Painkiller abuse

ALSO KNOWN AS: Opioid use disorder (OUD); Analgesic abuse

DEFINITION: A painkiller is an opioid medication used to reduce or alleviate pain. Painkiller abuse, or opioid use disorder (OUD), is the excessive use of painkilling drugs or use for nonmedical purposes. OUD is the condition of physical or psychological dependence on a painkiller. The drugs are obtained legally through prescription or by purchasing as an over-the-counter medication, or they are bought illegally.

Causes

Opioids come in two forms: natural and synthetic. Natural opioids are derived from the opium plant; synthetic (artificial) and partially synthetic opioids are structurally similar to natural opioids. Morphine and codeine are purified from the crude opium latex. Partially synthetic drugs derived from morphine include heroin, oxycodone (OxyContin), hydrocodone (Vicodin or Lortab), hydromorphone (Dilaudid), and oxymorphone (Numorphan). Synthetic compounds that resemble morphine in their chemical structure include fentanyl (Duragesic), levorphanol (Levo-Dromoran), meperidine (Demerol), methadone, and dextropropoxyphene (Darvon).

All opioids exert their effect by modifying the transmission of the nerve impulse between neurons (nerve cells). Neurons are separated from each other through short spaces called "synapses." When the nerve impulse reaches the terminal end of one neuron, neurotransmitters are released into the synapse. The neurotransmitter travels across the synapse and binds to receptors on the terminal of the next neuron to allow continuation of the nerve impulse. In the case of opioids, this neurotransmitter is dopamine.

Opioids act to increase and maintain the concentration of dopamine in the synapse by two methods. Some drugs prevent the reuptake of dopamine from the synapse by binding to proteins that normally transport dopamine. Other drugs act to increase the release of more dopamine from the presynaptic neuron terminal. The result is the maintenance and enhancement of the pleasurable effect promoted by dopamine.

Opium and its synthetic counterparts have structural similarities to natural pain relievers in the body called endorphins. Endorphins are secreted by the pituitary gland in response to pain stimuli, resulting in the relief of pain by binding to pain receptors and preventing transmission of the pain impulse. Endorphins are also secreted in response to pleasurable activities, such as eating and having sex, resulting in a high that is similar to that caused by morphine. Endorphins are more potent than morphine, but they do not lead to addiction because they are broken down by enzymes and do not accumulate.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are painkillers that act in the body by a different mechanism. The most common NSAIDs are acetaminophen, acetylsalicylic acid (aspirin), and ibuprofen, which are readily available over the counter. NSAIDs act by inhibiting the cyclooxygenase enzymes 1 and 2 that are involved in the synthesis of prostaglandins. Prostaglandins are involved in a variety of body processes, including sensitization of nerve endings.

NSAIDs are most commonly used for headache relief; however, they are often used to treat symptoms for which they are not recommended, such as anxiety, sleep problems, and stress. Authorities generally agree that the use of NSAIDs rarely leads to physical dependence.

Risk Factors

OUD may include self-medication, or the use of the drugs without a prescription to relieve pain or other symptoms. Chronic pain is a common cause of painkiller misuse. A person with chronic pain may begin to take painkiller medication beyond the physician’s prescription in larger doses or more frequently. People also use drugs for recreational purposes to produce euphoria, an emotional state of intensely pleasurable feelings.

Many pain medications first became available in the 1990s, and during the twenty-first century, more painkillers were available than ever before because of an increasing awareness and desire of physicians to reduce severe pain in their patients. In many cases, only opioid drugs can reduce severe pain. Physicians need to balance the need for relieving a patient’s pain versus the chance that the patient’s opioid use may lead to addiction. The availability of painkiller drugs can lead the patient to ignore alternative, less-addictive means of pain control.

Social factors can be important in OUD and painkiller misuse. Exposing drugs to adolescents and young adults is a critical factor, as it can lead to a lifetime of drug abuse. A family structure lacking stability or that is disruptive or violent can result in a lack of good role models and a poor sense of direction for children. Pain medications may be readily available at home, leading teens to take them to relieve pain or stress without a doctor’s prescription.

Peer pressure, the influence of friends and acquaintances in school and on the street, can be an important driving force, too. Adolescents often seek acceptance within particular groups, and adolescents may be prone to drug experimentation within these groups. Some persons of any age are more likely to become drug dependent, especially those who lack confidence or self-esteem, who may look to drugs to fill a void or to overcome loneliness or depression.

Genetic susceptibility can be a factor in painkiller abuse, although it is difficult to separate genetic from environmental influences. An estimated 40 to 60 percent of the variability of addiction is caused by genetic factors or by combined genetic and environmental interactions.

Symptoms

Signs of OUD and painkiller misuse can be psychological or physical. Psychologically, the person abusing drugs is focused on obtaining more drugs. He or she may increase the dose over time and often continues to use drugs after his or her medical condition has improved. Physical appearance often declines, and the person may show shifts in energy, mood, and concentration. He or she may withdraw from family and friends and might neglect household and work responsibilities.

Typical symptoms of painkiller addiction are feelings of euphoria, lethargy, mental confusion, nausea, and poor judgment. Less specific symptoms include slurred speech, shallow breathing, bloodshot eyes, constipation, and unusual drowsiness. The person misusing the drug eventually develops a tolerance for the drug, requiring higher doses to obtain the same effect. Withdrawal often occurs if the person abruptly stops using the drug. Withdrawal symptoms may include agitation, muscle aches, insomnia, anxiety, cramps, and nausea and vomiting.

Screening and Diagnosis

A physician will take a complete history of the patient, perform a physical examination, and send blood or urine samples to a laboratory to test for the presence of suspected drugs. Although blood tests are more likely than urine tests to detect drugs, urine tests are more common. Opiates are usually found in the urine within twelve to thirty-six hours of last use. A particular drug abuse screening test was developed in 1982, and it consists of questions to be answered by persons concerned about their involvement with drugs.

Treatment and Therapy

Treatment of painkiller misuse requires the person to stop using the drug. Abrupt discontinuation of drugs by long-term users, that is, going “cold turkey,” results in severe withdrawal symptoms. A more practical treatment involves slowly decreasing the use of the drug (through a process known as detoxification); complete abstinence follows.

Patients can work through recovery with the help of other drugs. While this may seem counterintuitive, many patients have successfully detoxified from painkillers and opioids with the help of medications. Medication treatment for OUD (known as MOUD) became more popular in the early twenty-first century as drug misuse was rising. Drugs such as buprenorphine and naltrexone block the effect of opiates on the body, thereby reducing withdrawal symptoms and the length of withdrawal. Patients taking buprenorphine also can become dependent on that drug. A newer version of the drug has been introduced; it is combined with another drug, naloxone. When this drug combination is injected, the person goes into withdrawal, thus preventing misuse.

Psychological addiction may continue long after physical withdrawal from the drug. The recovering person can experience difficulties in coping with daily activities, and there is a great danger the user will return to drug use. Each patient needs to be treated on an individualized basis. The detrimental mental and emotional states that led to drug misuse need to be identified and addressed, and the patient needs to be taught how to avoid drugs and drug culture. These changes may include new activities and new social and relational contacts.

Furthermore, individual therapy as well as group counseling can help people in recovery find personal strength and community as they navigate life without drug misuse. Group counseling coupled with approaches like Contingency Managements, which affords patients incentives and rewards for meeting goals or achieving success in recovery, as well as cognitive behavioral therapy (CBT) treatments, which incorporate mindfulness and patient-centered management of thoughts and feelings, have proven beneficial for many patients.

Prevention

Prevention is based on removing risk factors. Educating children about the dangers and consequencespainkiller misuse is paramount. Beyond the potential physical harm drug misuse can cause, it can also lead to the loss of one's job, loss of friends and family, and legal ramifications. Many schools and extracurricular clubs address issues of misuse and addiction in an effort to deter young people from attempting drugs themselves. Furthermore, parents and guardians need to keep prescription pain medications away from children. Finally, for persons taking prescription painkillers to manage chronic pain, it is important to use the medication only at the prescribed dosages to avoid developing a dependency.

Bibliography

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