Do Prescription Opioids Increase Social Pain and Isolation?

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Long-term use of opioid medication may increase social isolation, anxiety and depression for chronic pain patients, according to psychiatric and pain management experts at the University of Washington School Medicine.

In an op/ed recently published in Annals of Family Medicine, Drs. Mark Sullivan and Jane Ballantyne say opioid medication numbs the physical and emotional pain of patients, but interferes with the human need for social connections.

“Their social and emotional functioning is messed up under a wet blanket of opioids,” Sullivan said in a UW Medicine press release.

Sullivan and Ballantyne are board members of Physicians for Responsible Opioid Prescribing (PROP), an influential anti-opioid activist group. Ballantyne, who is president of PROP, was a member of the “Core Expert Group” that advised the CDC during the drafting of its controversial 2016 opioid guideline. She has retired as a professor of pain medicine at the university, while Sullivan remains active as a professor of psychiatry.

In their op/ed, Sullivan and Ballantyne say it is wrong to assume that chronic pain arises solely from tissue damage caused by trauma or disease. They cite neuroimaging studies that found emotional and physical pain are processed in the same parts of the human brain.  While prescription opioids may lessen physical pain, they interfere with the production of endorphins – opioid-like hormones that help us feel better emotionally.

“Many of the patients who use opioid medications long term for the treatment of chronic pain have both physical and social pain,” they wrote. “Rather than helping the pain for which the opioid was originally sought, persistent opioid use may be chasing the pain in a circular manner, diminishing natural rewards from normal sources of pleasure, and increasing social isolation.

“To make matters worse, the people who need and want opioids the most, and who choose to use them over the long term, tend to be those with the most complex forms of chronic pain, containing both physical and social elements. We have called this process ‘adverse selection’ because these are also the people who are also at the greatest risk for continuous or escalating opioid use, and the development of complex dependence.”

Sullivan and Ballantyne say doctors need to recognize that when patients have both physical and social pain, long-term opioid therapy is “more likely to harm than help.”

“We believe that short-term opioid therapy, lasting no more than a month or so, will and should remain a common tool in clinical practice. But long-term opioid therapy that lasts months and perhaps years should be a rare occurrence because it does not treat chronic pain well, it impairs human social and emotional function, and can lead to opioid dependence or addiction,” they wrote.

Angry and Depressed Patients

It’s not the first time Sullivan and Ballantyne have weighed in on the moods and temperament of chronic pain patients. In a 2018 interview with Pain Research Forum, for example, Ballantyne said patients often have “psychiatric comorbidities” and become “very angry” at anyone who suggests they shouldn’t be on opioids.

“I’ve never seen an angry patient who is not taking opiates. It’s people on opiates who are angry because they’re frightened, desperate, and need to stay on them. And I don’t blame them because it is very difficult to come off of opiates,” she said.

In a 2017 interview with The Atlantic, Sullivan said depression and anxiety heighten physical pain and fuel the need for opioids. “People have distress — their life is not working, they’re not sleeping, they’re not functioning,” Sullivan said, “and they want something to make all that better.”

JANE BALLANTYNE                        MARK SULLIVAN
JANE BALLANTYNE MARK SULLIVAN

In a controversial 2015 commentary they co-authored in the New England Journal of Medicine, Sullivan and Ballantyne said chronic pain patients should learn to accept pain and get on with their lives, and that relieving pain intensity should not be the primary focus of doctors. The article infuriated both patients and physicians, including dozens who left bitter comments.

Drinking linked to a decline in brain health from cradle to grave

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The evidence for the harmful effects of alcohol on brain health is compelling, but now experts have pin-pointed three key time periods in life when the effects of alcohol are likely to be at their greatest.

Writing in The BMJ today, researchers in Australia and the UK say evidence suggests three periods of dynamic brain changes that may be particularly sensitive to the harmful effects of alcohol: gestation (from conception to birth), later adolescence (15-19 years), and older adulthood (over 65 years).

They warn that these key periods “could increase sensitivity to the effects of environmental exposures such as alcohol” and say harm prevention policies “must take the long view.”

Globally, around 10% of pregnant women consume alcohol, with the rates considerably higher in European countries than the global average, they write.

Heavy alcohol use during pregnancy can cause fetal alcohol spectrum disorder, associated with widespread reductions in brain volume and cognitive impairment. But data suggest that even low or moderate alcohol consumption during pregnancy is significantly associated with poorer psychological and behavioural outcomes in offspring.

In terms of adolescence, more than 20% of 15-19 year olds in European and other high income countries report at least occasional binge drinking (defined as 60 g of ethanol on a single occasion), they add.

Studies indicate that the transition to binge drinking in adolescence is associated with reduced brain volume, poorer white matter development (critical for efficient brain functioning), and small to moderate deficits in a range of cognitive functions.

And in older people, alcohol use disorders were recently shown to be one of the strongest modifiable risk factors for all types of dementia (particularly early onset) compared with other established risk factors such as high blood pressure and smoking.

Although alcohol use disorders are relatively rare in older adults, the authors point out that even moderate drinking has been shown to be linked to a small but significant loss of brain volume in midlife, although further studies are needed to test whether these structural changes translate into functional impairment.

Furthermore, demographic trends may compound the effect of alcohol use on brain health, they write. For example, women are now just as likely as men to drink alcohol and experience alcohol related harms, and global consumption is forecast to rise further in the next decade.

The effects of the covid-19 pandemic on alcohol use and related harms are unclear, but alcohol use increased in the long term after other major public health crises, they add.

As such, they call for an integrated approach to harm reduction at all ages.

“Population based interventions such as guidelines on low risk drinking, alcohol pricing policies, and lower drink driving limits need to be accompanied by the development of training and care pathways that consider the human brain at risk throughout life,” they conclude.

‘Diseases of despair’ have soared over past decade in US

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‘Diseases of despair’, such as substance abuse, alcohol dependency, and suicidal thoughts and behaviours, have soared in the US over the past decade, reveals an analysis of health insurance claims data published in the online journal BMJ Open.

And they now affect all ages, with suicidal thoughts and behaviours among the under 18s rocketing by 287% between 2009 and 2018, and by 210% among 18-34 year olds, the analysis shows.

Between 2015 and 2017, life expectancy fell year on year in the USA, the longest sustained decline since 1915-18. And deaths among middle-aged white non-Hispanic men and women rose sharply between 1999 and 2015.

These premature deaths are largely attributable to accidental overdose, alcohol-related disease, and suicide.

Such ‘deaths of despair’ have coincided with decades of economic decline for workers, particularly those with low levels of educational attainment; loss of social safety nets; and stagnant or falling wages and family incomes in the US, all of which are thought to have contributed to growing feelings of despair.

Despair may in turn trigger emotional, behavioural and even biological changes, increasing the likelihood of diseases that can progress and ultimately culminate in deaths of despair, say the researchers.

To characterise trends in diseases of despair over the past decade and identify associated demographic risk factors, they drew on detailed claims data extracted from Highmark, a large US-based health insurance company.

Highmark members are concentrated in states that have been disproportionately affected by deaths of despair: Pennsylvania; West Virginia; and Delaware.

In all, the researchers analysed information for 12 million people enrolled in a Highmark health insurance plan between 2007 and 2018, and who had valid details on file.

Diseases of despair were defined as diagnoses related to alcohol dependency, substance misuse, and suicidal thoughts/behaviours, and analysed among the following age groups: under the age of 12 months; 1-17 year olds; 18-34 year olds; 35-54 year olds; 55-75 year olds; and those aged 75+.

Overall, 1 in 20 (515,830; just over 4%) of those insured were diagnosed with at least one disease of despair at some point during the monitoring period. Some 58.5% were male, with an average age of 36.

Of these, over half (54%) were diagnosed with an alcohol-related disorder; just over 44% with a substance related disorder; and just over 16% with suicidal thoughts/behaviours. Just under 13% were diagnosed with more than one type of disease of despair.

Between 2009 and 2018, the rate of diseases of despair diagnoses increased by 68%. The rate of alcohol-related, substance-related, and suicide-related diagnoses rose by 37%, 94%, and 170%, respectively.

The largest increase in alcohol and substance-related diagnoses was seen among 55-74 year olds: 59% and 172%, respectively.

Among infants, substance-related diagnoses, which were attributable to neonatal abstinence syndrome linked to maternal drug abuse — for example opioid addiction — rose by 114%.

While the absolute numbers of suicide-related diagnoses were lower than for other types of diseases of despair, the relative increases were large. Among 1-17 year olds, the rate increased by 287%, and by 210% among 18-34 year olds. A relative increase of at least 70% occurred in all other age groups.

Diseases of despair diagnoses were associated with significantly higher scores for coexisting conditions, higher rates of anxiety and mood disorders, and schizophrenia for both men and women across all age groups.

The researchers acknowledge that it wasn’t possible to find out about potentially influential social determinants of health from the claims data, added to which, given that an estimated 87 million working adults in the US are uninsured or underinsured, it is hard to gauge the true scope of the diseases of despair, they say.

Nevertheless, they urge: “While the opioid crisis remains a top public health priority, parallel rises in alcohol-related diagnoses and suicidality must be concurrently addressed.”

Story Source:

Materials provided by BMJNote: Content may be edited for style and length.

Fentanyl and Heroin Use Rise During Pandemic

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The use of illicit fentanyl and heroin rose dramatically during the first two months of the COVID-19 pandemic, according to a large new study by Quest Diagnostics. Misuse of hydrocodone, morphine and some other opioid medications also increased.

The study adds to growing signs that Americans are turning to potent illicit drugs to cope with the stress and economic disruption caused by the pandemic.

“It’s the social isolation, the depression, the anxiety, stress, job loss, the loss of health insurance and the election. All these things that add stress to our lives are driving people to increase use of alcohol at home and, in the case of this study, drug misuse,” said co-author Harvey Kaufman, MD, Senior Medical Director for Quest Diagnostics. 

Kaufman and his colleagues analyzed data from over 872,000 urine drug tests, comparing samples taken before the pandemic to those taken from March 15 to May 14, 2020. The urine samples came largely from people undergoing substance abuse treatment or were prescribed opioids and other controlled substances, and are not representative of the population at large.

Interestingly, while the rate of drug misuse remained largely the same before and during the pandemic – about 49 percent – there were notable shifts in the type of drugs being misused.

Drug positivity rates increased by 44% for heroin and 35% for non-prescribed fentanyl, a synthetic opioid that is 50 to 100 times more potent than morphine. Positivity rates for non-prescribed opiate medication (hydrocodone, hydromorphone, codeine and morphine) rose by 10 percent. There were no significant changes in the misuse of oxycodone and tramadol. 

Fentanyl was frequently found in urine samples that tested positive for amphetamines (89%), benzodiazepines (48%), cocaine (34%), and opiates (39%). The abuse of multiple substances in combination with fentanyl has been a growing problem for years, but Quest researchers were surprised by how much it has accelerated.

“It’s shocking that something could move that quickly. It’s been well underway for half a dozen years, but the pandemic supercharged it,” Kaufman told PNN.

Gabapentin Misuse

One surprising detail in the Quest study is that the nerve drug gabapentin (Neurontin) is being misused more often than any other prescription drug. Non-prescribed gabapentin was found in nearly 11% of urine samples — second only to marijuana — in the first two months of the pandemic. While that’s down from pre-pandemic levels, it adds to a growing body of evidence that

The use of illicit fentanyl and heroin rose dramatically during the first two months of the COVID-19 pandemic, according to a large new study by Quest Diagnostics. Misuse of hydrocodone, morphine and some other opioid medications also increased.

The study adds to growing signs that Americans are turning to potent illicit drugs to cope with the stress and economic disruption caused by the pandemic.

“It’s the social isolation, the depression, the anxiety, stress, job loss, the loss of health insurance and the election. All these things that add stress to our lives are driving people to increase use of alcohol at home and, in the case of this study, drug misuse,” said co-author Harvey Kaufman, MD, Senior Medical Director for Quest Diagnostics.

Kaufman and his colleagues analyzed data from over 872,000 urine drug tests, comparing samples taken before the pandemic to those taken from March 15 to May 14, 2020. The urine samples came largely from people undergoing substance abuse treatment or were prescribed opioids and other controlled substances, and are not representative of the population at large.

Interestingly, while the rate of drug misuse remained largely the same before and during the pandemic – about 49 percent – there were notable shifts in the type of drugs being misused.

Drug positivity rates increased by 44% for heroin and 35% for non-prescribed fentanyl, a synthetic opioid that is 50 to 100 times more potent than morphine. Positivity rates for non-prescribed opiate medication (hydrocodone, hydromorphone, codeine and morphine) rose by 10 percent. There were no significant changes in the misuse of oxycodone and tramadol.

Fentanyl was frequently found in urine samples that tested positive for amphetamines (89%), benzodiazepines (48%), cocaine (34%), and opiates (39%). The abuse of multiple substances in combination with fentanyl has been a growing problem for years, but Quest researchers were surprised by how much it has accelerated.

“It’s shocking that something could move that quickly. It’s been well underway for half a dozen years, but the pandemic supercharged it,” Kaufman told PNN.

Gabapentin Misuse
One surprising detail in the Quest study is that the nerve drug gabapentin (Neurontin) is being misused more often than any other prescription drug. Non-prescribed gabapentin was found in nearly 11% of urine samples — second only to marijuana — in the first two months of the pandemic. While that’s down from pre-pandemic levels, it adds to a growing body of evidence that gabapentin is being overprescribed and abused.


Gabapentin was originally developed as an anti-convulsant, but it has been repurposed to treat chronic pain and is often prescribed off-label as an alternative to opioids. When taken as prescribed, there is little potential for gabapentin to be misused. However, when taken with muscle relaxants, opioids or anxiety medications, gabapentin can produce a feeling of euphoria or high.

A likely factor in the decline in gabapentin misuse during the pandemic is a drop in physician visits. Fewer visits mean fewer prescriptions, and gabapentin may have become less available for diversion.

Just as stay-at-home orders forced many patients to cancel or postpone healthcare appointments, it also led a significant decline in drug testing. Orders for lab tests by Quest dropped by as much as 70% in the first few weeks of the pandemic. They have since rebounded, but are still well below pre-pandemic levels.

“COVID-19 interrupted non-essential patient care, but it hasn’t stopped drug misuse,” co-author Jeffrey Gudin, MD, Senior Medical Advisor to Quest, said in a statement. “Given the psychological, social, and financial impacts of the COVID-19 crisis, more efforts are needed to ensure that patients are taking medications as prescribed. While the nation focuses on the pandemic, we must not lose sight of the ongoing drug misuse epidemic, which continues to kill upwards of 70,000 Americans each year.”

“COVID-19 interrupted non-essential patient care, but it hasn’t stopped drug misuse,” co-author Jeffrey Gudin, MD, Senior Medical Advisor to Quest, said in a statement. “Given the psychological, social, and financial impacts of the COVID-19 crisis, more efforts are needed to ensure that patients are taking medications as prescribed. While the nation focuses on the pandemic, we must not lose sight of the ongoing drug misuse epidemic, which continues to kill upwards of 70,000 Americans each year.” 

After briefly declining in 2018, drug overdoses began rising again in 2019. According to one preliminary study, drug overdoses are up about 17 percent so far this year. Story courtesy of the Pain News Network

SOURCE: QUEST DIAGNOSTICS

After briefly declining in 2018, drug overdoses began rising again in 2019. According to one preliminary study, drug overdoses are up about 17 percent so far this year.

Addiction treatment shrinks during the pandemic, leaving people with nowhere to turn

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Josh Ledesma displays safe injection supplies with outreach specialist Rachel Bolton outside the Access Drug User Health Program drop-in center in Cambridge, Massachusetts on March 31, 2020. Craig F. Walker/The Boston Globe via Getty Images

Elizabeth Chiarello, Saint Louis University

COVID-19 has overshadowed the U.S. opioid crisis, but that doesn’t mean opioid addiction has gone away. During the COVID-19 pandemic, the opioid crisis has gotten worse. Drug overdose death rates rose 13% in the first half of 2020. COVID-19 threatens to dismantle an already frayed addiction treatment system, creating a crisis on top of a crisis.

The opioid crisis, or, more aptly, the overdose crisis, has plagued the U.S. for two decades. Drug overdose is the leading cause of accidental death, claiming 70,000 American lives each year. Opioids contribute to 130 deaths daily, enough people to fill a commercial airliner.

As a medical sociologist who has researched the opioid crisis for the last decade, I have seen the havoc it has wrought. Here is how I see COVID-19 making it worse.

A glimmer of hope, dashed

A road sign advertises help for addiction in West Virginia, one of the states hit hardest by the opioid crisis.
In the city of Logan, West Virginia, a road sign advertises help for addiction. Andrew Lichtenstein/Corbis via Getty Images

Overdose deaths increased steadily each year since 1999 until they declined 4.1% in 2018, largely due to fewer deaths involving prescription opioids. Experts suggest that lower opioid prescribing rates, expanded treatment access and increased naloxone access help explain the decline.

That brief downturn gave way to steeply rising overdose death rates in 2019 and 2020 as deaths involving other drugs like cocaine and methamphetamine rose.

Not only are numbers going up, but the drugs that contribute to overdose have changed.

Many overdose deaths involve multiple drugs. Prescription drugs now play a less prominent role than heroin, cocaine and methamphetamine. Synthetic fentanyl – a potent illegal opioid manufactured in labs – poses the biggest threat. It contributes to twice as many overdose deaths as prescription opioids.

Inadequate addiction treatment

The overdose death rate – 20.7 deaths per 100,000 people – comes as no surprise to people familiar with U.S. addiction treatment.

Only 17% of people with addiction get treatment.

And addiction treatment is notoriously fragmented and underfunded. Cordoned off from mainstream health care, the addiction treatment industry receives scant regulation. Quality varies. Only one-third of facilities provide medications for addiction treatment, evidence-based care that reduces overdose risk.

In the face of inadequate addiction treatment, harm reduction strategies are effective. Harm reductionists encourage people who use drugs to use strategies that protect them from overdose, infectious disease and abscesses from sharing or reusing syringes.

Programs that reduce harm include naloxone programs that distribute naloxone throughout communities and syringe services programs that distribute clean syringes to people who inject drugs. These programs, while effective, receive tepid support, largely due to stigma. Naloxone distribution programs and syringe services programs operate on shoestring budgets with limited hours that have only become more restricted during the pandemic.

COVID-19's emergence has further complicated the opioid crisis.
A medical assistant in Charlestown, Massachusetts takes a swab sample from from a patient. Matt Stone/MediaNews Group/Boston Herald via Getty Images

Clash of the crises

When the COVID-19 pandemic began, the federal government took measures to lessen the pandemic’s impact on the opioid crisis.

The government lowered barriers to medications for addiction treatment by allowing methadone clinics to give patients medication to take home and by allowing physicians to provide buprenorphine, another drug used in recovery, through telemedicine. These measures reduced in-person contact.

But people dealing with the disorder still face challenges. For one, they cannot attend in-person support groups. Social isolation increases the likelihood of drug use and overdose. While figures are not yet available, much anecdotal evidence suggests that coping with the pandemic increases stress and anxiety while disrupting routines that are important for recovery.

And, COVID-19 has made the illegal drug supply more dangerous. In the illicit market, drugs contain various substances. A person who purchases heroin might end up with a mix of heroin, fentanyl and oxycodone, drugs of varying strengths. People who use drugs typically get them from a known supplier, so they know what they are getting and how much to take.

COVID-19 interrupted the illicit drug trade, so there were fewer drugs coming into the country. When supply runs low, people do not stop using drugs; they get drugs of unknown composition from new suppliers. If someone buys heroin but unknowingly receives much stronger fentanyl, the overdose risk skyrockets. People die because they do not know what drug they are taking.

Crisis compounded

In addition, COVID-19 exacerbates the trauma that leads to overdose. Addiction is a “disease of despair,” meaning it is more common among people with poor social and economic prospects. Mental health conditions, job loss and housing instability all contribute to drug use.

COVID-19 makes treatment less available. Treatment centers struggling to stay open are reducing hours and furloughing staff. Syringe service program site closures and stalled naloxone programs undermine harm reduction efforts.

Strategies to expand treatment have been of some help. However, only physicians who already have an X Waiver – a special dispensation to prescribe opioids for addiction – can provide telemedicine for buprenorphine. The federal government’s actions have moved care online, but only minimally increased treatment capacity.

A systemic solution

Things are dire, but leaders can deploy effective strategies now. In the short term, leaders can double down on harm reduction. They can blanket communities with naloxone, putting it in every library, gas station, pharmacy and vending machine, making it as commonplace as a fire extinguisher. They can invest in syringe services programs and encourage people to use drug test strips to test for fentanyl.

They can expand medications for addiction treatment by eliminating the X waiver, letting all licensed physicians provide them, and by allowing pharmacists to provide buprenorphine, an approach showing favorable results in Rhode Island. They can expand Medicaid, which requires insurers to cover treatment for addiction. These measures could save lives.

Leaders also need a long-term strategy that tackles the root causes of addiction. As COVID-19 makes clear, disrupting the drug supply does not make addiction disappear – it puts people with addiction at greater risk. The rise in cocaine overdose deaths is especially worrying, because while medications for addiction treatment work for opioid use disorders, they do not work for cocaine use disorders.

In the last 20 years, the U.S. has cycled through overdose spikes due to prescription opioids, then heroin, then fentanyl. Now cocaine and methamphetamine pose looming threats.

Investing in healthy communities is the best line of defense against overdose. A stronger social safety net would improve problems that lie at the root of addiction such as unemployment, homelessness and mental health conditions. Building infrastructure to prevent and treat addiction will equip our communities to weather storms like COVID-19.

[Deep knowledge, daily. Sign up for The Conversation’s newsletter.]

Elizabeth Chiarello, Associate Professor of Sociology, Saint Louis University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

A Crisis Collision: Will COVID-19 Disrupt Efforts to Address the Opioid Epidemic?

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Prior to the advent of the coronavirus disease 2019 (COVID-19) pandemic, the opioid epidemic had been sweeping through the United State. An opinion piece recently published in the Annals of Internal Medicine highlights growing concerns among medical professionals about the exacerbating effects the pandemic may have among people with opioid use disorder (OUD).

Job loss, food insecurity, and overall morbidity have disproportionately affected marginalized communities, including people with medical and psychiatric comorbidities. This has left the medical community with concerns about the potential rise in substance use disorders and opioid overdose. In the published opinion piece, William C. Becker, MD and David A. Fiellin, MD, explore the importance of uninterrupted access to methadone and buprenorphine for patients with OUD.

For quarantined patients, mobile teams were suggested as a way to deliver methadone, considering physical examination requirements have been relaxed and extended supply of the medication for stable patients has been allowed. The authors also encouraged the use of settlement funds from a buprenorphine manufacturer to address limited access to the drug due to financial constraints. The safer pharmacologic properties of buprenorphine allow it to be dosed less frequently, and in-home initiation of the drug is now supported by new dose titration protocols.

Currently, first year clinicians are required to limit the number of patients they treat concurrently; however, authors suggest this restriction be temporarily lifted in order to compensate for the limited number of physicians available due to the COVID-19 crisis, and support networks should be funded from local, state and federal governments to address patient needs.

In addition to highlighting the importance of uninterrupted access, the authors also implore the federal government to maintain funding for opioid-related projects, as the race for a COVID-19 vaccine threatens to halt strides in research on OUD treatment.

Finally, medical professionals are concerned that COVID-19 may delay remunerations for families affected by the opioid crisis. Financial insecurity due to the crisis makes it increasingly important to facilitate the acceleration of cases nearing resolution, because the postponement of court hearings in the era of social distancing may delay the compensation of victims of opioid manufacturers’ malfeasance.

“The response to COVID-19 and the speed with which regulatory barriers are being reconsidered and removed should be translated to opioid-related clinical, research, and legal policy”, the opinion authors noted. “In the absence of such efforts, we risk more catastrophic effects from these colliding epidemics.”