Physical Dependency on Prescription Opioids is a Slippery Slope

Harold Clifton Urschel III, MD, MMAChief Medical Strategist, Enterhealth

According to the American Society of Addiction Medicine (ASAM), American doctors in 2012 wrote 259 million prescriptions for opioid pain medications; that is one bottle of pills for every adult in the country. The United States uses approximately 80% of all opiates prescribed in the world even though we only have about 5% of the global population. Approximately 1.9 Americans struggle with prescription opioid abuse or dependence, of which 17,000 fatally overdose each year. That’s an average of two people every hour, every day who die from a prescription drug overdose. Many of them developed this problem with no clue of what could be in store for them. 
We, both prescribers and patients, are fortunate to have effective prescription opiates like hydrocodone and OxyContin to alleviate our patients’ pain and benzodiazepines like Valium and Xanax available for the treatment of anxiety. However, since many patients do not understand the risks widely associated with these drugs, prescribers must take responsibility, given their authoritative role in providing firsthand medical or psychiatric treatment to those at risk for addiction.
The burden for stemming the growing epidemic lies heavily on those providers who are overprescribing.
This phenomenon can start somewhere as innocuous as a dentist’s office. After oral surgery, the patient receives a prescription for 30 hydrocodone — take two every four hours as needed for the pain. While the pain is gone in two days, she still has more than 20, so she finishes them off because she feels really good when she takes them. 
10 days later, the pill bottle is empty, but she is full of angst at not having any more, along with physical symptoms from the sudden absence of the medication in her system.
Physical dependence can occur when opiates are taken every day for more than four weeks. Stopping the medication starts the physical withdrawal symptoms caused by your body — mainly your brain — working to rebalance itself without the medication. You can also experience physical withdrawal from other non-addictive medications (blood pressure medicines, antidepressants, or even insulin), when you stop them abruptly, because your body is used to them and has to recalibrate how it will function without them. This recalibration can take from 3-7 days for opiates, depending upon how much has been used and for how long, as well as the level of the body’s dependency.
Opiate withdrawal is very uncomfortable and the discomfort depends upon how long the drug lasts in the body — the shorter amount of time the opiate lasts, the quicker the withdrawal. It usually peaks around day three as your body simply readjusts. Despite widespread discussion of the difficulty of opiate withdrawal, it is in fact a very temporary process that can be treated symptomatically as you would the flu. Symptoms can include:
• Goosebumps and chills• Runny nose, teary eyes• Agitation, irritability and insomnia• General muscle aches• Nausea, stomach pain, vomiting, diarrhea
Because you feel like you have a really bad case of the flu, another temporary symptom many report is, “I feel like I’m going to die.” It’s common for the patient to mistakenly assume on her first day of discomfort that she’s in physical withdrawal which must mean she’s addicted. Given the lack of understanding and stigma of alcohol and drug addiction as the chronic brain disease that it is, if she seeks aid from what she knows will provide her “relief”, she can easily spiral into an actual prescription opiate problem where we see escalation of both the dose of opiates and addictive-type behaviors.
It is illegal to obtain any prescription drug except by way of a prescription written for you by your doctor. Some patients will go to other physicians with complaints of insufferable pain even though there might be no physical source of pain except their body’s growing dependence. When that option is no longer viable, they will buy these drugs off the Internet at a very high price. Others will steal them from the medicine cabinets of friends, family, even strangers, which is immoral and illegal.
So when the patient might have endured a few days of temporary sickness, allowing their desire for more opiates presents them with a future of failing health plus three more risks:  legal, financial, social
The patient who may not have initially become addicted will likely do so through escalation of the dose — as the body adjusts to higher levels of opioids, even larger doses are required and even greater risk incurred when trying to procure them through legal channels. Prescription drugs are controlled substances with government restrictions, so many of those who are addicted to them will now start buying heroin because it is much cheaper, and unfortunately, much more widely available.
Heroin is a street drug, not controlled by FDA regulations, meaning users don’t know the potency of the opioids it contains, nor what other substances have been mixed in with it. There is some semblance of control when you know how many milligrams there are in a pill, but heroin can be so potent that accidental fatal overdose is common. Also, very few people stop at only using opiates once they are abusing a street drug like heroin, so their addictive behavior becomes more expensive and dangerous on many levels. 
Recent studies have found 50-69-year-old adults with health insurance are the fastest-growing demographic of Americans addicted to opioids and the rates of addiction for women have doubled in the period from 2010-2013. The higher prescribing rates can be explained by the prevalence of common types of pain for this segment of the population, such as recovery from childbirth or lower back pain for women, and chronic age-related pain in the older population. Because of the addictive properties of opiates plus the high cost of maintaining a prolonged prescription drug habit, another recent study of self-reported heroin users showed that 75% started down their path of addiction by abusing prescription opioids that were originally prescribed for legitimate physical pain.   
The government and medical societies are working hard to better educate physicians to change their prescribing patterns, which will hopefully stem the tide of new cases of prescription opiate abuse. For those already experiencing physical dependence, it is important that they see this as an illness that can be treated immediately and effectively with medication, instead of a hopeless fight against an inevitable addiction.
The good news is, there are anti-addiction medications such as Suboxone and Naltrexone to treat opiate addiction and withdrawal by helping the brain recover from the intense opioid cravings and discomfort associated with it. 
In my book Healing the Addicted Brain, I expand on how these medications work chemically with the brain’s receptors in terms of addiction. Hopes are that with the awareness that there is something to help you with cravings and to again feel normal physically, while you battle recovery on the psychological front that more people will choose this successful road to recovery. 
But before we or our loved ones have to walk that road to recovery, let’s first recognize and stop abuse where we can. 
Get rid of unused prescription pills of any kind, removing temptation for you or others who might have access, like your children or their friends. And be honest with yourself about the signs of abusing opiates, such as:
• Taking more than a doctor prescribes when the pain does not warrant it.• Going to multiple physicians because of running out early, wanting more, and trying to hide it from everyone, or:• Accepting opiates from someone else, buying, gifting or getting them online.
At Enterhealth Ranch, our opiate treatment protocol is based on the latest research and our treatment is three times more effective than traditional addiction treatment models.
The highly personalized, science-based treatment plans at Enterhealth enable us to be vigilant in our hope of protecting Americans from becoming another sad statistic in the current prescription opioid epidemic.