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.

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Interviewer: So, when it comes to opioids and being prescribed opioid painkillers, do most doctors at this point in time all operate from a similar paradigm when it comes to whether they should prescribe them, whether they should not prescribe them to a particular patient? Or do patients still need to kind of have a working knowledge of opioid pain pills? Because they scare me. I hear some of these stories and they sound a little frightening.

Dr. Miller: Well, as you know, the news is out that opioids are very addictive. The statistic is something like 80% of current heroin abusers had started out on prescription opioids. And so we have a track record in this country now over the last 30 years of overprescribing opioid narcotics for the treatment of pain, and that has led unfortunately to an increase in deaths from opioids and heroin use and other bad things.

So, in answer to your question, there is not a policy about prescribing opioids that applies to all physicians. And, more importantly, we're not yet all completely on the same page about how to use and treat people with opioid painkillers.

Interviewer: Yeah. So, to some extent, the consumer, the healthcare consumer should have a working knowledge. And as somebody that might find myself in the healthcare system, how would I know whether or not it's appropriate for me if all doctors aren't operating from the same paradigm as of yet? And why is that? Why aren't they? Is it just because the information hasn't caught up to everybody yet?

Dr. Miller: I think that's part of it. They're individual prescribing practices, and some physicians don't prescribe opioids very commonly while others do. And presumably, the ones that are now prescribing opioid for pain and do quite a bit of that are well versed in how to use that, setting up contracts with their patients on how to take opioids and when to report in and when to get their refills and so forth.

So there is a spectrum of understanding of how to prescribe opioids. It starts back with medical student training and then residency training. We have not had what I would consider to be top-of-the-mark training in opioid use throughout our medical training, and that's changing over time.

Interviewer: Gotcha. Just takes a little time for that to kind of roll out, yeah.

Dr. Miller: It takes time.

Interviewer: So, back to my original question. I asked somebody who might find themselves in the healthcare system and now I'm trying to determine, "Is this really the right course of action for me or not?" how would I make that informed decision?

Dr. Miller: That's a great question. It starts with a question. So asking your physician how your pain can be best controlled is the way to start. What is the best way that you, meaning the physician, think that your pain should be treated? How do we do that?

In general, it depends on the type of procedure you're having or the pain you're experiencing. And the plan is really to start slow and use non-opioid substances or drugs, like non-steroidal anti-inflammatories like aspirin or ibuprofen or Tylenol, or other modalities, like massage or other physical therapy efforts.

Interviewer: Which I've read, and people might find this hard to believe actually can be just as effective if not more effective than opioids for chronic pain, those types of things.

Dr. Miller: That's true. Yeah, I think we were under the misassumption that opioids treated all types of pain pretty easily as a public, and that's not true. There are many other ways to treat pain. Acupuncture is another way that works well for some patients.

But again, you have to assess the severity of the problem, the potential severity of the pain. So if you have an open abdominal procedure where the muscles of the wall of the abdomen are cut, you're very likely going to have some pretty intense pain for a while.

And then you work with the physician to decide how much pain medicine you need and for how long. So, in general, shorter courses are preferred. And you don't want to be taking large amounts of opioids for a long period of time for a problem that is healing itself.

So, again, you start with questions. You start with, "What is the best way to treat the pain you might anticipate that I will have? What is your standard of practice?" or "I have this particular pain. What do you think the best way for me to have it treated is?" And then listen carefully to what they tell you.

If it starts off with a conversation that seems unclear or moves very quickly to opioid narcotics, then you might want to ask more questions about why are we starting with that particular medication rather than something that's potentially less addictive.

Interviewer: If we were to try to draw a visual path, I have the feeling that opioids might be prescribed for chronic pain, which is long, ongoing pain, like severe back pain that you're suffering from, or it could be pain that you might experience during a surgical procedure. Those would be the two different paths possibly?

Dr. Miller: Right. So there's chronic pain, pain that you can expect to have for weeks and months and perhaps years.

Interviewer: Yeah. And those are the types of things that some of these other modalities, as you said, massage, acupuncture, physical therapy, exercise could possibly mitigate and would be a better option.

Dr. Miller: Correct. At least trying that initially or working through that without using opioids initially would be a good point.

Some of the illnesses that we've gotten away from prescribing opioids would be things like migraine headaches, fibromyalgia, types of pain that are chronic, that don't really have a well-understood initiating cause or a cause that we think is going to heal over time, or pain that is episodic. If you treat that with opioids, sometimes that leads to a higher rate of addiction.

Interviewer: Gotcha. And in a surgical procedure, say I'm going to go into a surgical procedure and my physician says, "Yeah, this is going to be pretty intense for a couple of days. I'm going to recommend opioids." They're saying it right away, but they're also saying it's only going to be for a couple of days possibly. Should I be frightened of that?

Dr. Miller: No, you should not. I think most surgeons now are very well aware of the amount of narcotics that they're going to need for the particular duration of healing that you're going to experience.

If you're getting a month's worth of narcotics for a procedure that you might expect to be out of the hospital for in several days, then that is probably too much, and you could just say, "How many days do you think I'll be needing to take these medicines?" And then you might ask to say, "Look, why don't you just give me a week or two weeks or whatever you think is best for this particular healing period?"

Interviewer: Read an interesting article. The surgical department here actually did a study that found out that, as of right now, prescribing of opioid-based painkillers after a procedure is . . . they don't take the individual into consideration. Everybody would get them whereas they felt that they should talk to each patient to try to figure out what would be appropriate for that patient.

Dr. Miller: Correct. So what that study or that . . . it's not a study, but what that approach shows is just what you and I are talking about, that every patient has an individual need for the way their pain is treated and that depends on the procedure. So it depends on the type of the procedure, the length of the incision, the area of the procedure, and then the assumed time of healing.

So laparoscopic procedures, where they make very small incisions, are likely to heal quite a bit faster and would need less pain control and possibly could be managed without narcotics. Larger procedures, possibly longer periods of time, a week to two weeks, where they might need opioids. Again, it's quite individual.

And this is another thing. The science is not well worked out in terms of why one person's pain requires more and different types of analgesics than others. It's not known yet. So everybody is a little bit different.

Interviewer: And I think that brings up an important point too, that another way that people get into trouble is they are prescribed to take a certain amount over a certain time and they're like, "Well, I know my body and I don't normally react, so I'm going to take two instead of one." And with Tylenol, it's probably not a good idea, but with opioids, it's a really bad idea to start changing that dosage.

Dr. Miller: Yes. Again, we're not entirely clear why some people start on a path and then become rapidly addicted to opioids and seek opioids for the pain relief. It's not quite clear. Some people can be on opioids for some time and stop and it's not a problem. We don't really understand that completely.

Interviewer: But maybe not a gamble worth taking if you think you could . . .

Dr. Miller: Well, yeah. What we know now, given the evidence of the '90s and the last decade, is there was too much opioid prescribing, and it did lead to higher rates of addiction. So, obviously, the more opioids that are out there that people are taking for longer periods of time or perhaps in higher doses leads to higher rates of addiction.

Interviewer: So the important takeaway from this, it sounds like, is if you're finding yourself in position where that is a recommended way to deal with your pain from a physician, to start having a conversation. Because not having that conversation and just perhaps taking those pills could lead to a place you don't want to be.

Dr. Miller: That's correct, or it could lead you to have excess opioids at home, whatever type or form you have, and somebody else could maybe use that and that would lead to some problems down the road for them.

Interviewer: What about a resource if somebody wants to read a little bit more? The CDC? Is that a good place to go to learn more? Or National Institutes of Health?

Dr. Miller: CDC has guidelines, and we've actually repurposed the guidelines in our community clinic group as a training tool and an education tool for physicians in our community clinic group to read and learn from. So the CDC would be a good place to start.

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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.

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Interviewer: How should you handle an overdose situation? We'll talk about that next on The Scope.

Announcer: Health tips, medical news, research and more, for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Hopefully, this is a situation you never find yourself in, but, in the event that you happen to be around when somebody is having a drug overdose, what should you do? Dr. Troy Madsen is an emergency physician with University of Utah Health. What should I do? That could be very scary I'd imagine.

Dr. Madsen: It can be. So drug overdoses, you think of a lot of different things. You can have people who just accidentally take too much of their medication, people who are taking opioids or illegal drugs and overdose on those, or people after suicide attempts who may take any of a number of different medications. And we see all of these in the ER. So I think the number one thing is, you got to get them to a hospital, and if it's as serious thing where they're not breathing, obviously, you've got to get 911 there and get them help as quickly as possible.

The other thing you can always think about is if you live with someone or if you are someone who uses opioids, potentially has an abuse problem, you can get naloxone. This is a medication that reverses opioid overdoses. You can get it through EMS departments, through state health departments, county health departments, and it's something that can absolutely be lifesaving. It reverses the effects of opioids, obviously that's a huge issue in the country. It's a huge issue in the state of Utah, I think we're number five or six right now in terms of opioid overdose deaths. So, if you have that issue, if you know someone who does, have that medication around.

Other overdoses we think about are things like, I mentioned like suicide attempts, and they're really serious thing there. It can be things like Tylenol, opioid medications again, things that make you stop breathing, some of the heart medications that can cause big heart problems. There, there's not a lot that you can do emergently.

I would tell you one thing not to do it, is not to make the person vomit. And some people may think, okay, person swallowed a bunch of pills, let me stick something down their throat or have them try gag themselves to vomit this back up. That can just create worse problems because if they're already a little bit drowsy or they're trying to vomit this stuff up, they can then breathe that into their lungs and that can make it a lot worse. So you don't try and do that.

You may have heard someone say, "I went to the ER and got my stomach pumped, someone put a tube down there and sucked everything out," we don't even really do that anymore. We just found out that the risk of aspiration of breathing that stuff into lungs was much greater.

So I would say the number one thing to do, any of these overdose scenarios, make sure the person is breathing okay, make sure they're alert, get them to the hospital, if it's a time dependent issue where they're not breathing well or they're drowsy, get 911 there, have naloxone around for people who have potential opioid problems or abuse issues and make sure that they get the help they need.

Interviewer: I'd like to back track just briefly here. What's that fine line between having too much and going to be okay versus going to go into an overdose situation? How do you make that call? What should I look for?

Dr. Madsen: Yes, that's a really tough call, because in medication like Tylenol, you may not know that's a serious overdose for several days. But, you've got to get the treatment for it as quickly as possible. So, if you live with someone and they're just not sure how much of the medication they took, it's going to be really tough just to look at that person, say, "Well, they're probably fine," because if they took too much of their blood pressure medication, they may act okay, but their heart may be in an abnormal rhythm that could then worsen to a life-threatening rhythm.

So it's hard to say, just look at how they look, look at how they're acting.

Interviewer: Really kind of follow your gut on that sort of a deal.

Dr. Madsen: You do.

Interviewer: What about like illegal drugs.

Dr. Madsen: So illegal drugs, yeah, I mean there it's . . .

Interviewer: If somebody is passed out after doing illegal drugs, would you call someone for it?

Dr. Madsen: Yeah, you really do. If they're passed out, you know, you don't know if they're just going to come to within an hour or so, versus are they passed out and they're just not breathing well and they're potentially having severe brain injury because they're not getting enough oxygen? That's really a tough situation. But I'd say, if they're not responding, you really need to get them to the ER.

Interviewer: Something not to mess around with?

Dr. Madsen: Yeah.

Interviewer: What about myths? You had mentioned one, that you want to get somebody to vomit up whatever it is they had, which you say, don't do because it just causes more problems. What about you got to keep somebody awake and they're going to be okay then?

Dr. Madsen: Yeah, you know, I guess it's more just monitoring them to see if they're staying awake, but if it's at that point where they're nodding off and you're really worried they're not going to stay awake, you really need to get them in for help because at that point, yeah, I mean, you're going to be trying . . . some of these medications are going to last at least four to six hours. And some medications they overdose on could last 24 to 36 hours. So you've got to get them in and get them help. You can't just sit there and try and keep them awake for hours on end, exactly.

Interviewer: What about privacy concerns? Because if I was in that situation and somebody overdosed because of illegal drugs, for whatever reason I happen to be there, if I call 911, now I'm afraid that there's going to be a bigger problem on the other end of it for everybody.

Dr. Madsen: Yes. That's a common concern. In the ER, everything is private. We're not reporting someone for drug use. I've never asked the police to come and arrest someone for drug use, that's just not something that happens. So don't let that stop you from getting help. All those things, things not to worry about and things, they're not going to be prosecuted for.

Interviewer: So don't play the what if game.

Dr. Madsen: Right.

Interviewer: If you truly are scared, probably best just to call 911.

Dr. Madsen: Exactly. Best to call 911, best to get them to the ER. understand that we see these sorts of things all the time. The good news is, 70, 80% of that time things are fine, the other 20% of the time, we may need to keep people for a while and admit them to the hospital to start treatment.

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Interviewer: By focusing on the opioid epidemic, are we missing the bigger problem? We'll talk about that next on The Scope.

Announcer: Health tips, medical news, research, and more for a happier, healthier life. From the University of Utah Health Sciences, this is The Scope.

Interviewer: Mark Ilgen is an associate professor at the Department of Psychiatry at University of Michigan, and much of his current work focuses on improving treatment outcomes for patients struggling with substance abuse disorders that are also complicated by co-occurring problems like chronic pain. Dr. Ilgen, when you say that to really solve the opioid problem that the conversation needs to be about a bigger issue, can you tell me what you mean?

Dr. Ilgen: The topic of opioid use and opioid overuse has received a lot of attention in the national media. You often hear about what's often called the "opioid epidemic" as something that's grown within the last 5 or 10 years, but prior to even the last 7 to 10 years, there was still the problem that many individuals with pain were not functioning well. And a large portion of those individuals coped with their pain by misusing or overusing substances, and that's not limited to opioids.

Someone can drink too much to manage their pain, use marijuana to manage their pain or overuse marijuana to manage their pain, or use either street or prescription opioids. And so the broader issue of pain management has, in some ways, been lost. And there's really a lot of concern that in our conversation about, "How do we keep people safe from opioids," that we might also be losing sight of the fact that many people still have chronic and poorly-managed pain. And those individuals are often left without a lot of very attractive treatment options.

Interviewer: So what can you do? What is the bigger solution to the problem?

Dr. Ilgen: I think that pain management as a topic is one that I think we need to be giving more attention in our health care system, so it's a difficult topic for a lot of treatment providers to discuss. And I think a big part of why opioids became the problem that they are now is that they presented or were, in some ways, billed as a solution and as an easy solution to the problem of pain. And so that was appealing to primary care physicians and other treatment providers because they felt like they could do something to help someone who was struggling with chronic pain.

But a true, honest conversation about chronic pain requires going into more depth, understanding what the patient's going through, getting better diagnostic information about the pain, and then coming up with coping strategies that are more comprehensive that go beyond what you can usually achieve with a medication.

Interviewer: What are some of the solutions that you're seeing out there that are offering some promise?

Dr. Ilgen: Well, the hard thing with . . . it's a very complicated issue, and the solutions to pain are going to look very different, depending on the nature of the chronic pain. So again, unfortunately, for a long time, the solution to chronic pain was often pitched as opioids, and those were applied across a number of chronic pain conditions, from fibromyalgia to migraines to lower back pain.

But in fact, the different solutions to the pain conditions often really vary substantially, depending on what the presenting problem is. So a first step in doing something about the pain is just to make sure you get an accurate diagnosis, and in many cases, that means going to a pain specialist and getting a better sense of what's actually going on.

And for a lot of individuals who have musculoskeletal pain, they need forms of treatment that focus on their physical functioning as well as their pain level. And most effective treatments for long-term, let's say, back pain involve both helping the person manage the pain in the moment, but also helping them remain active in their life, get physical therapy, in some cases get certain pain-specific types of psychotherapy that help them cope with their pain and better adapt to the pain condition.

Interviewer: And to some extent, I would imagine one of the challenges, too, is helping us, as patients, overcome this notion of the easy solution of the pill, like the pill or the painkiller is the ultimate thing. Because physical therapy and staying active, all that stuff take commitment and work, and people can also be skeptical that that's actually going to do anything.

Dr. Ilgen: Exactly. I think managing expectations around what is or isn't possible is very important, so unfortunately, often the case, that you don't have an easy solution to the pain. Instead, you're looking at scaling back on the pain from a level that really is impairing to a level that's easy to cope with. But it often doesn't go away. It's just at a lower and more manageable level.

Interviewer: Yeah, so as a patient, suffering from pain from a particular condition, it sounds like your recommendation be, first, make sure that I have an accurate diagnosis of what's causing that pain. So then that would lead to the ability to come up with a plan to help manage that pain, which comes back to your concept of it might not go completely away, but you do what you can do. And then, at that point, just realize that it's a process, and it's going to take some time, and maybe that's a good trade-off for the downside of a potential addictive substance that could ruin your life.

Dr. Ilgen: Yeah, and I don't want to overstate the potential downsides of opioids. So there's a lot of controversy in the field about whether opioids are ever an effective and appropriate treatment for chronic pain, and then, if so, at what level? And I think those decisions are just made on a case-by-case basis with a treatment provider.

What we see that's problematic is when someone is taking a moderate or high dose of an opioid and not getting a lot of relief and then ends up escalating and needing a higher dose to get some relief and then even that's not working, that's when someone's kind of going down a path towards not getting a lot of return on the medication. It's not really giving them a lot of pain relief, and the risk for side effects is going up.

And that's when you really want to be concerned and be careful and to stop and have a really frank conversation with your treatment provider about, are you on the right path here? Or are you really getting greater and greater physical dependence on the medication for either continued not-very-good or maybe, in a lot of cases, a worse degree of pain relief than you did initially?

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Interviewer: What are emergency rooms doing about opioids? That's next on The Scope.

Announcer: This is From the Frontlines with emergency room physician, Dr. Troy Madsen on The Scope.

Interviewer: Dr. Troy Madsen is an emergency room physician at University of Utah Health. And of course, by this point, most of us know that opioids are a major problem and it seems like taking that first one is what really lead you down that path. And for many people, they might have gotten them in the ER at one point. So I'm curious, Dr. Madsen, is that the case? Did you use to give out opioids for pain and has that changed?

Dr. Madsen: So I've absolutely given out opioids and we still do. I mean, there are cases where people need some kind of pain medication and, often, that's the only thing that's going to help them in the short term. But we've definitely seen the pendulum swing in the last few years. It used to be, in the ER we always talked about, "We're not treating pain adequately. We're not giving enough medication." And I think the response to that, 15, 20 years ago was to say, "Let's get more opioids. Let's prescribe more, let's give more IV medications."

Now, we've seen what's resulted from that. And it's not just the ER, it's primary care physicians, it's pain clinics, it's specialists. It's all across the spectrum of health care in the United States.

Interviewer: In the ER, was the opioid generally in pill form, or did you give it through IVs?

Dr. Madsen: We have often . . . and again, to say we don't do this, we do it because there is a role for opioids, and I think there's something we need to make sure we understand too is that there's a role for these medications people that have severe injury, long bone fractures, things like this, that's the only thing that's going to treat their pain adequately.

And so we do give at IV. There are IV forms of opioid medications like Morphine or Hydromorphone. And then there are pill forms as well that we can prescribe, hydrocodone, oxycodone, things like that. You've heard of Lortab, Norco, Percocet, all these sorts of brand names. So there are those two options that we use in the ER and that people use elsewhere as well.

Interviewer: So if I'm a patient, I find myself in the emergency department, and I'm told that my pain is such that you would recommend that I should have an opioid-based painkiller. Should I be nervous that I could possibly get addicted to it?

Dr. Madsen: I think the big issues with addiction come when we're taking medication not to treat the pain but often for the way it makes us feel. And if this is a new injury, if it's a serious injury, or if it's a serious issue like severe abdominal pain and that's the only thing that's going to control it, I think you need it. And I think you have to make sure you have some balance there and not just think, "Opioids are bad. I'm going to get addicted if I even have a touch of this medication." That's not the case.

So when people take it long term, they're taking it more for the way it makes them feel rather than, say, coming in for severe pain and I'm taking this because I need this pain in my abdomen treated right now because I've got a ruptured appendicitis or something like that going on.

Interviewer: So how have things changed in the ER?

Dr. Madsen: Yeah, so I think one of the biggest changes I've seen, so a couple of areas. Number one, we have a statewide database we can use and it's very useful. I can look up, if someone comes in and I can see have they gotten multiple prescriptions for opioids?

If they have and it's come from lots of different physicians, particularly lots of different ERs, I'll talk to that person and I'll express my concern, say, "We're seeing lots of different prescriptions from lots of different places. I'm concerned about the possibility of, maybe, addiction here. You need to go to one person, get this from one doctor so they can monitor what you're getting and make sure you're staying safe with these medications."

The second thing we've seen are just, like I talked about, decreased prescriptions for opioids for a lot of stuff that maybe we used to prescribe it for, for bumps and bruises and back pain because we wanted to make sure people's pain was taken care of. Now, I think it's more like saying, "Hey, try Ibuprofen. Ibuprofen, it's a great medication. Avoid opioids if at all possible."

Again, still there are cases where opioids are necessary. It's the only thing that's going to really adequately control someone's pain, but a lot of those kinds of gray zone areas. I think a lot more physicians are moving away from opioids altogether or are really limiting the number of opioids they're prescribing to those patients.

Interviewer: So this is a good first step, I would imagine. What else needs to be done?

Dr. Madsen: Well, I think we need to know a lot more about how we can better address pain and if there are other factors. Does anxiety really play into this, is something we studied in our ER. Patients who come in who are feeling very anxious, how much does that amplify the pain? If I address that anxiety, is that going to help with the treatment of pain?

Something else we're doing really new in our ER and one of the few places doing this is we have a physical therapist in our ER as well. So we're using our physical therapist to come in and see a lot of these people with back pain, work with them right there, get them set up with physical therapy to hopefully avoid the opioid prescription, to get them some treatment and say, "Hey, you don't need just to take pills for this. Here's some exercises, some strengthening, some stretching. It's going to give you a whole lot more relief than taking some sort of opioid."

Interviewer: So just like anything else, it's a useful tool. It's just that maybe we haven't been using it the best that we should up until this point?

Dr. Madsen: That's exactly right. I think the pendulum swung too far one direction and it's going back the other way. Hopefully, we can have some nice balance here and address this, what it really is, a nationwide epidemic.

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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.

Interviewer: Using Imodium to treat opioid withdrawals: a bad idea. We'll find out more about this disturbing trend next on The Scope.

Announcer: This is "From the Frontlines" with emergency room physician Doctor Troy Madsen on The Scope. On The Scope.

Interviewer: Doctor Troy Madsen is an emergency room physician at University of Utah Health Care and he said he'd seen a couple instances where people are using Imodium, which is an anti-diarrhea medication, as a way of trying to treat their withdrawal symptoms from opioids. I find this hard to believe. What's going on?

Dr. Madsen: Yeah. So this is really interesting. So as you may know, there's an opioid epidemic in our country and the Centers for Disease Control has acknowledged this and said we have so many people who are using opioids now. So prescription opioids, things like Percocet, Norco, Oxycodone are using that for to get high. Essentially what they may consider it legal high because they're getting a prescription or it's a prescription medication they're buying from someone.

So then, these individuals may then be saying to themselves, "I really can't be doing this. I need to get off this medication." So they're finding things on the Internet that discuss using Imodium or loperamide is the generic name and using that to sort of detox, taking that as a bridge to give yourself some of the same effects as the opioids give you while allowing your body to adapt and adjust and then gradually get off the medication.

Interviewer: So, first of all, bad idea trying to self-treat an addiction like that?

Dr. Madsen: Absolutely, not a great idea. But the reason they're doing this is because it's probably been out there for years and then I think it's just gained steam with some people posting things on the Internet about this. But Imodium or loperamide is actually an opioid. It doesn't give you the same high as things like Oxycodone, but it has kind of the same effects, acts on some of the same receptors in the body.

That's why it help with diarrhea because if you've ever heard of someone who says, "Hey, taking all these Percocets and I can't have a bowel movement. It constipates me." Well, that's kind of how this stuff works for diarrhea. Same kind of idea. It slows down the bowels but also then acts on somebody's same receptors in the body that opioids act on that people are using for highs.

Interviewer: Yeah. So self-treating bad but, above and beyond that, Imodium causes other problems that you see then?

Dr. Madsen: It does. And the big thing we're seeing is some of these people are just taking such incredibly high doses that it's been putting their heart into these arrhythmias, these abnormal heart rhythms that are life-threatening. And that's where we see it in the ER. I've seen cases of people coming in who are in just these crazy heart rhythms, these life-threatening heart rhythms and it's because they're taking large doses of Imodium and then that is triggering this heart rhythm.

And really, it's the kind of heart rhythm where you've got to shock their heart to get them out of it, get them on medication, do something for it or their hearts just not going to keep working and they're going to die from this.

Interviewer: That doesn't sound much better.

Dr. Madsen: It doesn't. It's not a great thing to do.

Interviewer: It doesn't sound like a great solution to the original problem.

Dr. Madsen: Yeah, there's not. There are much better solutions to opioid addiction and to getting off that. It's a sort of thing where you've come into the ER, we will often get people into in-patient detox programs. We can also prescribe medications that can help with this. So I would not recommend taking Imodium or loperamide. Again, that's the generic name for it. I would not recommend taking that to treat an opioid addiction because of the threat of these abnormal heart rhythms.

And this really comes up because there was actually just a study published or report in one of the big emergency medicine journals talking about increasing cases of this and increasing calls to poison centers for people who are taking more and more of these medications to try and treat opioid addictions and then are having very bad effects from this.

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