Opioid Epidemic: Background, best practices, and next step

New tools in the treatment of opioid addiction

The opioid epidemic has become a defining health crisis of our time. Individuals, families, and entire communities have been struck by the perils that come alongside addiction. Education about the nature of the addiction is necessary to combat the stigma that is so often perpetuated onto those who are afflicted, as well as strategize the best route to recovery.

Now more than ever, people need hope that there is a light at the end of the tunnel. It is vital for healthcare providers to speak out and discuss their role in defeating this crisis. Patrick Slifka (Q), the Senior Clinical Director for ncgCARE, sat down with Dr. Jitendra Desai (A), Medical Director of ncgCARE, to discuss the background of the epidemic, the latest best practices in treatment, and the next steps forward.

Dr. Jitendra Desai is the founder of both Walnut Avenue Associates and Avenues to Recovery, now known as Avenues to Wellness. He has been a member of the Roanoke community for over 35 years, and has proven to be a local expert in battling the opioid epidemic. He is board certified in addiction psychiatry, as well as adult and geriatric psychiatry. Dr. Desai has been recognized by local publications, including Roanoker Magazine's Top Docs, as an outstanding physician and having the best bedside manner in the Roanoke area multiple times. Dr. Desai was one of the physicians recognized in the very first edition of Top Docs in 1992 and was recognized again in 2017. Q: What are the most common opiates or opioids being prescribed today? A: For pain, Lortab and Oxycodone. They are opioids. Lortab is Hydrocodone… And then there is Oxycodone. Among opiates, it is morphine and codeine. These are the most commonly used and misused opioids out there. Opiates are derived from opium, Opioids are synthetic. Q: Are these prescription opioids mostly or is at a combination of prescription and illicit and illegal substances, like heroin and fentanyl? A: It starts out as a prescription… And then there are two ways it can go. People who don’t have prior addiction problems or a family history of addiction – they are able to get through the withdrawal without much problem. People, on the other hand, who are addiction prone - they’ll have a terrible time coping with the discontinuation and they’ll search for other ways to starve off the withdrawal symptoms. They turn to street drugs such as heroin or fentanyl. And there are more than 3 million people who are affected by this epidemic in the country today… And there are many more additional victims… Family members, newborns. This whole thing started in the late 1990’s when the drug companies started telling doctors that people don’t get easily addicted to painkillers…doctors started prescribing painkillers and patients started loving it because these opioids can relieve pain, can create euphoria, can give energy, and make them feel calm at the same time. All of these factors converged to create an opioid epidemic. What is also interesting, historically, is that during and after every war we have dealt with an opioid epidemic… And this goes all the way back to the Civil War. So, maybe there’s something about war, something about war-related injuries, something about people being anxious about war… And all those factors combined created this perfect storm. Q: You mentioned two types of people who can develop problems with these substances… Those who are prone to addiction and those who are not. For someone who is not prone to addiction… No genetic or family history… How quickly can someone develop a tolerance and/or a dependence on these substances, even if taking them as prescribed? A: Tolerance develops very quickly. I would say within weeks. Nowadays, doctors are scaling back and they are only prescribing painkillers for a week at a time… And they’re hoping that will keep them from becoming tolerant and/or dependent. Q: Is this a new approach? JD: Correct. The new approach is to really restrict and monitor the doctors who prescribe pain killers. This includes surgeons, orthopedic doctors, and pain management doctors. The FDA and DEA are keeping very close tabs on the prescription patterns of all doctors. Q: I’m really glad to hear that. Is this part of the Prescription Monitoring Program? A: Yes, the Prescription Monitoring Program is part of that. DEA and government agencies simply don’t allow people to be taking these medications forever. In our suboxone program, we use the Prescription Monitoring Program regularly… Every visit we do that. That helps us to keep track of whether or not clients are getting prescriptions from other providers.

Q: For those individuals who continually seek medications from doctors and then perhaps from multiple providers… And can’t get these medications… Is this when they turn elsewhere? A: Right. They either buy the painkillers on the street or they switch to heroin or fentanyl. And that is the most dangerous path because there is never any standardization about how strong the medication is that’s available on the street. New stronger forms of fentanyl are lethal even in very small quantities. Q: What’s the difference between an “opiate” and an “opioid”? A: Opiates are derived from opium, and there are three in that category: Heroin, Morphine, and Codeine. The opioids are synthetic. They look and act like opiates, but they’re synthetic… And then tend to have a stronger punch. Q: What help is available to those who have a dependency on these substances? A: Historically, back in the 70’s after the Vietnam War, the only thing that was available was Methadone. There are still some Methadone clinics out there. But Suboxone changed the playing field. The difference between Methadone and Suboxone is that Methadone – the more you take, the better you feel. These are addicts and they want to take more to feel better. This could lead to lifelong addiction or overdose. Suboxone is a partial agonist/antagonist, which means that half of it acts as an opiate and the other half acts as an anti-opiate. So, there is a built-in safety… And people don’t feel better if they take more. It is safe from an overdose standpoint and it is safe from an abuse standpoint. You don’t get as strong as an effect if you take… The limit is 16 milligrams a day. If you take more than 16 milligrams, it doesn’t make you feel any better. Q: What happens if an individual were to take an opiate/opioid, like heroin, in combination with either Methadone or Suboxone? A: On Methadone, it will kill them most likely. With Suboxone, they’ll feel worse but will not die from it. Q: Medication Assisted Treatment (MAT) for opiate/opioid dependence is reportedly an evidence-based intervention but not everyone is “on board” with this approach. Why is that? A: We need to compare how we treat alcoholics and how we treat opiate addicts. With alcoholics, we do a detox that goes on for seven days, two weeks at the most. And then we say “OK, gentlemen… No more alcohol in your lives, start going to AA meetings.” With opiate addicts that’s just not possible. It has to do with brain structure. There is a panic button in the brain, believe it or not, and these people who are addicted to opiates have a very sensitive panic button. And when opiates are not available, they truly feel and believe that their survival is at stake. So, panic is misinterpreted as death… And the only thing that can resolve or put a damper on that panic button is opiate, so they keep going back to the opiate. We think that opiate addicts are different from alcoholics in that sense… It takes a long time for the panic button to be reset completely and fully. Q: Does the panic button ever reset fully or does the brain physically change to such a degree that it can never return to its baseline? A: It takes time… It may take as long as one year without doing opiates. In our addiction work, we know if a person successfully abstains from any substance for a year their chances of staying abstinent are very good. It’s in the first year where there are a lot more relapses… And those relapses are more common in the first week or first month. This is when the drug is calling them. This is when the panic button is pressed and it is continually pressed. If they stay in recovery longer, then their chances of having their panic button reset are very good. Q: This is part of their treatment, correct? This education about their panic button and other aspects of their conditions, their lives, their recovery. Medication Assisted Treatment includes a treatment aspect, a therapy aspect… Beyond just medication, is that right?

A: Absolutely. What we do in Roanoke is we try to get the family involved; we want very strong accountability from the patient, we do drug screens every day… Whenever they come in, and if there is anything positive in that office-based drug screen we then send it off for confirmation to a lab. There are consequences if they give us a dirty screen, as in attending more groups or in reducing the dose of Suboxone. Q: Is there a standard Medication Assistance Treatment program protocol? Is it like a structured program with phases… And how long is the treatment?

A: The duration of our program is two years. If relapse occurs, more frequently in the first week or the first month, we want to see them more frequently during that time. We expect them to attend eight groups in a month or more – if they need to. We see them, the physicians, see them once a week individually. There are three visits a week in the first month or month and a half. If their drug screens don’t stay clean then we continue that process for another month. There are more frequent visits and drug screens and group therapies during the first couple of months. If they continue to do well and give us clean drug screens then we reduce the frequency of visits. We will see them maybe once every two weeks and have them come to groups once a week… With the caveat that they can come to more groups if they need to. We don’t discourage them from coming to groups at all. We check their PMP every visit.

Because we’re a psychiatric center we also provide psychiatric care and follow up. There’s a high degree of comorbidity between opioid addiction and unresolved grief, chronic pain, anxiety, and depression. These five things go hand-in-hand in the majority of patients. About seventy percent of our opiate addicts might be depressed.

Q: What other drugs are you screening for other than opiates?

A: We have a panel of twelve substances that are popular on the street and we also check for Suboxone to make sure that they’re taking Suboxone.

Q: Let’s talk about this new medication Lucemyra. How is this different from Suboxone?

JD: Suboxone is an opiate… Half opiate and half anti-opiate… And if you really want to go for a totally non-opiate treatment then Lucemyra is the medication. It doesn’t help everybody. Where it will help is - remember we talked about how surgeons and orthopedic doctors are supposed to give pain medications for only a week at a time and not for months and months - that person who is about to be cut off would be an ideal candidate for Lucemyra. They give them this new medication and it pretty much takes care of the opiate withdrawal in a non-narcotic way. These are patients who will not want to use opiates after that. In our program we’re very excited about this medication because we have quite a few patients who are towards the tail end of a taper off the Suboxone. We started them at either twelve or sixteen milligrams, and now they’re taking two milligrams, they’re down to almost nothing – but the idea of going off of Suboxone really terrifies them. Those are the people where we would prescribe Lucemyra. I think an ideal candidate is somebody who has gotten tons and tons of painkillers for surgery or whatever and then they want to stop taking it. Lucemyra will come in like a knight in shining armor… And without any potential for addiction.

Q: What exactly is Lucemyra if it’s not an opiate?

A: It is not an opiate. It goes back to our discussion about the panic button. The panic button, anatomically, is known as the locus coeruleus which literally means “blue dot.” And in the brain stem region of the brain there is that blue dot. They have seen it since the 1700’s, but we became more familiar with it and what it does in the last fifty years. This medication stops that panic button from going off. There may be other uses for it in the future, like for anxiety disorders.

Q: Is it on the market yet and, if not, when?

A: It is being used in other countries and has been since 1992. There’s a large body of evidence. It will be released here, I believe in a month or two.

Q: How will it be prescribed?

A: Any doctor can prescribe Lucemyra. With Suboxone there are some restrictions. You have to be credentialed in prescribing Suboxone. With Lucemyra there are no restrictions. A surgeon can prescribe it, an orthopedic doctor or pain management doctor or a psychiatrist can prescribe it. I think it is going to be used primarily by surgical specialties and addiction specialists.

Q: What provider guidelines will there be for how to prescribe Lucemyra - like dosage, frequency, duration?

A: We generally will start slow and it’s to be taken four times a day. The dose can be flexible – it can be increased or decreased depending on how the patient reacts. It can be stopped within two weeks maximum.

Q: Any contraindications for its use?

A: Heart problems and liver problems. With those conditions we will start them at a low dose and we’ll keep them at a low dose.

Q: So this is used as an adjunct to Suboxone treatment, to be used at a later point in treatment?

JD: It will be used toward the tail end of the treatment. What we want patients to do is learn some coping skills – how to cope with life. Life has a terrible way of showing up when you least expect it. And the first thing they think of is “Hey, can I get my drug?” So we teach them coping skills which will help them stay in recovery. That takes some time. I would say that about a year or two or maybe even six months – some people might be willing to go off opiates and Suboxone in six months. Lucemyra will be a very handy tool for us. Because it is the fear of withdrawal and the setting off of the panic button that simply makes it impossible for them to stop.

Q: Does treatment really work? What are the percentages? How are we doing in our program and how do we define success?

A: We’ve looked at our data about Medicaid patients. Medicaid has a very good, easy access program for Medicaid recipients. We saw about eighteen patients and six of them dropped out within the first month. The siren call from the drugs was very strong. They could not resist. But the others are hanging in there with treatment. Our policy is not to displace patients who have dropped out of treatment. We tell them to come back in three months, come back when you’re ready and we’ll try to help you again. It’s possible that they might come back. Treatment outcome-wise I would say that I have, out of fifty-eight patients, I have maybe ten who are not on any opiates including Suboxone. That comes out to be about 10 out of 60. I don’t know what the percentage would be, less than 20 percent for sure. The other patients are still in treatment and are getting the fruits of recovery and abstinence. How do we define success? Do we define success just by abstinence – then we have a pretty high number. But if you define success as abstinence 2 years down the road, or one year down the road after finishing the treatment, then our numbers go bad.

Q: Abstinence alone is not recovery. There are so many other factors.

A: In addition to abstinence, patients need to learn coping skills. If they lapse for a short duration it should not be seen as a total treatment failure.

Q: Relapses are often opportunities to learn, so I certainly get that. Is there anything else you’d like to add to this discussion?

A: I love to help people start programs like this everywhere in the state under the aegis of ncgCARE. I said three million people are affected by addiction and Virginia is just slightly below the national trend. The overdoses are also just slightly below the national trend. The newborn babies born addicted to painkillers is also slightly below the national trend. Virginia is doing better than the rest of the country, but it’s really just a minor difference. So, we’re right up there. There’s a need for it. Any location that wants to start a Medication Assisted Treatment program I’ll be happy to guide them. I’ve been doing this for, working in the addiction field, for thirty-five years. I’ve been working with Suboxone for about fifteen years. I have a lot of experience and I would love to share it with people.