Addiction Specialist Mark L. Kraus, M.D., FASAMA recent Centers for Disease Control and Prevention (CDC) report, released late last year, revealed some troubling findings about prescription painkillers. The abuse of well-known, pain-relieving opioids such as Vicodin, OxyContin, and Percocet, has reached epidemic proportions. In fact over 12 million people reported the non-medical use of prescription painkillers in 2010. Not surprisingly the number of overdoses has also increased, representing an annual death toll of 15,000 people in the U.S. alone. But there is hope for those dependent on opiates in the form of convenient and confidential treatment options, according to physician and addiction specialist Mark L. Kraus, M.D., FASAM. Healthline recently spoke to Dr. Kraus, who has treated many patients facing opioid dependence, about, among other things, the genetic predisposition for opiate addiction, the proper and improper dispensation of painkillers, and effective treatment options.
Dr. Kraus, for clarity’s sake, what is the difference between dependence on and addiction to an opiate medication?
Somebody who is physiologically dependent on an opiate would need more drug to create like effect and if they stop the drug they have physiological withdrawal.
Someone who becomes an opiate addict has those two elements plus other elements. Other incidents that would be involved would be missing social events, missing work, having family problems, having financial problems, having legal problems—actually, they’re basically out of sorts with their life. They’re spending a lot of time doctor shopping and even though they know it’s bad for them, they still persist in that behavior. As a chronic disease, it can have remissions or exacerbations (what people call, ‘falling off the wagon,’) where they go back and use drugs.
Is there a genetic predisposition to opiate addiction?
There have been some recent findings that there may be a genetic predisposition. Let me give you an example: Josh and Mark get prescription pills for lower back pain and Josh takes his medication just as it’s prescribed, does everything he’s supposed to do, but Mark actually fell in love with how he felt. That pill made him feel unreal, better than he’s ever felt and he just can’t have that feeling back, so he starts this run of taking medication.
For some people there may be a genetic quality to what triggered them to have that feeling, so now there’s thinking about that maybe being the cause. Over a period of time that person is going to have to take more medication to feel that effect. That’s a property of opioids—more medicine to achieve like effect, because of tolerance—and then when they’re cut off, they go into withdrawal and feel the worst flu they’ve ever felt.
Are some opiates more addictive than others?
Because we’re dealing with a chemical structure that is quasi the same and all of them can precipitate having the addiction, all of them can lead to a horrible life. But in the hands of a physician with a patient using it properly for pain, that’s something that’s a good drug, because none of us want to suffer in pain.
And we don’t want to see these drugs taken off the market, because unfortunately, at one time of our life we’re going to need pain relief, and without these kinds of drugs we won’t have that. There is science behind these medications; we just need to know how to apply them properly and we need to know who to apply them to.
So how can a physician tell when a patient is in legitimate pain and in need of medication versus an addict trying to scam their doctor for drugs?
We define pain as 'a perception of discomfort.' There is acute pain from a trauma or broken bone; malignant pain, which is cancer; non-malignant pain, which is arthritis and disc disease; and withdrawal-related pain.
To uncover pain, a physician is trained to take a history, a good, thorough history, and based on that history, comes the physical examination. The physician is trained to examine the person and solicit evidence from their clinical evaluation as to whether there is or isn’t something there that indicates pain. If that doesn’t really show up, he or she might decide to get some lab/X-ray data to help them or nerve-conduction tests, ancillary things to help them make this diagnosis.
So the diagnosis of pain isn’t a slam bam; it just isn’t like that. You have to look into it. If someone has lower back pain or pain from a broken arm or toothache, you can understand it, but you don’t have to go at it with an opiate. You can start with acetaminophen or non-steroidals, and working your way up is the way to go—not starting off with a heavy-duty oxycodone or vicoprofen. So we need to know that there’s also physical therapy, hypnosis, etc., and knowing that, the doctor can start out treating the patient while he or she is doing the work up.
It seems like there are two types of doctors: the ones who throw painkillers at the problem and the ones who are overly cautious about prescribing anything.
It is a dilemma, and with all the hype that’s been in the media, doctors are more on guard with giving patients medications for pain that could lead them into trouble. They’re worried about the ramifications of that from the patient’s point of view; there’s worry about litigation if you’ve done the wrong thing. There have been legal cases because of that, so doctors are in a really precarious situation because they’re trying to do no harm and also trying to take care of the suffering, so they need to know the score. Most colleagues know the score.
Then there’s Florida.
There are always rotten apples in the barrel. I mean, Florida, known for being a ‘pill mill’ state, is an example of addict-controlled, write the script, and give me a check. That’s not medicine; I wouldn’t want a doctor like that. So we need to educate the professionals, and the government is trying to do that, but we also need to educate the population, too, that they can’t misuse, abuse, and divert the medication—like I have a headache and you say, ‘I have a Percocet,’ and you give it to me. That’s against the law, but people do that and all these things happen.
If a patient came to you, asking for help with an opiate addiction, how would you treat them?
First, they’re evaluated, because we want to find out the scope of the problem. We ask them to bring in their significant other, spouse, or partner, so we can talk, because that’s a lot of information. Then we make a game plan up. Some people need extreme structure, and those patients need inpatient; some people need structure but not inpatient and can do it in an outpatient setting called a partial hospital program; some people need the next level of intensity, intensive outpatient, maybe spend five hours, not eight hours at the program; and some people need to be in an outpatient setting, and maybe three or four visits in the first week or so and then come in every other week, so it depends on the person, how they present, what they’re presenting with, how out of control they are, how medically compromised they are, to determine what level of care they need.
As far as treatment, I know that there are two commonly prescribed medications: Methadone and Suboxone.
There are two medications to treat opiate dependence, Methadone, which has been around for 50 odd years and Suboxone, for around 15 years. [Addiction] is a chronic disease that has evidence-based medicine that can help someone regain function and health, no differently than if you were diabetic and I gave you insulin and you had to take that to stay well, physically, emotionally, and mentally.
Not only should they be taking a medical assisted part of their treatment, but also the psychosocial part, and the reason for that is, unfortunately with this disease there’s a high prevalence of psychiatric disorders.
So are these medications for life?
Wouldn’t a diabetic need insulin for life? One of the things we know about opiates is that there’s a high recidivism rate when people stop taking medical assisted treatment, be it Methadone, we know it’s in the high 90s, or Suboxone which is in the 80 to 90 range, when they stop taking it.
So how do we get out of this mess?
From my own perspective, educate the public about keeping medicines in a safe, locked box area, to keep them away from children and others. We need to talk about medical assisted treatments and educating physicians, nurse practitioners, and physician’s assistants about the proper way of using them so they’re not misused. I think it will make a huge difference if we have the cooperation of the entire community.
Mark L. Kraus, M.D., FASAM is a General Internist in private practice at Westside Medical Group, Waterbury, CT. Dr. Kraus is a fellow of the American Society of Addiction Medicine (ASAM) and a Diplomat of the American Board of Addiction Medicine, who has treated many patients facing opioid dependence. To find a physician who specializes in addiction in your area, visit www.TurnToHelp.com.