Welcome back! Last week, we talked about Fawning. If you missed this blog and would like to catch up, click HERE.
This week, we are going to get a little dark. Heroin is becoming more and more the “go to” drug, now that prescription opioids are being taken from people who are experiencing horrific pain. While the opioid crack down may be good in some ways, it is irrefutably not good in others. For those who truly suffer, day in, and day out, heroin is becoming their best friend. It’s cheap, it’s easy to purchase, and it works.
The problem with heroin, unlike prescription opioids, is the lack of ability to stop using and go back to a normal life. It’s very, very, very difficult. It requires a multidisciplinary approach. Going “cold turkey” is only one step, in the many steps, to maintaining sobriety.
The National Institute on Drug Abuse (NIH) states that “The number of people using heroin for the first time is high, with 170,000 people starting heroin use in 2016, nearly double the number of people in 2006 (90,000). In contrast, heroin use has been declining among teens aged 12–17. Past-year heroin use among the nation’s 8th, 10th, and 12th graders is at its lowest levels since 1991, at less than 1 percent in each grade level“.
The message? It’s not the kids using heroin anymore. It’s the adults. Further, “Heroin use no longer predominates solely in urban areas“. The message? It’s everywhere now.
In 2017 the numbers didn’t look any better. The CDC reports, “In 2017, nearly 494,000 people in the United States (12-years old or older) reported using heroin in the past year, which is an estimated rate of 0.2 per 100 persons“.
The people who are advocating for stricter prescription opioid laws may be on the money in terms of damage control, but at what cost? Are they a day late and a dollar short? Are we too far down the opioid river of darkness to pull back on the reigns? Is it morally and ethically right to leave pain patients with no options, but to go to the streets for pain management? Advocates may say, “an addict will always find a way“…but is that true all of the time for all of the people?
On condition of anonymity, “Beth” shares her story. “I was diagnosed with Fibromyalgia and Osteoarthritis. The doctors said prescription opioids were my only option, so I agreed to a contract. I used opioids for ten years, and they worked fairly well. I never needed an increase in my dose. Some months I was able to go off them altogether. On the days I needed them, it was the difference between getting out of bed or staying home.
“A year ago, my doctor told me I had to titrate off the medications. She said there was a crisis and it was out of her hands. She was being told to take them from me. I went off the opioids, but the pain was unrelenting. It got to the point where it was all I could think about. I started abusing NSAIDs and got a stomach bleed. Then I was told I could no longer take NSAIDS. I planned my suicide daily. I finally decided that I had to get relief. I’m a 52 year old mother and grandmother, I’m a professional and have a solid career, I own my own house, and I’m a heroin addict. There will never be a ‘going back’ for me. I’m addicted”.
So let’s talk about Heroin and how it works in the brain. The NIH reports that, “Once heroin enters the brain, it is converted to morphine and binds rapidly to opioid receptors. People who use heroin typically report feeling a surge of pleasurable sensation—a ‘rush.’ The intensity of the rush is a function of how much drug is taken and how rapidly the drug enters the brain and binds to the opioid receptors. With heroin, the rush is usually accompanied by a warm flushing of the skin, dry mouth, and a heavy feeling in the extremities. Nausea, vomiting, and severe itching may also occur. After the initial effects, users usually will be drowsy for several hours; mental function is clouded; heart function slows; and breathing is also severely slowed, sometimes enough to be life-threatening. Slowed breathing can also lead to coma and permanent brain damage.
“Repeated heroin use changes the physical structure and physiology of the brain, creating long-term imbalances in neuronal and hormonal systems that are not easily reversed. Studies have shown some deterioration of the brain’s white matter due to heroin use, which may affect decision-making abilities, the ability to regulate behavior, and responses to stressful situations. Heroin also produces profound degrees of tolerance and physical dependence. Tolerance occurs when more and more of the drug is required to achieve the same effects. With physical dependence, the body adapts to the presence of the drug, and withdrawal symptoms occur if use is reduced abruptly.
“Withdrawal may occur within a few hours after the last time the drug is taken.”
WOW. A very different response than that of prescription opioids. Basically, the take away is that the drug changes the structure of the brain, withdrawal is very soon after the last dose, and then, what are the withdrawal symptoms?
“Symptoms of withdrawal include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps (“cold turkey”), and leg movements. Major withdrawal symptoms peak between 24–48 hours after the last dose of heroin and subside after about a week. However, some people have shown persistent withdrawal signs for many months. Finally, repeated heroin use often results in heroin use disorder—a chronic relapsing disease that goes beyond physical dependence and is characterized by uncontrollable drug-seeking, no matter the consequences. Heroin is extremely addictive no matter how it is administered, although routes of administration that allow it to reach the brain the fastest (i.e., injection and smoking) increase the risk of developing heroin use disorder. Once a person has heroin use disorder, seeking and using the drug becomes their primary purpose in life.”
Say that again slowly: “Once a person has heroin use disorder, seeking and using the drug becomes their primary purpose in life.“
What does the NIH say about opioid addiction? It’s a different story. Here’s the bottom line, ” Taking opioids over a long period of time produces dependence, such that when people stop taking the drug, they have physical and psychological symptoms of withdrawal (such as muscle cramping, diarrhea, and anxiety). Dependence is not the same thing as addiction; although everyone who takes opioids for an extended period will become dependent, only a small percentage also experience the compulsive, continuing need for the drug that characterizes addiction.”
Dependence vs. addiction. Muscle cramping, diarrhea and anxiety vs a life long addiction where “seeking and using the drug becomes their primary purpose in life.“
Opiate contracts are controlled by the physician. The person receiving the opioids has to submit to drug screens on demand. They cannot get their opioids from any other source. They are monitored for signs of addiction. Street drugs are unpredictable. They get cut with horrible ingredients (draino), and are often stronger than anticipated (Fentanyl) leading to poor outcomes. Prescriptions on the other hand, are less dangerous, more fully monitored, and have a less likely chance of a poor outcome.
Heroin addicts are on their own. Even when deciding to quit, a life of replacement drugs will be in order. Drugs like Suboxone or Methadone will be given once a day at a certain time (usually morning) when the client shows up at the clinic for their “dose“. The users brain has been permanently changed, and a return to the streets assured without proper follow up and consistent use of these medications.
Did this current increase in Heroin use start with prescription opioids? Yes. They were over prescribed. No doubt about it. But do chronic pain patients still need them? Yes. There is no getting around that. Living with pain day in and day out is something many, if not most, doctors cannot relate to, so the empathy bar drops. They only see “seekers” and poor internal reviews when the pay raises are brought out.
I would challenge any and all doctors to put a clip anywhere on your body. Make sure it’s tight enough that it pinches. Wear it there for a week. Any time you want to remove it and say “ok, I get it“…don’t. Leave it on. You will have a different understanding of pain, and be a better doctor for having tried this experiment.
Now some will say this blog totally missed the point…the point being that the heroin addiction starts with the opioid prescription. I would challenge that thinking. The Heroin addiction starts with unrelenting pain, which the medical doctor rightly tries to decrease. As long as the doctor is in the picture and monitoring the patient appropriately, it stops there. If the opioids are withdrawn from the patient, then the patient seeks pain management on the streets, enter Heroin.
Let’s not throw the baby out with the bath water. We can all agree that any type of pain management needs to include other approaches before cracking open the prescription pad, but once there, it is unsafe and inhumane to back track and force a person onto the street for pain relief.
I will leave you with this, again from NIH: “Every day, more than 130 people in the United States die after overdosing on opioids. The misuse of and addiction to opioids—including prescription pain relievers, heroin, and synthetic opioids such as fentanyl—is a serious national crisis that affects public health as well as social and economic welfare. The Centers for Disease Control and Prevention estimates that the total ‘economic burden’ of prescription opioid misuse alone in the United States is $78.5 billion a year, including the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement.“
No matter which way you slice the cake, this is serious. Chronic pain patients are completing suicides for lack of pain management. We have a much better chance of helping those who would become addicted if we keep the opioids in the hands of the doctors, not the drug dealers.
Don’t get it twisted. The man in this video could be your son, cousin, uncle, father, grandfather, friend or extended family. Heroin doesn’t care who you are…it only wants to eat your soul. Period. Heroin addicts are misunderstood, and held in contempt for something they don’t want to be doing themselves. There is a lack of treatment facilities, a lack of mental health funding, and very few resources available.
This blog was printed in the Tillamook County Pioneer, and these were the comments:
Erin McLucas Skaar This is a very good read to understand some of the challenges of reducing opioid use for chronic pain. This is not a simple problem to solve!
Ocie Marie Johnson Very good article.
You can’t always just “do away” with something. You have to think it through and attack the underlying problem.
Wendy Wagner Brown Excellent article. I know and have known people who were forced off their opioids and went to heroin eventually. Our medical laws are failing many. So sad.
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Debbie Dew: I had a really bad back injury in 1978. It has given me terrible pain. I have had a prescription for pain pills since then. The only effect I have from the pain pill is relief. I don’t feel a high and I don’t feel a need to take them unless my pain is overwhelming. I have been proscribed 30 pills at a time. They generally last me a minimum of a year. There may be a week I take 3. There may be a week I take one. There may also be a month I take none. I live on Advil mostly. As it can handle a lot of my pain and reserve the proscription for when the Advil doesn’t work well enough. If the medicine was prescribed like that and not prescribed at 150 a month then weening off would not be a problem.
It should not be used as a daily med for a long term without detoxing under doctors care and weening off slowly regardless of insurance. It should be part of the prescribed plan if it is prescribed daily and continuous. I am very aware of addition.
I lost my brother do to drugs and have a very close relative that was proscribed 150 Vicodin monthly. She lost tract how often she took them, she over took and had all kinds of personal problems, functioning problems and poor choices. She lost her job of 10 years which resulted in a loss of insurance. Which resulted in no medical care. Her prescription stopped, street drugs were sought out and in the end she lost job, her children and some of her families support. No detox, no follow up nothing. 150 Vicodin’s to zero. Thankfully after a 3 year spiral she regained it all back but many times that’s not the norm.
So there you have two different story’s. One proscribed in a manor that relieved pain and were taken as directed. Then you have a story of over prescribed, under supervised and destruction. From what I understand nowadays with pain medicine you’re in a pain contract and if you brake the pain contract they take you off the medicine. Maybe if they look at breaking the contract as a beginning of a problem instead of dropping people at that point maybe there’d be an answer somewhere in between.
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Candy Craig Manns: I have suffered chronic pain most of my adult life. I have degenerative disc disease, fibromyalgia, arthritis, thyroid disease and some other issues. I was on opioids for about thirty years. Not especially great for my kidneys. I was only taking them for breakthrough pain, and using cannabis the rest of the time. At the time I was a patient at the Canby Providence clinic. I got a urinary tract infection and my doc wanted me to come in for a test because of my bad kidneys. She was off that day but had made arrangements. I got a phone call to come back the next day to do it again, even though she was still out of the office. Not thinking anything amiss I went. The nurse grabbed my purse and shoved me into the bathroom like I was some kind of druggie. I was in my mid 50’s. I didn’t react like I wish I would have because I was shocked. When I saw my doc she was not happy either. She was informed that she had to tell me that because there was marijuana in my system, that was none of their fricken business, I could either give up weed, or my opioids. And if I chose to keep the opioids, I would be drug tested on the regular, like a felon. Doc and I both left providence shortly after that.
The only prescription for opioids I can get now is because I broke my shoulder. And even though the pain isn’t getting any better after a point, I will stop getting the pills here soon. After all, it’s been 2 1/2 months. I might get addicted. Even though I didn’t in 30 years. Wouldn’t want us to get any real relief now would you?! ??
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Shellianne Toftemark: The horrible thing is the people experiencing true pain like my step dad who is a veteran and retired firefighter paramedic awaiting a kidney transplant..
He was taken off his pain medication suddenly.. because of the fear that he will become addicted.. and right now he is literally dying.
I was prescribed hydrocodone for extreme pain during connective tissue/auto immune flare up.. then with tooth pain. I never finished using a whole prescription..
But addicts in my life would steal them any chance they could :/
Too me it was important to have them for flare ups.
In the police report on my stolen prescription the officer recorded that i had Oxycodone and that was inaccurate.
I was given oxycodone for pain in the hospital and it did nothing for the pain.
I have used these medications without becoming addicted.
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Natasha VanWormer: Most people who are doing heroin started with prescriptions. They didn’t abuse them, took them as prescribed. Then the govt declares a “crisis” and cut them off. Purdue (the creator of oxy) said that it wasn’t addictive (less than 1%). If you need pain meds to function normally then are suddenly cut off, withdrawal will make you feel close to death. These people who actually need pain meds were forced to buy them off the street and then resorted to heroin. It’s a sad sad story.
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Ally Mock I have Cystic Fibrosis and suffer from pain everyday been on prescription opioids since I was 8 I am now 21 and I was cut off cold turkey because of the epidemic we are encountering because of them taking my pain meds away I seeked out to medicate myself since the drs wouldn’t help me . I realized heroin is not the answer and am now clean and still struggling with daily pain . I’d definitely agree to the fact that pain ridden patients are the victims here. Whoever makes these laws needs to realize how much suffering they’re putting people like me through . When I was in the drug world to self medicate I heard soooo many stories of the reason people started using is because Drs cut them off and prescription and they couldn’t handle the suffering anymore . We don’t need to get rid of prescription opioids we need to monitor them . Have them brought in and counted or something to make sure people aren’t abusing them as well as still managing heir pain
Any doctors in the Junction City area that can help this lady?
Charo Schaeffer I’m interested to know more about this to help educate our community.
Linda Tate Can I repost your comment on the actual blog? There are many doctors that monitor those questions. If you don’t get a response, I will personally connect with you.
Charo Schaeffer Linda Tate yes please!
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Amy Sandford It’s very sad when someone who actually needs pain medication can’t get any. I was in Ohio in May and ruptured the patellar tendon in my knee. After a bumpy ambulance ride, the ER gave me one dose of iv pain medication and sent me home with an Rx for nine pills. Ohio has huge addiction numbers, so they are very hesitant to give anything.
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Jeffrey Salisbury No, there absolutely is not an damn opioid epidemic or crisis. And if you want to call it that, go ahead and use the correct term, that term is “government created crisis”! Enough said!!! I will state my facts that I have to call it what I do in a few. I’ve been a pain patient for a while now and work with many groups on this exact situation. Most people don’t understand that they classify this so called “epidemic” with some pretty dumb factors that actually have nothing to do with the “crisis” that has actually been created by our scandalous government. It’s all about the money!
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Lisa Searles I have two nieces who are free roaming heroin addicts. One in prison. All have had to be brought back via narcan or full on CPR. All while my father who was in constant pain and just wanted to move a little without excruciating pain . After the 5th time asking his doctor for something gave up after being told no . He died less then 6 months after. Flat out told me he was done with the pain and giving up. It amazed me how rapidity he declined from there. When one of his doctors called to offer their sympathies. I told him I blamed him . He wasn’t some 30 year old who wiped out on his motorcycle. He was a 79 year old vet who wanted to get the bathroom and out in the dining room for dinner.
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Rachelle Butcher There is no crisis with opioids, it’s the drug addicts that take opioids illegally. It’s more “fake news” people became immune to the heroin “crisis” so they came up with a new name, new push button. Regular people take their meds as prescribed, and are being punished, as well as doctors now being afraid to medicate and help.people. doctors are not the villains it’s the people that lie to them to obtain prescriptions they should not. My opinion is to.legalize it all, let the idiots weed themselves out. Countries with legalized narcotics have the lowest crime rates in the world, and some of those countries every home has a firearm
They have closed prisons and opened rehab centers, the United states has the most controlling government, they are going to save us from ourselves wether we want them to or not
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Carrie Cowan Henry I am a pharmacist and believe pain patients are gettting a raw deal from the government and insurace companys. The opiod crisis they are saying is so bad seems to be due to heroin and narcotics laced with fentanyl from foreign sources. It has gone from the govt saying we have a crisis due to pain patients getting no help to them now saying too much opiods are out there. It makes me angry. Tired of pain patients being treated like all of them are addicts. Most of them are not.
Thank you Linda. Excellently written. I feel this is something that should be presented to medical students as it is a much better presentation then the mandatory CME required for opiod prescribers. I did send a link to the Oregon Prescription Drug Monitoring Program committee. As a Hospice Medical Director, this is a dilemma that I do not see going away without societies collective input and insight how to best address the issues within our individual communities. I fear that I will be one of the few remaining physicians in our area willing to sign for comfort packs for hospice patients due to the rising fears of being identified as an “over prescriber”.
This is an important blog and should be viewed by everyone.
Although pain meds are available to prescribe, they are a double edge sword, and can lead to intensification and preoccupation with pain.
It is a difficult decision that I made when I decided that I would not use this modality for the majority of my patients.
Through my years as a clinician, I have noticed that pain medications can be disempowering and affect one’s seeking other modalities.
Pain is an amazingly subjective process. More intense pain can be realized when one is put in a more stressful reaction, through sleep deprivation and a history of trauma or abuse or after an accident and develops a comolex regional pain syndrome.
Pain is accentuated in these conditions. I focus on meditation, exercise and anxiety reduction techniques to mitigate the pain signals and control the reaction to the stimulus.
Regarding pain management, I usually use acetaminophen, ibuprofen,gabapentin and low dose cymbalta as supplements. Some have benefited from cbd or herbal options.
Does this correct the problem? Mostly it doesn’t completely wipe pain out. The strategy is pain mitigation though not pain eradication.. as with opiates this will ever be elusive… opiates intensify pain by altering expression of receptors, creating a dependence and blunting the effect.
I am so sorry to see people in a situation of requiring pain meds. I have seen it to be helpful in select patients … but it normalizes after a while and very often leaves a person to be back where they started.. not better off.
This isn’t coming from someone who hasn’t had his share of pain. After seeing the toll on my patients, learning more of addiction and hearing the stories of heroin addicts first person, I have elected to “not go there”. Life can be brain-altering, specifically regarding trauma… the brain can be altered in its production of serotonin. To some and possibly most, healing can occur from within …we can alter our brain just as someone can learn…
Thank you for this excellent topic and thanks for reading this comment.
As physicians, we must protect the rights of those truly in pain who are helped by opioids. They have to have them to get through the day or else they would be basically bedbound and in constant pain.
The current political plan is to throw the baby out with the bath water.
We need to quickly insert some common sense