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Continuing Education for Health Professionals

WV: Best Practices for Prescribing Controlled Substances and Preventing Drug Diversion, 3 units

Module 4

A Closer Look at Addiction

Health Risks of Opioids

Health effects related to opioid misuse and abuse include pain relief, drowsiness, nausea, constipation, and euphoria. An acute effect, when taken in ways other than prescribed, is life-threatening respiratory depression leading to coma and death. Long-term effects include drug tolerance and addiction. In combination with alcohol, opioid use can cause life-threatening slowing of the heart rate and respiration with potential coma and/or death.

Certain populations have additional health risks. Youth often think that prescription drugs are safer to use than illegal drugs because they are prescribed by a physician and manufactured by legitimate pharmaceutical companies. Pregnant women who use opioids nonmedically can have spontaneous abortions and low-birth-weight babies. Older adults are at greater risk for severe health consequences due to accidental misuse or abuse of opioids because of age-related changes in metabolism, alcohol use, or drug interactions with multiple prescriptions (NIDA, 2018c). Addiction and accidental overdose occurs in all populations.

Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is often characterized by behaviors that include one or more of the following:

  • Impaired control over use
  • Compulsive use
  • Continued use despite harm
  • Craving

Addiction medicine is a specialty field in the mechanism and treatment of addiction. The American Society of Addiction Medicine’s definition of addiction:

Addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one's behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. (ASAM, 2015)

How Addicting Are Opioids?

Opioids are a class of drugs that broadly includes heroin, hydrocodone, oxycodone, and other morphine-derived drugs. Brain abnormalities can result from chronic use of such drugs and they cause dependence (the need to keep taking drugs to avoid withdrawal syndrome) and addiction. Dependence can resolve after detoxification. Addiction, however, has complex and long-lasting effects, involving craving that can lead to relapse long after the patient’s dependence resolves (NIDA, 2018d, 2016).

The opiate travels through the bloodstream to the brain, where chemicals attach to proteins called mu opioid receptors on the surfaces of opiate-sensitive neurons. When the chemicals link with the receptors, a biochemical process of the release of dopamine into the nucleus accumbens rewards the individual with feelings of pleasure, in the same manner as when they experience sex and food. Although the opioid may be prescribed to relieve pain, the pleasure reward process is activated, building motivation for repeated use of the drug for pleasure.

The brain creates lasting associations of the feelings of pleasure with the circumstances and environment in which they occur, further cementing the motivation to continue taking the opioid, despite the risks and obstacles.

Although taking drugs for pleasure is the first stage of drug abuse, the behavior becomes compulsive, which leads to tolerance and dependence. Repeated doses of opioids alter the brain. It begins to function normally when the drugs are present and abnormally when they are not. Higher dosages are needed to achieve the surge of dopamine for the same pleasurable effect; this is known as tolerance. The brain’s opioid receptors gradually become less responsive to the opioid. The dopamine rush has a diminished impact on the reward circuit, which means the drug user experiences a reduced ability to enjoy not only the drug but also other pleasurable life experiences. This user might take more of the drug, trying to achieve the same dopamine high.

Drug dependence is the condition of being so accustomed to the drug that withdrawal symptoms occur if the drug is not used. Another brain change in the locus ceruleus from use of opioids results in withdrawal symptoms of jitters, anxiety, muscle cramps, and diarrhea because excessive levels of noradrenaline are produced. Dependence leads to daily drug use to avoid unpleasant symptoms of withdrawal (NIDA, 2018d, 2016).

Symptoms of drug withdrawal from opioids include:

  • Anxiety
  • Irritability
  • Craving for the drug
  • Rapid breathing
  • Yawning
  • Runny nose
  • Salivation
  • Gooseflesh
  • Nasal stuffiness
  • Muscle aches
  • Vomiting
  • Abdominal cramping
  • Diarrhea
  • Sweating
  • Confusion
  • Enlarged pupils
  • Tremors
  • Loss of appetite (WebMD, 2017)

According to the National Institute on Drug Abuse (2018d), long-term use also causes changes in other brain chemical systems and circuits, affecting functions that include:

  • Learning
  • Judgment
  • Decision-making
  • Stress
  • Memory
  • Behavior

It is important to understand the opioid dependence and addiction are chronic medical disorders. Although initially people may voluntarily take a drug to treat pain or to feel pleasure, the brain changes that result from opioid use can create a physiologic and psychological need that is difficult to resist (NIDA, 2016, 2018d).

Best Practices in Pain Management and Addiction

The West Virginia Board of Medicine expects that physicians to incorporate safeguards into their practices to minimize the potential for the abuse and diversion of controlled substances (WVBM, 2017). A comprehensive approach is necessary to achieve safe pain management and optimal patient functioning (physical, psychosocial, social, and work-related) while guarding against misuse, abuse, addiction, and overdose.

It is not enough merely to diagnose and treat patients’ pain. It is incumbent on clinicians to understand the treatment of pain, alternatives to opioids, and medical indications for using opioids in the treatment of chronic pain, including the drugs’ general characteristics, toxicities, and interactions. Medical provider training and education on prescription drug abuse is provided by the West Virginia Department of Health and Human Services Bureau for Behavioral Health and Health Facilities.

Of use to all healthcare providers is the Opioid Overdose Prevention Toolkit. It aims to educate healthcare providers, patients, and family members about the risks of opioid analgesic misuse, abuse, and overdose, how to identify overdose, how to treat it, how to appropriately prescribe and monitor the use of opioids (SAMHSA, 2016a).

In brief, the best practices approved by the West Virginia Board of Medicine and SAMHSA include the following:

  • Evaluation
  • Treatment plan
  • Informed consent
  • Agreement for treatment
  • Periodic review
  • Consultation
  • Medical records
  • Compliance with controlled substance laws and regulations

These best practice recommendations are echoed in publications by the Federation of State Medical Boards (2017) and the American Society of Addiction Medicine. New legislation in West Virginia, SB 273, the Opioid Reduction Act, codifies prescribing opioid practices.

Prior to prescribing opioids, clinicians must first prescribe treatment alternatives such as physical therapy. A prescribed opioid must not exceed a 7-day supply at the lowest effective dose, and the provider must explain the associated risks.

The provider must document the patient’s medical history, conduct and document a physical examination, develop a treatment plan and access relevant prescription monitoring information under the Controlled Substance Monitoring Program Database.

Subsequent prescriptions may only be issued at least 6 days following the initial prescription and the provider must document that it is necessary and appropriate for the patient’s treatment. A third prescription for ongoing treatment requires consideration of referral to a pain clinic or specialist.

For supplies greater than 7 days, a patient must sign a narcotics contract with the prescribing provider agreeing to get medication only from that doctor, use the same pharmacy each time, and notify the provider of any emergency where the patient has been prescribed a controlled substance. Adults receiving an initial opioid prescription in an emergency department or urgent care facility are limited to a 4-day supply of opioid pain medicine. Minors are limited to a 3-day supply (WV DHHR, 2018).

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