No doubt you’ve heard about the opioid epidemic that is literally killing more than 70,000 people every year. Ten years ago, about half that many people were dying by opioid overdose. How did it get so out of hand so quickly? One of the reasons is that medical providers were educated in a falsehood for decades. They were taught that if a person has chronic pain, they will not develop an Opioid Use Disorder (OUD is the new and correct term that replaces Addiction). We were told that less than one percent of individuals with chronic pain will develop problems with medications they were legitimately prescribed, regardless of the dose and regardless of their individual history of problems with substance abuse. How stupid could we all be? 

Opioid medications are so addictive because they interact with our internal opiate system. They provide not only pain relief, but also emotional pain relief, calm our anxiety and provide a pleasurable experience by activating a release of dopamine  (one of our neurotransmitters that is involved in our internal reward system). We know that this happens and it is not up for debate, this is factual.  Pain patients on opioids often respond by saying “but I don’t get high from these medications!” You may not experience a “high,” but your brain definitely notices the effect of these medications; hence, why we will refer to OUD as a “brain disease.” 

We now understand that it is not one percent of the people on opioids that develop an OUD, it is closer to 25 percent. An OUD is absolutely devastating for individuals. It means that your brain has developed an unhealthy connection to the medication.  Your brain wants it and needs it. An OUD is not just a physical dependence that can lead to withdrawals if you stop taking the med. It is your brain CRAVING that medication to feel better, you begin to have difficulty CONTROLLING your use of the medication and begin to have CONSEQUENCES due to your relationship with that medication.  These are often referred to the 3 C’s of a substance use disorder.

With the CRAVINGS, people begin to “clock watch” for their next dose.  They develop a focus on the medication throughout the day and night.  This leads to difficulty CONTROLLING their use.  They begin to use the doses closer together and run out of their medication by the end of the prescription and then experience the serious CONSEQUENCE of opioid withdrawal including diarrhea, vomiting, hot or cold sweats, dehydration, and flu-like symptoms.  During this withdrawal period their pain is actually worse, compelling most people to say “see the medication is working for my pain, I need it and I need more of it”.  Other CONSEQUENCES may be the impact on the family because the person is now focusing only on their medication. 

They do not feel “normal” without the medication, so we start to see more emotional behavior, depression when not on the medication in high doses, and anger / irritability become a new part of their personality.  Once they start overusing and end up running short on their meds, people start to find ways to get more medication that can be very expensive and dangerous.  They may also consider different ways to administer the medication to try to find ways that it may work better. They might try breaking the medication doses into small pieces and “chipping” with these small doses throughout the day.  They may start chewing their pills, crushing them, sorting them and even begin injecting them.

In the past given that we were told the one percent rule, if a person showed the behaviors noted above, we were encouraged to increase their dosage because they were doing this because their pain was not well enough controlled.  This was a concept called “Pseudo-Addiction,” meaning the person was showing the 3 C’s behavior that “looked like” the behavior of a person with addiction but it was really due to poor pain control.  Our team fell for this concept along with virtually all pain and medical providers.  We increased the dose and the behavior disappeared for a time, only to resurface a few months later; hence, another increase was needed and so on and so forth.  This was not a Pseudo-Addiction, it was the development of the unhealthy relationship with opioids that we now call an OUD.

You may be wondering, “how does the brain disorder develop in the person with pain?” Based on how the brain works, the question really is how does it only happen to 25 percent of those on opioids because our brain is really susceptible to the basic elements of these opioids.

You see, our brain has a special place for learning connections between the sensation of AVERSIVE experiences and anything that takes away or reduces those AVERSIVE experiences.  This connection is called NEGATIVE REINFORCEMENT in learning theory and boy does our brain pay attention to these experiences.  Pain is definitely aversive, withdrawal symptoms are definitely aversive, so anything that quickly and effectively removes pain or withdrawal symptoms will have our brain’s full attention.  Anxiety is also an aversive condition and anything that removes anxiety quickly (yes opioids do this too), our brain will again be paying attention.  So, act one of developing the brain disease of an OUD is to have something that quickly removes pain and the brain will say “Yeah, I like this substance” and to quote a line from Dumb and Dumber “I like it a lot.”  So this is a super strong connection developed in the brain, and there’s little we can do to combat it.

Then we have the dopamine issue, which is a whole different animal.  Dopamine is a neurotransmitter that often is noted to have a role in life or species-preserving behavior.  Dopamine is released when we eat food, when we have sex and when we love / care for our children.  The dopamine system has a limited range for those naturally occurring releases.  All addictive substances have an impact on the release of dopamine, and some release more dopamine than what our bodies can do on our own. Opioids produce changes in dopamine that are crazy far beyond what our body does on its own —  to the tune of six- to eight-times greater effect. Do you think your brain would pay attention to that?  Methamphetamine has about a 10-fold increase in dopamine, a main reason why people get so connected to the substance so quickly.  Here is the problem with our brain: when something pushes our brain’s neurotransmitters beyond what it is normally used to, our brain will push back.  It will begin to DOWN REGULATE the dopamine in our system.  In simplistic terms, it will start us out at a lower point of available dopamine each day, so that when we use a substance like methamphetamine or opioids we will not push our system to the extreme.  Did I mention that dopamine is an important neurotransmitter for depression too?  So, when our dopamine is down regulated, you guessed it, we feel down, irritable and sad.  Now we use the drug not to get a “high” but to “feel normal again.”  Not just in terms of pain, but in terms of basic dopamine.

These are a few basic concepts that we now understand about the brain disease of an OUD.  This is why this has become an epidemic that required a change in prescribing.  Many of the people that initially developed OUDs were people on chronic opioids for chronic pain.  They are not bad people, and they did not choose this. This is NOT a moral failing. They have the same willpower the rest of us do (that will be a post at some point) but they were exposed to something that fundamentally changed how their brain worked and they became connected to that medication in an unhealthy way.  THIS WAS THE FIRST OF FOUR REASONS WHY THE MEDICAL COMMUNITY NEEDED TO HAVE A DIFFERENT VIEW OF THE USE OF OPIOIDS FOR CHRONIC PAIN AND ALSO FOR ACUTE PAIN.  We now know that even short-term exposure to opioids for acute pain (e.g, after wisdom teeth removal or a knee surgery) can be enough to stimulate the brain to take action and move down the path towards an OUD.

This was a long post and I had to leave out many different parts to this equation.  Perhaps sometime I will put this all together in a e-book to allow full time to delve into all the issues.  I will post in the future on Opioid Use Disorders specifically because I believe very strongly that we need to understand this disorder and have compassion for those people that end up having it.  It is not a “them” or a “they” issue because all of us are susceptible to our brain connecting to these substances.