May 14 2018 . 15 min read
Breaking free from the Terrifying grip of opioids
Breaking free from the Terrifying grip of opioids
Could the answer be staring us right in the face?
Could the answer be staring us right in the face?
“We lose one Nevadan every day to opioid overdose — a mother, father, son, daughter, grandparent or close friend,” stated Governor Brian Sandoval during his 2017 State of the State address. “This has been a growing problem for over a decade and has now reached levels of epidemic proportion.”
In fact, 387 Nevada residents died from opioid use in 2016. Fifty-nine percent of Nevada’s opioid-related overdose deaths were caused by natural and semisynthetic opioids, 20 percent were caused by heroin, 13 percent were from methadone, 13 percent result from synthetic opioids, and the remaining 7 percent were unspecified opioids, according to 2016 data released by the Nevada Division of Public and Behavioral Health.
“Las Vegas was one of the worst in the country for these so-called pill mills,” said Dr. Scott Jacobson, who isn’t surprised by the numbers of Nevadans falling prey to opioid abuse. “Any patient could walk in off the street, say I am in pain, and get a prescription. So basically, they were like illegal drug operations.”
Dr. Jacobson’s assertion that the state is rife with pill mills is confirmed by 2012 data from the Nevada Division of Public and Behavioral Health which reports that clinicians wrote 94 painkiller prescriptions for every 100 Nevada residents. That was in 2012, before opioid-related hospitalizations spiked more than 150 percent from 2013 to 2015, according to the state health department’s data.
Although Nevada has had a Prescription Drug Monitoring Program (PDMP), where physicians and pharmacists can check for prescriptions written for a controlled substance prior to issuing one, for more than two decades it hasn’t helped curb abuse. That Nevada’s PDMP hasn’t helped get the state’s painkiller crisis under control also isn’t a surprise to Dr. Jacobson who has been practicing medicine in Las Vegas for the last eight years.
“A new patient came into my office and needed a refill on her Percocet. I looked in the prescription monitoring program and she had been prescribed 1,000 pills of Percocet in a single month at numerous pharmacies by different doctors,” recalled Dr. Jacobson. “Not one person had checked [the program] or if they did, they didn’t do anything about it. It just shows the ease at which people had access to pretty much as many pills as they wanted.”
Legislate it Away
During the 2017 Nevada Legislative Session, Governor Sandoval introduced the Controlled Substance Abuse Prevention Act, Assembly Bill 474, which was drafted to provide more training and reporting, and heightened protocols for medical professionals. It unanimously passed both the Assembly and Senate last year and became effective January 1 of this year.
The Controlled Substance Abuse Prevention Act establishes a standard of care for prescribers but, most importantly, it reduces the amount of inappropriate prescribing and prioritizes patient safety and responsibility. It also endeavors to prevent addiction to prescription drugs through monitoring and by attempting to mitigate risk.
Under the new law, doctors must limit initial prescriptions to two weeks and perform a patient risk assessment before writing a script. If prescriptions are extended to one month, doctors must enter into a written patient agreement, in which the patient consents to random drug testing and provides a list of other drug use or states where they’ve received a controlled substance prescription.
Dr. Jacobson has already seen effects from the newly implemented Controlled Substance Abuse Prevention Act. “They put such strict rules in place that most primary care doctors don’t even want to write these prescriptions anymore,” he said. “They are giving physicians five strikes and they are out. You can lose your license if you don’t follow these rules. They are just so strict and laborious and take so much time -- these are no longer patients that are easy money.”
Although the law is in place, penalties for not complying with AB 474 are to be established by medical licensing boards. The proposed penalities for doctors who issue “fraudulent, illegal, unauthorized or otherwise inappropriate” controlled substance prescriptions range from requiring doctors to complete two hours of continuing education for the first offense to revoking a doctor’s license for a fifth offense. This has created a chill across the medical community as physicians decide whether to completely opt out of writing prescriptions for pain pills rather than risk their licenses.
“So many patients are falling through the cracks because they initially were getting medicine from their primary care physicians, but when the new law went into place on January 1st the primary care doctors weren’t interested in spending all the time it takes to comply by these laws,” said Dr. Jacobson.
Because Nevada’s doctors have found the new legislative requirements laborious and question some of the regulatory language, the Division of Public and Behavioral Health will hold a public hearing on May 4 to consider amendments to the Nevada Administrative Code relating to reporting requirements for certain health care providers.
The Opioid epidemic's dirty little secret
While Nevada’s Controlled Substance Abuse Prevention Act is being reviewed and tweaked, there is still the matter of people who are already deep in the throes of opioid addiction. In 2017 alone, there were 7,125 emergency room encounters and 8,661 in-patient admissions of Nevada residents with opioid related issues, which can range from bowel obstructions and ulcers to renal failure and overdose.
Registered nurse Jen Shepherd outlines some of the lesser known complications patients who have become dependent on painkillers encounter. There’s the elderly who “get really hopped up on those things and fall,” she offered. Then Shepherd went on to reveal the dirty little secret of the opioid epidemic that you probably haven’t heard about: bowel obstructions.
“What nobody is talking about are the amount of people who have colon obstruction surgery because of their use of opiates. It makes them constipated to the point where they can’t move their bowels and then they have to go in and have a bowel obstruction removed and put themselves at risk for sepsis and all of the other complications that result from this type
Shepherd recalled a patient she worked with at a Trauma Center who was under hospital care for about four months with an obstruction resulting from opioids. “She wasn’t allowed to eat. I walked this woman every day and I was only allowed to give her ice chips. Until we wake your bowels back up because they just go to sleep, there’s nothing that can be done,” related Shepherd.
Taking up the slack with cannabis
“So what happens to all of these patients?” asked Dr. Jacobson, referring to people who find themselves without access to painkillers due to the tighter regulations implemented earlier this year. “They have nowhere to go. I think that’s an opportunity for cannabis to certainly take up some of that slack.”
He’s not the only one in the medical community who thinks cannabis has its merits. According to the National Institute on Drug Abuse (NIDA), cannabis, much like opioids, has been shown to be effective in treating chronic pain. NIDA’s research suggests the cannabinoid and opioid receptor systems rely on common signaling pathways in the brain, including the dopamine reward system that is central to drug tolerance, dependence, and addiction.
In his latest documentary “Weed 4: Pot vs. Pills” which premiered April 29, CNN’s Dr. Sanjay Gupta references a 2017 National Academies of Sciences, Engineering, and Medicine study that finds opioids target the breathing centers in the brain, putting their users at real risk of dying from overdose. Dr. Gupta noted in an April 24th letter to U.S. Attorney General Sessions, prior to the documentary's airing, that “in stark contrast, with cannabis, there is virtually no risk of overdose or sudden death. Even more remarkable, cannabis treats pain in a way opioids cannot. Though both drugs target receptors that interfere with pain signals to the brain, cannabis does something more: It targets another receptor that decreases inflammation -- and does it fast.”
Data shows more and more people are finding their way to cannabis from opioids. New research published in April from two U.S. universities has shown states with legalized medical marijuana have lower issues of opioid abuse. JAMA Internal Medicine journal published the studies which compared opioid prescription patterns in states that have enacted medical cannabis laws with those that have not. One of the studies looked at opioid prescriptions covered by Medicare Part D between 2010 and 2015, while the other looked at opioid prescriptions covered by Medicaid between 2011 and 2016.
In those studies researchers found that states allowing the use of cannabis for medical purposes had 2.21 million fewer daily doses of opioids prescribed per year under Medicare Part D, compared with those states without medical cannabis laws. Opioid prescriptions under Medicaid also dropped by 5.88 percent in states with medical cannabis laws compared with states without such laws, according to the studies.
The studies also showed that states that permitted recreational use saw an additional 6.38 percent reduction in opioid prescriptions under Medicaid compared with those states that permitted marijuana only for medical use, according to Hefei Wen, assistant professor of health management and policy at the University of Kentucky and a lead author on the Medicaid study.
"We found that there was about a 14.5 percent reduction in any opiate use when dispensaries were turned on -- and that was statistically significant. So dispensaries are much more powerful in terms of shifting people away from the use of opiates,” said David Bradford, professor of public administration and policy at the University of Georgia and a lead author of the Medicare study, in a CNN article.
Additionally, the impact of cannabis laws also differed based on the class of opioid prescribed. Specifically, states with medical cannabis laws saw 20.7 percent fewer morphine prescriptions and 17.4 percent fewer hydrocodone prescriptions compared with states that did not have these laws, according to Bradford.
Though it is premature to draw a definitive cause-effect relationship between medical marijuana and opioid overdose, data from a study published in JAMA Internal Medicine in October 2014 suggests that medicinal marijuana could save up to 10,000 lives every year.
As multiple studies cited in this story illustrate, cannabis has become an obvious alternative for those who are addicted to turn to if it’s legally available because of it anti-inflammatory properties. Cannabis not only helps treat pain, reducing the initial need for opioids, but it is also effective at easing opioid withdrawal symptoms.
“Cannabis is a wonderful alternative to opiate medications not only because it does provide pain relief, but it is a much healthier alternative to using opioids. It’s so much safer but I would also talk to them (patients) about all the risks there are in continuing to use opioids like the bowel obstructions, addiction, death,” explained Shepherd, who once watched a woman spit in a doctor’s face over one Percocet. “I think these pills are the gateway drug for heroin because that’s what people turn to when physicians take them off their opiates. I have seen nurses steal mediations. It’s sad that this is legal and this is how our government runs.”
Breaking the Cycle of Addiction
Breaking free from the opioid cycle of addiction is not easy. “You have to want to wean yourself off because you are going to puke, you are going to poop, you are going to feel shitty, you are really going to have to really want it. A lot of people addicted to these opiates who are trying to come off them will sneak them and hide them because they are so sick. People can lose their lives trying to withdraw,” said Shepherd.
Dr. Jacobson agreed, “It’s really hard especially if you have been on them for a really long time. These are really hard medications to get off of for a number of reasons. The way the medicines work, you develop an increase in the pain receptors in your body and you become very, very sensitive to pain. And getting off them can be torture for a lot of people and cannabis can be really helpful for easing that transition.”
Shepherd tells the story of an older patient she worked with who really wanted to stop taking morphine and started by using edibles in the form of chocolate chip cookies. “Three days after buying the cookies she came back and said she had lost 10 lbs. and stopped 30 mgs of her morphine and she had been on 60 mg a day. I told her to taper down a little bit slower. The next time I saw her she told me she had thrown the morphine in the trash and she didn’t have the walker, and her gait was better too. This
was in the space of a month, it was insane. It took her a month to come off morphine, but she really wanted it badly,” said Shepherd.
Both Dr. Jacobson and Shepherd are emphatic that every case is different. “It’s all situational. I had a lady who wanted to get off Tramadol. She is just using the topicals right now because she doesn’t like to get high,” explained Shepherd. “Other people want to be high because it helps the pain. It’s all situational and it depends on the person. If you want to do quick pain relief, you smoke. If you have got localized pain and want to be able to still function, you do topicals. If you are in an extreme amount of pain, you do edibles and vaping and topicals -- use it all, it won’t kill you like opiates,” said Shepherd. “It’s a psychological addiction as well as a physical one. You have to overcome both addictions, and sometimes emotional too, if you are that attached to them.”
That has proven true for 66-year-old Kent Gregoire who started using cannabis three years ago to cut down on the pharmaceuticals he has been taking since 1985 to treat chronic pain resulting from two car accidents. “You can’t
see yourself ever living without pain pills again. That’s
the scary part. They become so intrinsic to the way you
live your life. I still do have anxiety about giving them
up to an extent,” said Gregoire, who has cut his use of hydrocodone in half since he started vaping CBD-dominant cannabis and no longer takes sleep aid Ambien or Flexeril, a muscle relaxant.
Charlo Crossley, 66, a dancer who injured her knee while performing in a Broadway show in 2004, agreed. “There’s a psychology behind Norco and Vicodin that not only does it take away your pain, but it gives you an upbeat feeling. The only thing I can compare it to is Quaaludes. It makes people very loose and upbeat. It was like drinking a bunch of tequila,” relayed Crossley, who started using cannabis last year and has been able to cut her Vicodin use in half. “Pain causes anxiety. It’s just upsetting, it slows you down and you want to be able to keep going. When I take the cannabis oil in the morning it definitely helps me feel better and it does lift my mood. It’s definitely making a difference in my world.”
Is Cannabis the answer?
Dr. Jacobson prefers a holistic approach and generally recommends CBD topicals, liposomal or sublingual products, and low temperature vaping to his patients. “For someone with chronic pain, I try to get them off smoking. I try to get them on a topical or a tincture, or a sublingual that’s going to be a standard dose. You take it four times a day and start with a set amount, whether its 10 milligrams four times a day, depending on what their tolerance is and kind of slowly go up on it until they get the desired effect. I usually like to help people at least be on equal amounts of THC/CBD,” he suggested.
But Dr. Jacobson asserts that there are downsides to cannabis too. “There’s lots of potential harms. Do we know all the harms yet? We certainly don’t know for sure. My feeling is it’s pretty safe and the evidence is that it’s pretty safe,” he said.
“There is certainly some concern over increasing risk of heart attack, increasing the risk of developing psychosis, increased panic attacks and anxiety in certain people. All of these are potential harms. I think people need to be aware of those,” stated Dr. Jacobson, who then asked, “What are the benefits of cannabis? Can we get them off opiates?”
As for addiction to cannabis, Dr. Jacobson concedes it’s absolutely a possibility. Because I work in a holistic fashion, I always want people to get off cannabis if possible. I want to get them off all the herbs and supplements that I prescribe. That should be the goal. They shouldn’t be dependent on anything. But if they need to stay on it, I am a lot happier that they are on cannabis than opiates. It’s not even a close call when you weigh the risks and benefits.”