Saturday, December 27, 2014

In a Bind

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Valley docs weigh the pros and cons of a drug that eases withdrawal from painkiller addiction.

Days shy of her 70th birthday, a woman named Joy carts around Scottsdale from lunch appointments to yoga. “It’s worth celebrating,” she says, “to be off that stuff, and to feel so much better.”

“That stuff” is Oxycontin, which Joy depended on around the clock for more than a year. The pain in her back led her to four doctors in 24 months. They just gave her more pills. “Finally, the fourth doctor told me, ‘Get off the pills.’ I said, ‘How?’”

Her psychologist referred her to Restore of AZ in Glendale, a clinic that serves as a rehabilitation and detox center for chronic pain patients – including those on high doses of prescription painkillers. Restore of AZ adheres to the functional restoration model, a multi-layered program addressing the relief of chronic pain through a team of professionals including psychologists, physical therapists and addiction-medicine specialists. Its success also largely hinges on a little-known and controversial drug called Suboxone.

Restore, in particular, treats patients suffering from opioid-induced hyperalgesia, a relatively obscure condition in which overconsumption of opioids reduces a patient’s pain tolerance so extremely that even light stimulus causes severe pain. Perhaps even less known than hyperalgesia is one of its treatments, Suboxone, used to combat analgesic withdrawal. It can also be used to treat heroin addicts, in lieu of the more widely prescribed methadone. Only a small fraction of physicians in Arizona are certified to prescribe Suboxone. Some laud it as a way to alleviate withdrawal and dependence on painkillers, while others are wary of its narcotic properties. But even some naysayers concede the benefits of Suboxone outweigh the risks.

“[Hyperalgesia is] well-documented,” says Dr. Gregory Bode, medical director of Restore. “Spend a day at Restore and you’ll see it’s true.” However, he suspects that few in the mainstream medical community know much about it.  

What is well-known is the U.S. has a well-documented dependence on prescription drugs to manage pain. Americans account for only 4 percent of the world’s population but consume 80 percent of its narcotics, according to the U.S. Centers for Disease Control and Prevention. More Americans die annually of narcotic overdose than car accidents, and the CDC says 60 percent of those deaths were related to overdoses of “pharmaceutical” drugs.

Chronic pain has become the number one cause of disability in the United States, and the effects can be life-altering. Most patients at Restore have been out of work for longer than a year. The $38,000 Restore of AZ program – usually paid for by workers’ compensation insurance – often comes near the end of a long cycle of drug dependency.

The primary agent in Suboxone is buprenorphine, a schedule III controlled substance, and an opioid agonist, meaning it binds to opioid receptors in the same manner as drugs like heroin and Oxycontin. In fact, it binds to the receptors even more agressively than those common drugs of abuse, essentially rendering them impotent to the user. Buprenorphine has an opioid effect (see graph), but the effect is limited, soothing an addict’s stimulation-starved neurons without producing intense euphoria and perpetuating the addiction cycle. “If someone were to take a narcotic, it cannot attach to the receptors because Suboxone is already bound tightly to the receptor,” Bode explains, adding, “I find it generally easy to taper people over about 4-6 weeks off the Suboxone and they are free of medications altogether.”

Out of more than 680 pain management and addiction medicine physicians in Arizona, roughly 220 are certified by the DEA to prescribe Suboxone, according to the Substance Abuse and Mental Health Services Administration. Many doctors choose not to prescribe it, including Dr. Jerome Julian Grove, a pain management specialist at the Arizona Center for Pain Relief.

“It’s not that I don’t believe in it,” he says. Rather, he says, Suboxone treats a population set that likely has struggled with mismanagement or abuse of narcotics, which he feels is best handled by an addiction specialist.

Grove has served as a medical expert for the Arizona Medical Board on cases resulting in disciplinary action against doctors mishandling pain treatment. Some of those cases involve Suboxone, which he said can become problematic when drug abusers see it as a reprieve from withdrawal between scores. He’s also seen cases where doctors may be irresponsibly using Suboxone to increase cash flow. The drug itself isn’t costly, but doctors who prescribe it are tasked with monitoring their patients throughout treatment – ensuring multiple office visits and fees.

Still, the pros of Suboxone outweigh the cons in Grove’s estimation. “It really helps people with serious addictions,” he says.

It helped Joy, too. Suboxone, along with Restore’s 6-week program, led to a new life. Her back pain isn’t totally gone, but the narcotics are. She takes aspirin when necessary.

After all, she’d trade yoga for hyperalgesia any day.

How Buprenorphine Works

Opioid receptor is empty. As someone becomes tolerant to opioids, they become less sensitive and require more opioids to produce the same effect. Whenever there is an insufficient amount of opioid receptors activated, the patient feels discomfort. This happens in withdrawal.

Opioid receptor filled with a full-agonist. The strong opioid effect of heroin and painkillers can cause euphoria and stop the withdrawal for a period of time (4-24 hours). The brain begins to crave opioids, sometimes to the point of an uncontrollable compulsion (addiction), and the cycle repeats and escalates.

Opioid replaced and blocked by buprenorphine. Buprenorphine competes with the full-agonist opiods for the receptor. Since buprenorphine has a higher affinity (stronger binding ability) it expels existing opioids and blocks others from attaching. As a partial agonist, the buprenorphine has a limited opioid effect, enough to stop withdrawal but not enough to cause intense euphoria.

Over time (24-72 hours) buprenorphine dissipates, but still creates a limited opioid effect (enough to prevent withdrawal) and continues to block other opioids from attaching to the opioid receptors.

Source: The National Alliance of Advocates for Buprenorphine Treatment naabt.org

 

 

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