medicine. So, for example, if you have high blood pressure, there's probably no cure. You can definitely treat it. You can do things. You can lose weight. You can exercise. But even people who are very thin and very athletic can have high blood pressure. It's a medical condition. You can do everything you possibly can with your life and you could still be suffering from addiction. You might try everything. You still have, for whatever reason, a very high risk of continuing to be unable to control your use, having craving, etc.

But the treatment that we have tries to at least arrest the process. So for opioid use disorder, one of the most effective treatments we have is medication for opioid use disorder, and this can be kind of controversial for some people, but methadone, buprenorphine, naltrexone, are all different medications that they work in different ways a little bit, but they do help people stabilize so that then they can get their lives back together, and then the behavioral treatments can work a lot better when your life is more stable.

So, really, treatment has to be a combination of things, and it doesn't happen overnight. There isn't a magic medicine, a magic bullet as people call it, to treat any kind of addiction, especially opioid addiction. And the medications only work when you're taking them. Once you stop taking them, your brain is still different and you can start having craving years after you ever used an opioid. And that's the disease if we want to call it a disease, or that's the difference in the brain is that the brain is always going to be seeking the drug even when the other parts of the brain know that it's destroying someone's life.

And I hear this from patients all the time. "I know this is killing me. I don't want to use, but I can't stop." And that's the terrible conundrum that people have when they're in the middle of their addiction and they want to stop. So our treatments are really to help them be able to stop safely and then try to get their lives back together and hopefully heal up some of the brain changes that have happened over the course of their addiction so that they can live a life without being addicted.

Interviewer: So now that we know a little bit more about opioid use disorder and how some of the physiological things that actually comes with this type of addiction, if there is a listener that either themselves or someone in their lives, you know, might be going through this kind of struggle, where do they start to get this treatment, to get this kind of, you know, get on the road to recovery or, I guess, remission if this is a disease?

Dr. Howell: You know, sometimes you can go to your primary care doc or provider and get some help. There are more and more primary care providers who are prescribing medication for opioid use disorder. But then there are others who don't or they don't feel comfortable with it, or they don't know that much about it. And so, then, you would go preferably to an addiction specialist of some kind. The fellowships that I run, the Addiction Medicine and Addiction Psychiatry Fellowships train physicians who finished a residency in a primary specialty to be addiction specialists and to be able to treat regular opioid use disorder and other addictions, but also how to be specialists for people who have really complicated problems, because often we see the patients who've been through many different kinds of treatment and nothing has really taken hold for them and we need to get a little bit more sophisticated or refined about how we're treating their specific addiction. And the medication is only part of it. By no means is it the only thing that you have to do. You can't just throw a medicine at somebody and expect that their opioid use disorder is going to be just fine. It doesn't work that way.

So what you would do is if you, you know, you could start with your primary care provider. If they are not knowledgeable or comfortable, then, you know, one of the things that you can do is you can call, actually, our University HMHI crisis line and they can often help people get connected to treatment because you may need to go in the hospital. It may be that severe. And yet you may just need outpatient treatment, and they can help people sort that out and figure out what's needed.

We also have a recovery clinic over at HMHI, and it's staffed by addiction psychiatrists and addiction medicine specialists and therapists and other staff. And our trainees also work there, and they can help with evaluations and recommendations for treatment. And if you can get treatment at HMHI, fine. If not, if your insurance doesn't cover it there, then we can help send, you know, refer you out to wherever you can get the treatment with your insurance coverage.

Interviewer: And for a listener who might not be in the state of Utah, I assume that there are similar crisis lines in other places of the world?

Dr. Howell: Right. Yeah. So if you're not in Utah, it varies drastically around the country, but there's generally a community crisis line. And the other thing is that there is a 1-800 number through the Substance Abuse and Mental Health Services Administration. But there is a website, and I think it's called "Find Treatment Now" that you can look up and find all kinds of treatment options within your ZIP code and within a certain range from your home.

Interviewer: And for listeners who might be interested in, say, those different resources, they'll be linked in the episode description, if you want to click on your app or on the website. Now, Dr. Howell, I guess the one last thing I kind of want to ask to kind of wrap this up is, what kind of hope do family members and people suffering from this disorder, you know, have when they get into treatment?

Dr. Howell: You know, most people come in to treatment and their families are pretty hopeless feeling. And I'm not trying to sugarcoat addiction. It is a disease that can be fatal, but it's not uniformly fatal. Even without treatment, a lot of people get better over time. But especially with treatment, it can accelerate that process.

There's two things that, I think, are important for opioid use disorder. One is if you are someone with opioid use disorder or you care about somebody who has opioid use disorder, you should definitely get a naloxone overdose reversal kit because the one thing I can't do is help somebody who's dead. And if you die of an opioid overdose when we could have prevented that with naloxone, it's really tragic and unnecessary. So once again, this depends on your community. In Utah, we have utahnaloxone.org and they can facilitate you finding a place that you can get a free naloxone kit to have on hand. And clearly, if you're the person overdosing, you're not going to be able to give yourself naloxone, so it's helpful to have it and for everybody in the family to know how to use it, where it is, etc. I have one in my bathroom. I have a sticker on my door at the house that says, "I have naloxone." And pretty much any addiction provider I know carries some of it around because we never know we could just be walking down the street and come upon somebody who needs to have an overdose reversal. So I would look into that and that's the first thing.

But the second thing is that there is hope for recovery, and I'm always meeting people who are in recovery, who've had severe addictions. I was in another part of the state recently and I was working with a guy on a community event, and he said, "I'm so-and-so and I used to be a heroin addict and, you know, I was . . ." and he told me all about the things in his life that were tragically going wrong. And he made a big change in his life and got into recovery. And I don't know all the specifics, but it's five years later, he's not been using for a while. He's taking care of his children. He's got his own business and he's really successful and he's very happy. So that's what I see can happen. And if you only see the tragic part, you see people in the emergency room or in the hospital with all their complications or you see people who are destroying things in their lives, you feel hopeless. But you never really get to see all the people that do well. And that's one of the nice things about our addiction care system that we have is that we get to see people on both sides, and we're not trying to sugarcoat the tragedies that can happen, but we definitely know people can get better and live productive lives.

Announcer: "Health Hacks" with Dr. Troy Madsen on The Scope.

Dr. Madsen: Today's health hack is using a combination of ibuprofen and acetaminophen instead of an opioid for injuries and pain from those injuries. This is all based on a study. Came out in the Journal of the American Medical Association a few months ago. It was eye-opening for me, for a lot of people I work with because we've always assumed that opioids worked better.

So this study, patients got a combination of ibuprofen 400 milligrams and acetaminophen, also known as Tylenol, 1,000 milligrams. These are standard over-the-counter medications, and they compared it to patients who got opioids. Those who got this combination of ibuprofen and acetaminophen did just as well with their pain. So I think the take home from this would be if you're in the ER and you're offered opioids, ask for some Tylenol, ask for ibuprofen. Avoid the opioids and avoid that addiction potential.

Announcer: For more health hacks, check out thescoperadio.com. Produced by University of Utah Health.

Announcer: Health information from experts supported by research. From University of Utah Health, this is thescoperadio.com.

Interviewer: Dr. Jennifer Plumb is one of the founders of utahnaloxone.org and is also in pediatric emergency medicine at University of Utah Health. From what I understand, the chances of me dying from an opioid-based overdose now is greater than me dying in a car crash. That shocked me when I heard that. Does that shock you? Should I be shocked?

Dr. Plumb: Well, you know, it doesn't shock me because I spend a lot of time thinking about and educating about in this world, but it's the truth. Right now, if you were to look at the most likely cause of death for yourself, opioid overdose would surpass cars, would surpass guns.

Interviewer: Some of this other data that had been released also says that you're more likely to die from opioids than falls, drowning, or even a gun assault. And again, these are all things you hear about all the time.

Dr. Plumb: Right.

Interviewer: We think this is the big threat, but it's actually that little bottle of pills in your medicine cabinet.

Dr. Plumb: Right. Well, or think about your family members, the children in your home, the people around you, as well as yourself, the things that you would be most concerned about, and I'll tell you, when I speak with families about keeping their kids safe, it isn't always on the top of their list of things that they worry about. They think about helmets, and they think about gunlocks, and they think about car seats.

Interviewer: All good things.

Dr. Plumb: Really important, smart things that we should all have in our homes. We should all have fire extinguishers. But for whatever reason, we have not been as astute and as knowledgeable about opioids and their potential risk in our homes and in our lives. We've gotten to this dreadful point.

Interviewer: Now, are we talking about pain pills or overdoses on legal opioid-based drugs?

Dr. Plumb: More illicit substances?

Interviewer: Yeah.

Dr. Plumb: So all of the opioids get lumped together when we look at data, and, personally, I think that's appropriate. It really is the substance that's killing someone. And if we go down the path of saying, "Well, you know, pain pills, that's different than heroin," we go down the same path of not acknowledging that, actually, those substances are very chemically similar, and they lead to overdose the same way, and the overdose death risk is equally high for them, and you respond to them the same way with having naloxone. So I think that, for all of us as society members, the key here is thinking about these substances in the same way we think about other risky constructs. So peak car crash deaths were in 1972. That's when we lost the most Americans to car crash fatalities. Think about all the things that have happened since then. We've put in airbags, and we've put in the brake lights. I think they're referred to as Dole lights. We have campaigns about getting people to drive smarter, Click It or Ticket, Arrive Alive, zero fatalities. We have a lot more cars on the road and a lot more people driving cars, but we have decreased those deaths.

We need to start thinking about opioid substances the same way. How do we make ourselves safer and smarter around them? How do we limit our exposure to the riskiness of them? And how do we be prepared for worst-case scenario? Which, I think, every time that we have a new way of looking at this crisis, and every one of them is horrifying, they come out and our life expectancy is going down. We're losing now 72,000 people in 2017 in the United States to opioid overdose deaths. That's 197 people every day. That's a 737 falling out of the sky every single day. Right?

Interviewer: Wow, all right. All right.

Dr. Plumb: I mean, it's enormous. And so we have to be thinking about these substances in ways that I don't want everyone to think, you know, I'm calling fire in a theater. I'm actually really asking be smart. If you do have these in your world, be prepared. What does an overdose look like? How do I respond to an overdose? What if that overdose was in my child? What if that overdose was somebody else around me? And then, if I'm going to allow these substances into my world, do I need them?

So, if you have a physician, a clinician, a prescriber wanting to put opioids in your home, in your life, ask a few things. Is this really necessary immediately? Do we need narcotics? Tylenol and ibuprofen are great options. Physical therapy, occupational therapy, mindfulness, acupuncture, acupressure, yoga, all of these have been shown to really help with pain. Should we look at those strategies first? Okay, we think we might still need those. I have a brother who died of a heroin overdose. Does the fact that addiction is in my family make us any more concerned about bringing narcotics into the home? Have that dialogue.

Then, finally have the dialogue, if it really does seem like they think that's the next big strategy, what's your plan to get me off of this in five days? Because in seven days, you can start having a dependence risk. In seven days, you can start developing that physical dependence on a substance that means that maybe in seven months you won't be able to stop.

Interviewer: Yeah. Or I've heard like if it's a 28-day supply, and 28 days coming off that could be just as hard as coming off if you were on illegal narcotics.

Dr. Plumb: Absolutely the same, exact withdraw, absolutely. So, as consumers and as health care consumers and individuals, we need to take that active role as well in having that dialogue with our team.

Interviewer: Yeah, especially with such dangerous substances. And I think one of the traps that we might fall into is, "Oh, I have a prescription for these drugs. I'm not an illegal drug user. So it's somehow safer." But as you said earlier, you got to judge the substance. The substance is the same regardless of how or why you're taking it.

Dr. Plumb: Right.

Interviewer: And now it's in your world, so what are you going to do to be safe about that? So I think that's a great point you bring up. Talk to your physician if they're going to recommend those, if you have a procedure coming up or whatever. Ask those questions that you asked. If you have somebody in your world that's a drug user, then you should also have naloxone around, because even if they're off now, they could relapse.

Dr. Plumb: Absolutely.

Interviewer: Or even if you just have the prescription opioid pills, have naloxone. It comes back to the substance again.

Dr. Plumb: Absolutely. And it is just like, to me, it really is just like a fire extinguisher. You have a kitchen. That means there's heat. That means there could be fire. Having a fire extinguisher is smart. It's safe, it's okay. Same thing, you have opioids in your world, whether it's for yourself or someone around you, you should have naloxone as well. Be prepared for that just-in-case scenario.

Interviewer: I hope that the big takeaway after somebody is done listening to this conversation is that these are serious substances that need to be treated seriously, and the data shows that a lot of people accidentally die from them.

Dr. Plumb: They do and that they perhaps are not perceiving just how risky they are. Be educated. Be aware. Be prepared.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.

Interviewer: Snail venom as a possible alternative to opioid-based painkillers, that's next on The Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs. "The Science and Research Show" is on The Scope.

Interviewer: Psychiatrist Michael McIntosh is involved in research that's exploring using venom from a small cone snail, which is common in the Caribbean Sea to treat chronic pain. And in this study, the researchers found that a compound isolated from the snail's venom acts on a pain pathway, which is different than the pathway targeted by opioid drugs. Thank you for joining me today. And the first question I have is to explain pain pathways because I think that's going to be an important part of this conversation.

Dr. McIntosh: Pain pathways involve sending the signal from the site of injury, you crushed your finger, processing it up through nerves through a place called the dorsal root ganglia into the spinal cord and up into the brain where we actually sense the pain.

Interviewer: Okay. And how many pain pathways do we have? Do we even know the answer to that question?

Dr. McIntosh: I don't think we know the answer.

Interviewer: Yeah. How many do we know of?

Dr. McIntosh: All the transmissions to sense pain go up through that back part of the spinal cord. But the types of pain and sensations that we can feel come from a variety of different receptors that can experience cold or heat or noxious pain, itch.

Interviewer: The pain that opioids help prevent is a very specific type of pain pathway and you discovered a different type of pain pathway that the snail venom actually affects. Explain that a little bit for me.

Dr. McIntosh: Opioids are outstanding medications for treating acute pain, pain that occurs in the short run. What's more difficult is to treat long standing or chronic pain and in particular, pain that comes from injury to a nerve or neuropathic pain. What these compounds from the snail do is they not only provide relief in the short run, they seem to provide long lasting relief and they seem to do so by actually preventing some of the pathophysiology that occurs after a nerve injury.

Interviewer: So it isn't so much the pain pathway is different, it's how the substance is acting because from what I understand, the body gets rid of the substance within four hours or so, but the pain relief of the snail venom lasts longer than that. Why do you think that is?

Dr. McIntosh: We think that's evidence that there is a rescue mechanism going on, some disease-modifying effect. The data indicate that after a nerve injury, you actually lose nerve fibers, you lose the insulating sheath around the nerves, but if you give this compound, it decreases the loss of nerve fibers, spare some of that loss of myelin and we think those changes then translate into longer lasting pain relief because there's less ongoing injury.

Interviewer: So what came first in this research? Was it the interest that it was a different pathway that this affected or was it . . . and then you discovered the side effect after the fact?

Dr. McIntosh: Really, basic research, our primary interest has been on the components in the venom themselves because they make outstanding tools for studying the nervous system. But there was an observation after injection of this compound that the animal seemed to experience less pain so we began investigating after that.

Interviewer: So you just kind of followed that lead . . .

Dr. McIntosh: Absolutely.

Interviewer: . . . that was presented. And then it's fascinating to me because you discovered that it seemed to lessen the pain but then you have to prove that or show how. I mean, you have to go through a lot of work to get to the end point. Explain some of that process.

Dr. McIntosh: We do. The things generally begin with animal studies and that's helpful. There was a related compound that reached human clinical trials and then the discovery was made that the compound was less effective on humans than it was on the animals because it was less potent on the responsible receptor. Part of our recent research has been to re-engineer the snail peptide into something that is effective not only in animals so you can conduct the animal studies, but also in humans.

Interviewer: And then the delivery is a little tricky too, isn't it?

Dr. McIntosh: Delivery is tricky because it's a small protein known as a peptide. If you swallowed it, your gastric enzymes would just digest it. So in this case, we delivered by what's called a subcutaneous injection much like diabetics use to inject insulin.

Interviewer: And, originally, what made you decide that looking at any sort of animal venom was a good place to start for any sort of research for medicine? That seems very counter-intuitive to me.

Dr. McIntosh: Each species, and there are hundreds of them, has hundreds of unique components in their venom. So there are literally tens of thousands of unique components which are designed to capture prey and, therefore, design to work on the nervous systems. o we felt that this would be a preselected library of compounds designed to act on the nervous system.

Interviewer: Yeah, why create them on your own when nature has created them and then you can see, well, what do they do?

Dr. McIntosh: Exactly.

Interviewer: And then you make adjustments from that point, if I understand correctly.

Dr. McIntosh: That's right.

Interviewer: So the latest bit of research that you did proved what, exactly? Because, I mean, this is a whole series of steps.

Dr. McIntosh: It proved two things. First, that we could take the compound evolved by the cone snails and turn it into a compound that's potentially useful with humans. Secondly, what we showed is that it could be used as a specific called chemotherapy-induced neuropathic pain. In short, what that means is people who get chemotherapy, say for a colon cancer, experience side effects that include damage to their nerves. This often limits the duration or amount of the compound that can be given and it's quite painful and uncomfortable for the patients. What we found, in this case, was that we could give the chemotherapy agent and our compound that we developed and prevent the nerve damage that normally occurs after the chemotherapy.

Interviewer: And what's next step for you with snails, venoms, and pain?

Dr. McIntosh: The next step is to conduct additional preclinical trials with the aim of applying to the Food and Drug Administration for investigational new drug status so that human clinical trials can begin.

Interviewer: And then beyond the chemotherapy, will there be other applications?

Dr. McIntosh: We think so. This appears to be a more general mechanism, so there is a variety of ways that nerves become injured. It can be through a disease process like diabetes and many diabetics have painful neuropathies. It can be through injury, a surgery, car accident, low back pain, things that cause injury to a nerve and the pain becomes chronic.

Interviewer: And I think I may have misled our listeners in the beginning of this interview because I didn't quite fully understand. But what makes this compound, and I think I've said this, but it bears worth repeating, what makes this compound really useful is it not only blocks some of the pain pathways but it also affects the nerve health and helps regenerate them so then the pain will no longer be there for the patient, hopefully.

Dr. McIntosh: That's correct.

Interviewer: That's pretty exciting, isn't it?

Dr. McIntosh: Yeah, that is very exciting. Because we want to get at the root of the problem, not just mask the symptoms.

Announcer: Interesting, informative, and all in the name of better health. This is The Scope Health Sciences Radio.