Category: Opioids

In the Opioid Epidemic, More Reasons for Hope Than Despair

Addiction Recovery Bulletin

NOT THE ONION –

August 8, 2021 – That picture won’t change much on Monday, when one of the nation’s biggest opioid settlements is set to be effectively resolved. A federal judge is expected to certify Purdue’s bankruptcy plan, which sits at the center of a $4.5 billion settlement between the company and thousands of state and municipal governments that have sued for damages related to the opioid epidemic. In many ways, that settlement is atrocious. Members of the billionaire Sackler family, which owns Purdue and profited most heavily from the company’s opioid dealings — will not have to admit to any wrongdoing. They will secure near-total immunity from any future litigation, and by the time the settlement is paid out they most likely will be as wealthy as they ever were.

But the deal will achieve at least some good: Millions of pages of documents, detailing the full scope of the company’s malfeasance, will be made public. Communities across the country will finally receive some of the money they need to address the ongoing crisis. And the resolution of so many lawsuits at once will bring a small measure of closure to a plague that has felt interminable and shows no signs of abating. That is nothing to scoff at, for a nation weary of epidemics and starved for closure of any kind.

As one chapter in this long and terrible story ends, it’s crucial not to lose sight of the human faces behind the grim statistics. Five hundred thousand is an incomprehensible figure, even — or especially — in the age of Covid. It includes sons and daughters and siblings and parents and spouses and friends. It includes the suffering of all the people who loved them. It includes so much heartache and despair that hardly anyone in America today remains untouched by it. And, of course, there are the two million or so more people who are still living, and struggling, with opioid use disorder and its consequences.

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California bill would allow supervised injection sites

Addiction Recovery Bulletin

 

STICK WITH THE WINNERS – 

June 3, 2021 – A proposed new law would allow for supervised injection sites in some California counties. Supporters say it would reduce drug overdoses while critics say it would just normalize drug addiction.

More than 81,000 people died of drug overdoses in the U.S. from June 2019 to May 2020, according to provisional data from the Centers for Disease Control and Prevention. That is the highest number ever recorded in a 12-month period.  A proposed new law would allow for supervised injection sites in some California counties. Supporters say it would reduce drug overdoses while critics say it would just normalize drug addiction.

More than 81,000 people died of drug overdoses in the U.S. from June 2019 to May 2020, according to provisional data from the Centers for Disease Control and Prevention. That is the highest number ever recorded in a 12-month period.

Opponents of the proposal from all over the world spoke out in a virtual news conference. on Wednesday.

“There is no safe way to inject illicit drugs into your system, simple as that,” said Chuck Doucette, a retired police officer and president of the Drug Prevention Network in Canada.

So far, the bill passed the Senate 21-11, with eight abstaining. The bill is expected to be heard in committee in the Assembly within a couple of weeks.

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How the VA Is Pushing Vets Into the Opioid Abyss

David Parker, whose 12-year military career included deployments as a Marine to Iraq and Afghanistan, was getting out of his car last July at the Veterans Health Administration outpatient clinic in Fort Collins, Colorado, to seek treatment for his injured back when it suddenly gave out.

His body below his waist went numb. His face hit the pavement, and he lost control of his bowels.

As a former military service member, he is one of more than nine million Americans who get medical care from the VA system, the federal government’s sprawling array of 170 hospitals and more than 1,000 clinics. Parker, who is 34, was transported to the hospital in an ambulance and was given a week’s worth of the opiate codeine as part of his treatment.

He regretted what happened next.

“You were supposed to take, like, two a day, max, and I was taking—I think, like, by the fifth day, I was taking four. Four or five a day,” he told The Daily Beast. “I was popping them like Skittles.”

  • Parker worried about becoming addicted. That’s why, the next month, after a cross-country move—when he went to an East Coast VA hospital for a pancreatic cancer screening and complained about his aching back—he was adamant that he not be given opiates. Staff gave him a pill that they said was ibuprofen, he claimed. In 20 minutes, his back felt great.

“Whatever that ibuprofen was, I need to get that prescribed,” Parker said he told the doctor.

“Well, it’s codeine,” the doctor replied, according to Parker.

He was stunned. He did not want opiates, for fear of addiction, and he said he had informed the nurse of that very concern. Yet he said he was given them anyway.

Although officials at the VA could not speak to Parker’s individual case due to privacy concerns, a spokesperson did tell The Daily Beast that the facility in question “follows standard guidelines for the safe prescribing of opioids and routinely monitors facility and provider level prescribing patterns.” They added that the facility was well below national targets for prescribing opioids.

But among former military members, Parker’s experience is far from unique, interviews and a review of recent audits of VA care show. And even as the coronavirus pandemic continues to dominate the public-health conversation in America, veterans and their advocates say the agency needs to do more to rein in opioids before it’s too late.

The Veterans Administration has come under withering criticism in recent years for contributing to the nation’s opioid epidemic. A decade ago, the VA prescribed opioids to one out of every four veterans in its care, according to government statistics. Due to injuries endured in combat, veterans are more likely than civilians to be dealing with serious pain. But the staggering number of prescriptions caused grave concerns.

Critics included the American Legion, one of the nation’s largest veterans’ groups, which in 2015 reported, “Overuse of opiate prescriptions clearly creates problems for veterans within the VA health-care system.”

Floyd Meshad, a Vietnam War veteran who runs the nonprofit National Veterans Foundation based in Los Angeles, California, opposes long-term opioid therapy for veterans in general. “If you get opioids and you stay on or get hooked, you don’t know if you’re better or not. You don’t feel anything,” he told The Daily Beast.

Read the complete article at The Daily Beast here

Doctors More Likely to Prescribe Opioids to COVID ‘Long Haulers,’ Raising Addiction Fears

Covid survivors are at risk from a separate epidemic of opioid addiction, given the high rate of painkillers being prescribed to these patients, health experts say.

A new study in Nature found alarmingly high rates of opioid use among covid survivors with lingering symptoms at Veterans Health Administration facilities. About 10% of covid survivors develop “long covid,” struggling with often disabling health problems even six months or longer after a diagnosis.

For every 1,000 long-covid patients, known as “long haulers,” who were treated at a Veterans Affairs facility, doctors wrote nine more prescriptions for opioids than they otherwise would have, along with 22 additional prescriptions for benzodiazepines, which include Xanax and other addictive pills used to treat anxiety.

Although previous studies have found many covid survivors experience persistent health problems, the new article is the first to show they’re using more addictive medications, said Dr. Ziyad Al-Aly, the paper’s lead author.

He’s concerned that even an apparently small increase in the inappropriate use of addictive pain pills will lead to a resurgence of the prescription opioid crisis, given the large number of covid survivors. More than 3 million of the 31 million Americans infected with covid develop long-term symptoms, which can include fatigue, shortness of breath, depression, anxiety and memory problems known as “brain fog.”

The new study also found many patients have significant muscle and bone pain.

The frequent use of opioids was surprising, given concerns about their potential for addiction, said Al-Aly, chief of research and education service at the VA St. Louis Health Care System.

“Physicians now are supposed to shy away from prescribing opioids,” said Al-Aly, who studied more than 73,000 patients in the VA system. When Al-Aly saw the number of opioids prescriptions, he said, he thought to himself, “Is this really happening all over again?”

Doctors need to act now, before “it’s too late to do something,” Al-Aly said. “We must act now and ensure that people are getting the care they need. We do not want this to balloon into a suicide crisis or another opioid epidemic.”

As more doctors became aware of their addictive potential, new opioid prescriptions fell, by more than half since 2012. But U.S. doctors still prescribe far more of the drugs — which include OxyContin, Vicodin and codeine — than physicians in other countries, said Dr. Andrew Kolodny, medical director of opioid policy research at Brandeis University.

Some patients who became addicted to prescription painkillers switched to heroin, either because it was cheaper or because they could no longer obtain opioids from their doctors. Overdose deaths surged in recent years as drug dealers began spiking heroin with a powerful synthetic opioid called fentanyl.

More than 88,000 Americans died from overdoses during the 12 months ending in August 2020, according to the Centers for Disease Control and Prevention. Health experts now advise doctors to avoid prescribing opioids for long periods.

This article first appeared on Medscape.com here

HHS Loosens Restrictions on Buprenorphine for Opioid Use Disorder

New practice guidelines released by the US Department of Health & Human Services (HHS) remove long-time barriers to buprenorphine for the treatment of opioid use disorder (OUD).

Specifically, the Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder exempts eligible physicians, physician assistants, nurse practitioners, and others from federal certification requirements related to training, counseling, and other ancillary services that are part of the current process to obtain a waiver to treat up to 30 patients with the drug.

“Increases in overdose deaths emphasize the need to expand access to evidence-based treatments, including buprenorphine that can be prescribed in office-based settings,” Assistant Secretary for Health Rachel Levine, MD, said in a release.

“These guidelines provide another tool to help communities respond to the evolving overdose crisis, equipping providers to save lives in their communities,” she added.

With respect to the prescription of certain medications covered under applicable provisions of the Controlled Substances Act (CSA), such as buprenorphine, practitioners licensed under state law who possess a valid Drug Enforcement Administration (DEA) registration, may be exempt from the certification requirements related to training, counseling, and other ancillary services.

Under the exemption, practitioners are limited to treating no more than 30 patients at any one time. Time spent practicing under the exemption will not qualify the practitioner for a higher patient limit.

In addition, under the exemption practitioners must be supervised by, or work in collaboration with, a DEA-registered physician if required by state law to work in collaboration with, or under the supervision of, a physician when prescribing medications for the treatment of OUD.

Record Number of Overdose Deaths

This requirement does not apply to practitioners who are employees or contractors of a department or agency of the United States acting within the scope of such employment or contract.

Under the guidelines, practitioners who do not wish to practice under the exemption and the 30-patient limit may seek a waiver per established protocols.

The exemption applies only to the prescription of Schedule III, IV, and V drugs or combinations of such drugs, covered under the CSA, such as buprenorphine. It does not apply to the prescribing, dispensing, or the use of Schedule II medications such as methadone for the treatment of OUD, the HHS notes.

Before treating patients with buprenorphine for OUD, practitioners must obtain a waiver under the CSA by submitting a Notice of Intent to the HHS’s Substance Abuse and Mental Health Services Administration (SAMHSA) under established protocols.

Provisional data from the Centers for Disease Control and Prevention show that more than 90,000 drug overdose deaths are predicted to have occurred in the United States in the 12 months ending in September 2020, the highest number of overdose deaths ever recorded in a 12-month period and such deaths have continued to accelerate during the COVID-19 pandemic.

“The spike we’ve seen in opioid-involved deaths during the COVID-19 pandemic requires us to do all we can to make treatment more accessible,” Acting Assistant Secretary for Mental Health and Substance Use Tom Coderre, who leads SAMHSA, said in a release.

“Americans with this chronic disease need and deserve readily available access to life-saving, evidence-based treatment options. These new guidelines are an important step forward in reducing barriers to treatment and will ultimately help more people find recovery.”

Support From AMA

In a statement, the American Medical Association (AMA) applauded the move and noted that it will remove “daunting regulatory barriers and eas[e] stigma facing patients with opioid use disorder.”

The AMA noted that patients with OUD struggle to find physicians authorized to prescribe buprenorphine and expressed hope that these new guidelines, which remove “onerous” regulations, will help them get the treatment they need.

“Treatment with buprenorphine allows patients with opioid use disorder to lead satisfying, productive lives. The policy announced today is a critically important step in making that happen. Going forward, the AMA is supporting legislation to remove the waiver requirements altogether and will advocate for that in Congress,” the release said.

This article first appeared on Medcape.com here.

Biden Pledges Assertive Action to Address Opioid Crisis

Addiction Recovery Bulletin

BY DOING WHAT? – 

April 5, 2021 – The crisis is national, but the struggle is personal—deeply personal,” he said.

Biden became the third sitting U.S. president to address the Rx Summit, joining President Donald Trump in 2019 and President Barack Obama in 2016. Former President Bill Clinton also spoke at the Rx Summit in 2018. In its latest projections, the U.S. Centers for Disease Control and Prevention estimates 88,000 individuals died from a drug overdose in the U.S. between August 2019 and August 2020, a 27% increase year-over-year that Biden said has been largely driven by social isolation and financial insecurity. Recently, he signed the American Rescue Plan, legislation that provides $4 billion to support mental health and substance use disorder treatment, including $1.5 billion for prevention and treatment initiatives, with $400 million earmarked for Certified Community Behavioral Health Clinics.

“We need to meet this crisis with urgent action,” Biden said, adding that the American Rescue Plan is “just the start.”

Biden said his administration is committed to expanding access to treatment, supporting proven recovery and prevention efforts, and reducing the supply of illicit substances coming into the U.S. Members of his administration are slated to discuss those measures in greater detail during the Rx Summit later this week.

“The addiction crisis has already taken so much, and I grieve with all those who have lost someone,” Biden said. “We also celebrate those who are recovering. We hold them in our hearts and commit ourselves to helping more families know the joy and relief of recovery.

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Carrying Naloxone Can Save Lives but Newly Abstinent Opioid Users Resist

Opioids are the main driver of fatal drug overdoses in the United States, according to the Centers for Disease Control and Prevention, resulting in 46,802 deaths in 2018, usually because the person stops breathing.

Naloxone — a Food and Drug Administration-approved medication used to reverse overdoses from opioids, such as heroin, morphine and oxycodone — works by restoring normal respiration to a person whose breathing has slowed or stopped.

“Opioid overdoses cause the largest number of accidental and avoidable deaths,” said Peter Davidson, PhD, associate professor in the Department of Medicine at University of California San Diego School of Medicine. “The human toll of drug addiction is devastating. Using naloxone to prevent opiate overdoses can and has saved many lives.”

In a study published in the March 23, 2021 online edition of the International Journal of Drug Policy, Davidson and an international group of researchers, found that opioid users who participate in a 12-step abstinence program and recently stopped using drugs refused to take home naloxone, even if having it on hand might save lives.

For the study, trained interviewers visited areas known for high drug use in three Southern California counties: San Diego, Orange and Ventura. Forty-four participants were asked questions about drug use initiation, overdose experiences, both their own and observed and past treatments.

“In our research, individuals who were newly abstinent from opioid use believed that carrying naloxone symbolically tied them to a drug-use identity that they were trying to leave behind,” said first author Jeanette Bowles, DrPH, who is now a postdoctoral fellow with the Centre on Drug Policy Evaluation in Toronto, Canada, but was a UC San Diego School of Medicine postdoctoral fellow at the time of the study.

“Twelve-step programs promote abstinence through social behaviors that include staying away from people, places and things considered to be tied to drug use. Naloxone was seen as an item linked to their drug use and clashing with these sober behaviors and their goal of abstinence.”

To reduce the stigma associated with naloxone, researchers suggest reframing the meaning of carrying naloxone to represent a commitment to group safety and the wellbeing of those “who still suffer” and relabeling naloxone training programs in substance use disorder treatment settings as “overdose first aid.”

In addition, researchers propose focusing on the lifesaving impact those trained to administer naloxone can have on their peers, and re-targeting naloxone distribution efforts to include persons at any phase of their drug use, including abstinence.

“It is very important that people understand that after periods of abstinence, the body is less tolerant if an individual resumes drug use, making them physiologically more vulnerable to overdose and death,” said Davidson, co-corresponding author and principal investigator. “If someone is experiencing an opioid overdose, it is important to recognize the signs and respond quickly to prevent death.”

In the United States, laws now allow people to access and use naloxone to respond to overdose with protection from liability.

The Addiction Recovery and Treatment Program at UC San Diego Health provides patients with outpatient behavioral treatment for substance use, such as cannabis, alcohol and opioids.

Guideline for reducing opioid use post-surgery leads to high pain management satisfaction and disposal rates

A prescribing guideline tailored to patients’ specific needs reduced the number of opioid pills prescribed after major surgery with researchers reporting a greater than 90 percent patient satisfaction rate with pain management and the highest compliance rate to date with appropriate disposal of leftover pills. The study was selected for the 2020 New England Surgical Society Program and published as an “article in press” on the website of the Journal of the American College of Surgeons (JACS) in advance of print.

The researchers focused on a post-surgery opioid prescribing guideline developed by surgeons at the Dartmouth-Hitchcock Medical Center, Lebanon, N.H. The guideline is based on the number of opioids patients take on the day before they are discharged from the hospital.

Lead study author Richard J. Barth Jr., MD, FACS, section chief of general surgery, explained that the guideline recommends discharging patients with no prescription for opioids if they have taken no opioids on the day before; 15 pills if they have taken one to three pills; and 30 pills if they have had four or more pills.

“This guideline was designed to satisfy the pain management needs of about 85 percent of patients,” said Dr. Barth, who led a previous study published in JACS in 20181

that proposed the guideline and showed that the number of opioids taken the day before discharge was the best predictor of how many opioids patients used after discharge.

The 2018 study involved only general surgery procedures, whereas the latest study included a broader cross-section of surgery: general surgery, as well as colorectal, gynecological, thoracic, and urological operations.

“In this new prospective study we found that 93 percent of patients had their post-surgery opioid needs satisfied,” Dr. Barth said of the most recent JACS study.

“This finding means that this guideline can be used for a wide variety of operations to guide surgeons on how many opioids to prescribe when sending patients home after surgery.”

Researchers consider patient’s perception of pain
This study is unique because it’s a prospective one of a post-surgery pain management guideline that takes into account an individual patient’s perception of pain. A prospective study enrolls patients before they’ve achieved the study outcome—in this case, an operation and their opioid use afterward—whereas a retrospective study evaluates outcomes after the fact. Other guidelines, which base the number of opioids prescribed solely on the operation that was performed, do not take into account individual variations in patients’ responses to pain. Minimizing opioid use among surgical patients is an important strategy for medicine because studies have found that up to 10 percent of patients who have undergone surgery, but have not used opioids before, may go on to become chronic opioid users.2

Study details
The study enrolled 229 patients admitted to the hospital for at least 48 hours after their initial operation. Upon discharge, patients received prescriptions for the non-opioid medications acetaminophen and ibuprofen, as well as opioids based on the guideline. Researchers used a protocol that deviated slightly from the post-discharge opioid prescribing guideline:

Patients who used no opioids—calculated as zero oral morphine milligram equivalents (MME)—on the day before discharge were sent home with five oxycodone 5-mg pill equivalents (PEs)
Patients who used up to 30 MME received 15 PEs
Patients who used 30 MME or more received 30 PEs
The lower the opioid usage was before hospital discharge, the higher the level of patient satisfaction with pain management: 99 percent of those in the zero-MME group reported satisfaction, as did 90 percent in the middle MME group, whereas 82 percent in the 30-plus MME group did so (P=0.001).

Despite being given an opioid prescription, 73 percent of the zero-MME group used no opioids at home, and 85 percent used two pills or less.

Surgeon’s role in minimizing opioid use
Dr. Barth noted that surgeons play a pivotal role in minimizing opioid use in their patients by setting expectations for pain management. That discussion involves letting patients know they are likely to be discharged with either no opioids or a small amount based on their opioid use on the day before they go home. “Explain to the patient, ‘We’ve studied this issue; we’ve figured out how many opioids you are likely to need,’” he said.

“The other part of that discussion involves letting patients know that they should expect some pain, that our goal isn’t to get rid of every last bit of their pain,” he added. “That was something that surgeons tried to accomplish years ago, but that’s not what we’re aiming for now. A low level of discomfort is acceptable, and patients need to have that expectation.”

That process also involves prescribing, not just recommending, over-the-counter non-opioid analgesics. “By prescribing non-opioid analgesics the surgeon sets the expectation that they should be used,” he said. “It’s a big difference if a surgeon prescribes non-opioid analgesics compared with just recommending that a patient take acetaminophen or ibuprofen that they might have at home.”

He added, “In this study, 95 percent of the patients took either acetaminophen or ibuprofen and 70 percent took both, whereas in previous studies1 where we had just recommended that they use them, 85 percent reported taking one or the other, but only 20 percent reported taking both.”

Opioid disposal rate soars with surgeons’ input
Proper disposal of unused pills is another key component of responsible opioid management. In this study, 60 percent of patients had leftover pills. “We worry about unused pills because those pills could be used by that individual patient and might predispose them for long-term or chronic use,” Dr. Barth said. “Those excess pills could also be diverted to others and perpetuate opioid misuse in the community.”

The Dartmouth-Hitchcock investigators employed several strategies to encourage patients to properly dispose of leftover pills. In addition to educating patients about the potential for opioid misuse and diversion, one strategy was to install a drop box for leftover pills in the institution’s pharmacy, located near the surgeons’ outpatient offices. A phone call before the post-surgery follow-up appointment also reminded patients to bring their unused pills with them to dispose. “These are easily actionable items that can really impact the disposal of excess opioids,” Dr. Barth added.

When these strategies were employed, 83 percent of patients disposed of their excess opioids using a method that complies with Food and Drug Administration recommendations. This rate is substantially higher than rates of disposal in the 20-to-30 percent range reported by other investigators who relied on patient education alone.3 Fifty-one percent of the patients who disposed of their excess opioids used the drop box in the hospital pharmacy, while 28 percent used a drop box in a police or fire department and 21 percent used other FDA-compliant methods of disposal. A total of 2,604 pills were prescribed in the study; only 187 of them (7 percent) were kept by patients.

This article first appeared at Facs.org here

Study finds unintended consequences of state, opioid policies

Original post: Newswise - Substance Abuse Study finds unintended consequences of state, opioid policies

n response to the increase in opioid overdose deaths in the United States, many states have implemented supply-controlling and harm-reduction policy measures aimed at reducing those deaths. But a recent study from Indiana University found the policies may have had the unintended consequence of motivating those with opioid use disorders to switch to alternative illicit substances, leading to higher overdose mortality.

“Literature from public health to social sciences has presented mixed and contradictory findings on the impact of opioid policies on various opioid adverse outcomes,” said Byungkyu Lee, assistant professor of sociology at IU and co-author of the study. “Our findings suggest that the so-called opioid paradox — the rise of opioid-related deaths despite declines in opioid prescriptions — may arise from the success, not the failure, of state interventions to control opioid prescriptions.”

Researchers used the National Vital Statics System and Optum Clinformatics DataMart to look at drug overdose mortality data from 50 states and claims data from 23 million commercially insured patients in the U.S. between 2007 and 2018. They then evaluated the prevalence of indicators of prescription opioid abuse, opioid use disorder and overdose diagnosis, and the prescription of medications-assisted treatment and drug overdose deaths before and after implementation of six state-level policies targeting the opioid epidemic.

Policies included prescription drug monitoring program access, mandatory prescription drug monitoring programs, pain clinic laws, prescription limit laws, naloxone access laws and Good Samaritan laws.

The study, published in the JAMA Network Open, found that supply-controlling policies were associated a lower proportion of patients who take opioids, have overlapping claims, receive higher opioid doses and visit multiple providers and pharmacies. They also found that harm-reduction policies were associated with modest increases in the proportion of patients with overdose and opioid use disorder. Additionally, the proportion of patients receiving medications-assisted treatment drugs increased following the implementation of supply-controlling policies.

Brea Perry, professor of sociology at IU and co-author of the study, said these findings demonstrate the power of big data to provide insights into the opioid epidemic and how to best reverse it.

“Our work reveals the unintended and negative consequences of policies designed to reduce the supply of opioids in the population for overdose,” Perry said. “We believe that policy goals should be shifted from easy solutions such as dose reduction to more difficult fundamental ones, focusing on improving social conditions that create demand for opioids and other illicit drugs.”

In terms of overdose mortality, the study found that all overdose deaths increased following the implementation of naloxone access laws, especially deaths attributable to heroin, synthetic opioids and cocaine. Good Samaritan laws were also associated with increases in overall overdose deaths.

Furthermore, mandatory prescription drug monitoring programs were associated with a reduction in overdose deaths from natural opioids and methadone, and the implementation of pain clinic laws was associated with an increase in the number of overdose deaths from heroin and cocaine. However, having a prescription limit law was associated with a decrease in overdose deaths from synthetic opioids.

“Our work demonstrates that there is no easy policy solution to reverse the epidemic of opioid dependence and mortality in the U.S.,” Lee said. “To resolve the opioid paradox, it is imperative to design policies to address the fundamental causes of overdose deaths, such as lack of economic opportunity, persistent physical, and mental pain, and enhance treatment for drug dependence and overdose rather than focusing on opioid analgesic agents as the cause of harm.”

Other co-authors of the study are Wanying Zhao, Kai-Cheng Yang and YY Ahn, all from the IU Luddy School of Informatics. This work was supported by a National Institute on Drug Abuse grant.

IU Research

Indiana University’s world-class researchers have driven innovation and creative initiatives that matter for 200 years. From curing testicular cancer to collaborating with NASA to search for life on Mars, IU has earned its reputation as a world-class research institution. Supported by $854 million last year from our partners, IU researchers are building collaborations and uncovering new solutions that improve lives in Indiana and around the globe.

This article first appeared at Newswire.com here

New hope for treating chronic pain without opioids

According to some estimates, chronic pain affects up to 40% of Americans, and treating it frustrates both clinicians and patients––a frustration that’s often compounded by a hesitation to prescribe opioids for pain.

A new study from the University of Michigan School of Dentistry confirms that a low dose of a drug called naltrexone is a good option for patients with orofacial and chronic pain, without the risk of addiction, said first author Elizabeth Hatfield, a clinical lecturer in the Department of Oral and Maxillofacial Surgery and Hospital Dentistry.

Naltrexone is a semisynthetic opioid first developed in 1963 as an oral alternative to naloxone, the nasal spray used to reverse opioid drug overdoses. When prescribed at doses of 50 to 100 milligrams, naltrexone blocks the effects of alcohol and opioids.

Low-dose naltrexone has been used off-label for years to treat chronic pain, but Hatfield said this is the first in-depth, systematic review of the literature to determine if the drug is indeed a good option for patients and deserving of more formal study.

“We found a reduction in pain intensity and improvement in quality of life, and a reduction in opioid use for patients with chronic pain,” said Hatfield, who hopes to initiate a randomized control trial of low dose naltrexone.

Low doses of naltrexone (0.1-4.5 mg) works by acting on a unique cellular pathway in the nervous system through which it delivers chronic pain relief without opioids, Hatfield said. If patients are working with a physician to treat pain, it’s appropriate for them to raise the topic of low-dose naltrexone as a possible alternative.

Chronic pain is pain that persists for several months, or after the initial injury or trauma has healed, and the way clinicians and scientists think about chronic pain is changing. It’s now thought that some chronic pain has more to do with how our body reports pain to the brain, than the actual injury.

“Normally, chronic pain leads your body to go through a sensitization process whereas your nervous system becomes more sensitive, and this can happen even to nonpainful stimuli,” Hatfield said. “The way I like to explain it to learners or patients is how a sunburn makes you feel, when things that normally feel OK hurt, like a warm shower or a sheet touching your skin.”

This concept of the nervous system being sensitized is promoted by cells called glial cells. Low-dose naltrexone targets these cells that keep the nervous system sensitized, thereby reducing the pain threshold and the sensitivity of the nervous system over time.
Traditional pain management has focused on treating the injury or trauma site, but low-dose naltrexone works on the overactive nervous system.

“Low-dose naltrexone begins to address the cause of pain and not just mask it, which allows us to better target diseases causing chronic pain, as well as potentially consider pain control outside of opioid use,” Hatfield said.

It is best used on centralized pain disorders, conditions where the nervous system is in that hyperexcited state, Hatfield said. Those conditions include myalgia, complex regional pain syndrome and temporomandibular joint disorders, commonly called TMJ, among others. Low-dose naltrexone is inexpensive and has few side effects. However, it’s not an option for people who use alcohol or opioids regularly.

Hatfield became interested in the field of orofacial pain after study co-author Lawrence Ashman, clinical assistant professor of dentistry, started a residency in orofacial pain in 2018. Two years later, Hatfield was the first graduate of the two-year Orofacial Pain Residency program in the OMS/Hospital Dentistry Department.

There are only 13 residencies in orofacial pain in the country, Hatfield said. However, the pain specialty makes sense for dentistry, because this pain is related to joint and muscles surrounding the oral cavity and hasn’t been previously “owned” by dentists or medicine.

Many patients are first exposed to opioids through dentistry. While there is a place for well-managed opioid treatment for chronic pain patients, alternative treatments are needed, she said.

This article first appeared at UMich.edu