What started the opioid crisis (epidemic)?
In the late 1990s, pharmaceutical companies reassured physicians and other providers that patients wouldn’t become addicted to opioid pain relievers.
This led to more patients becoming dependent on opioids as well as more opioids available for diversion. In 2017, an estimated 2 million people suffered from opioid use disorder–both prescription opioid and heroin use disorder.
What’s the difference between being an opioid-dependent versus being an opioid addict?
Let’s use nicotine as an example. A person may use nicotine and find themselves needing more than the original amount to have the same positive effects. This is defined as tolerance.
When the person doesn’t use nicotine they may have negative side effects, this is defined as withdrawal. Wanting to have nicotine and it being on your mind is defined as craving. Using the money you may have saved for something else relates to the compulsion associated with addiction.
So when an individual uses a substance and then misuses or abuses it, that leads to dependence or addiction.
Once the neurobiology of the brain has been altered secondary to misuse or abuse a person may have a chronic lifelong addiction or use disorder.
How do you use methadone to help with opioid dependency in pregnancy?
I am waivered to prescribe buprenorphine, both Suboxone and Subutex. If the patient prefers to take either of these medications I am able to prescribe these medications and work with them to manage their continuous care both during and after pregnancy.
If they have been on methadone and are stable then it is recommended that they continue to use methadone. Patients on methadone would see me for their obstetric care and obtain their prescription of methadone from a methadone clinic.
Is long term use of opioids indicative of dependence or addiction?
Regular use of opioids increases the chances of being dependent or addicted. This is why doctors are discouraged from prescribing patients opioid pain relievers for chronic pain like headaches, back pain, or pelvic pain that hasn’t been evaluated by imaging or other diagnostics.
Opioid pain medication is best for acute pain like a broken bone, just after a surgery, or in terminal (end of life) circumstances.
What are the main differences between Oxycodone and Hydrocodone?
Oxycodone is made by modifying Thebaine, an organic chemical found in opium. Hydrocodone is semisynthetic, made from codeine.
How long does hydrocodone stay in your system?
Hydrocodone has a longer half-life than oxycodone, so it stays in your system longer. For instance, hydrocodone can be detected in your system for 2-3 days after ingesting. Of course, taking either for a long period of time may result in developing a “physical dependence” on them.
What is Norco?
Norco is the brand name of the combination drug that has hydrocodone and acetaminophen (Tylenol).
Is Pentazocine, or any other mixed opioid agonist/antagonist, being used or investigated for opioid dependence applications, like suboxone/buprenorphine?
Pentazocine is an agonist at the K-opioid receptor unlike most of the other opioids which primarily act at the mu receptor.
What are the main differences between suboxone, subutex and methadone for severe opioid dependence?
Opioid use disorder is classified as mild, moderate or severe depending on the number of criteria met. There are 11 criteria that are evaluated if 2-3 are present that would be considered mild, 4-5 moderate and 6 or more severe.
The current MAT is Methadone, Suboxone (buprenorphine/naloxone) and/or Subutex (buprenorphine alone) which is really only used during pregnancy.
Suboxone has naloxone added to prevent the medication from being tampered with and used intravenously. We use Subutex in pregnancy because of the concern that the naloxone could stimulate withdrawal in the pregnant patient and cause untoward effects in the fetus.
All three of the MAT medication work well. Methadone is a full agonist and as a side effect has the same ability to decrease respiratory effort as any other opioid. It can only be obtained from a methadone clinic.
Suboxone is a combination drug, including the partial agonist (buprenorphine) and antagonist (naloxone). The buprenorphine has a greater affinity for the mu receptor but does not have the same ability to decrease respiratory effort or symptom relief. This is called a ceiling effect. As a result, this has rendered the drug safer than methadone.
A lot of research is being done in the space of pregnancy, opioid use disorder, and the effects on newborn babies. Current literature suggests buprenorphine has earlier and shorter neonatal abstinent syndrome (NAS) than methadone.
Buprenorphine can be prescribed by doctors with an X waiver on their DEA registration. This is often more convenient for patients especially when they are far away from a methadone clinic.