By Kathleen Doheny
WebMD Health News
Opioid painkillers — also known as narcotic painkillers — are powerful drugs that can effectively treat pain when needed. But they are also potential killers: in 2013, they were linked to 16,000+ deaths, more than any other drug or drug class. And nearly 5 million people could be addicted to the drugs, says a new report from the Johns Hopkins Bloomberg School of Public Health.
The report, called “The Prescription Opioid Epidemic: An Evidence-Based Approach,” offers a number of solutions to the problem. One is to expand access to an addiction treatment called buprenorphine. Experts will discuss the report’s findings at a forum co-hosted by the Clinton Health Matters Initiative and Johns Hopkins at 3 p.m. on Tuesday, Nov. 17.
Andrew Kolodny, MD, chief medical officer for Phoenix House, a national nonprofit addiction treatment agency, was one of the experts who helped draft the report. He is also a senior scientist at Brandeis University’s Heller School for social policy and management and executive director of the Physicians for Responsible Opioid Prescribing. He answered questions about narcotics addition and buprenorphine.
WebMD: The opioid addiction problem has been well publicized, but what exactly is an opioid?
Kolodny: Opioids are drugs that come from opium. They include oxycodone, hydrocodone [and many others]. They produce effects in the brain not distinguishable from heroin. They are very important medicines for easing suffering at the end of life, or prescribed on a short-term basis such as after surgery. They need to be prescribed very carefully. The majority are not [prescribed] for end of life or short-term use. It’s the reason drug overdose deaths are at historically high levels.
WebMD: Are you seeing more patients with opioid addiction in your practice? If so, why?
Kolodny: Yes. We have an epidemic of opioid addiction that has been caused by overexposure of the U.S. population to opioid medication. Not very long ago the #1 drug problem would have been alcohol, followed by cocaine, followed by opioids. Our treatment programs … are flooded with people who are opioid-addicted. The epidemic began in the late 1990s; that is when the prescribing began to take off. If you were a doctor in the late 1990s through 2000, you really began to hear from every direction that the proper way to treat chronic pain was with an opioid prescription.
WebMD: How did most of the patients you see start out using opioids?
Kolodny: Over the past decade, two age groups of people have become addicted. The younger group is in their 20s and 30s. Some get addicted by recreational use, some by medical. The younger group, once addicted, they end up on the black market pretty quickly … [Some] young folks who get addicted have been switching to heroin. The older group, 40s and above, get addicted more through medical treatment. They haven’t been switching to heroin.They can generally find doctors who will give them all the pills they need.
WebMD: How is opioid addiction different than alcohol addiction?
Kolodny: Alcohol addiction typically runs in families. You see a strong genetic predisposition. Ninety percent of our population is able to use alcohol without becoming addicted or developing alcoholism. Opioids are different in that genetics play a much less important role. They are inherently more addictive than alcohol. Repeated exposure to the drug plays more of a role than genes.
WebMD: In your experience, what works best to treat patients with an opioid addiction?
Kolodny: Buprenorphine is safer than methadone. If you take too much methadone, you stop breathing and you can die. Buprenorphine works differently from other opioids in that it is a partial agonist; there is a ceiling on the effect. It’s quite hard to overdose on buprenorphine. People perhaps also feel more alert on buprenorphine than methadone.
I don’t want to make it sound like this is the only way. I think it’s first line for many people who have opioid addiction. The way it works is, the drug controls the craving.
WebMD: Buprenorphine prescriptions are regulated, with required doctor training and a federally-imposed cap on the maximum patients each doctor can treat. Your report recommends that this cap be lifted. Are you turning away patients who need it?
Kolodny: Yes. Buprenorphine became available as a treatment for opioid addiction in 2003 [approved in late 2002.] It was seen as an economic threat [by methadone clinics]. They lobbied for the very burdensome restrictions on buprenorphine so that only a doctor who takes an 8-hour training program can prescribe it. And the doctor is limited in the first year to only treating 30 patients. In the second year they can apply to go over that, but only up to 100. When someone is interested in treatment, you want to see they have access to that immediately [not be put on a waiting list].
WebMD: In your opinion, what impact would easing these restrictions have on the addiction problem?
Kolodny: It would have an enormous positive impact. How do you end disease epidemics? You prevent new people from getting the disease. And you see that people who have the disease get effective treatment so the disease does not kill them.
I would estimate that 5 million Americans have the disease of opioid addiction. The federal estimate is 2.5 million have opioid addiction from heroin or non-medical use of pain killers. But we have about 10 to 12 million pain patients on long-term opioids. About a third appear to be addicted. If they have to jump through tons of hoops to find someone who can treat their opioid addiction with buprenorphine, but can walk into a pill mill [for opioid painkillers], it’s hard to engage them in treatment.
WebMD: If someone has a loved one they are concerned might have an opioid addiction, what advice can you offer them?
Kolodny: If they are looking for information about where to get addiction treatment, I’d recommend the SAMSHA website. You can find a doctor [there] who can provide buprenorphine. They should realize their loved one is suffering from a life-threatening condition. Those who are opioid addicted feel awful. They wake up in the morning feeling like they have been hit by a baseball bat until they take their first dose. I think many do want help. It’s just very hard to find help.