For centuries, people have used various types of opioids for pain relief. These powerful drugs are very effective for acute pain from a broken leg, bad burn, or recent surgery. Unfortunately, opioids are often overused, or misused for lesser aches and pains, or abused as recreational drugs. As we have learned from America’s raging opioid crisis, these drugs can be extremely addictive.
In this podcast, Dr. Ramanu Naidu, Medical Director of Pain Management at MarinHealth Medical Center talks about pain relief and how opioids work compared to other types of medications used to control pain. Dr. Naidu covers a variety of topics, including the difference between dependency and addiction, and the social, cultural, and hereditary factors that can make people more prone to opioid addiction.
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The Use – and Misuse – of Opioids
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Learn more about Ramana Naidu, MD
Ramana Naidu, MD
Ramana Naidu, MD is an anesthesiologist and pain physician who is the medical director of pain management at MarinHealth Medical Center.Learn more about Ramana Naidu, MD
Transcription:
The Use – and Misuse – of Opioids
Bill Klaproth (Host): The misuse of and addiction to opioids has become a public health crisis, so when it comes to opioids and pain management, what do you need to know? Well here to talk with us about this is Dr. Ramana Naidu, Medical Director of Pain Management at Marin General Hospital. Dr. Naidu, thank you for your time. So let's start at the very beginning, I guess. What is an opioid?
Dr. Ramana Naidu, MD (Guest): An opioid is any substance that binds to receptors in our body that are called opioid receptors. So a lot of the medications that we commonly use in medicine include morphine, hydromorphone also known as Dilaudid, anesthesiologists use fentanyl, and then of course the more notorious substance is heroin or other drugs that are used illegally.
Bill: Dr. Naidu, let me ask you this then, how are they different from other types of pain relief, like over-the-counter aspirin that we would take to try to manage pain?
Dr. Naidu: Sure, so each pain medication has a certain mechanism of action. And so the opioid family, as we just talked about, are specific medications that work via those receptors. If you look at medications like aspirin, or ibuprofen, or Naprosyn, also known as Aleve, they work by inhibiting specific enzymes that's involved in inflammation. And then separately, Tylenol, or acetaminophen, works by a completely different mechanism, and in fact, we don't know exactly how it works. We have many theories, but it works very differently than the other two classes I mentioned. And there are many, many other receptor types or mechanisms to other types of pain medications.
Bill: So these were supposed to be a breakthrough in pain management. Well something happened along the way, in fact making things much worse for some people through dependency. What happened? Why did we not see this coming?
Dr. Naidu: Some would argue we've always known it was coming, but I think there are many, many factors as far as why this has become such a problem in our country. And I have to point out, this is a relatively unique issue we're dealing with for this country. And yes, there are some other developed countries such as Canada, Germany, Denmark, and others who are sort of seeing some of the same problems, but we're leading the way when it comes to this, and I'll go into some of those issues. So firstly, opioids are effective for pain. There's only so much you can get out of pain management from a Tylenol, or from ibuprofen. And what's unique about opioids as far as comparing all the medications we have here in 2018, you can give more and more opioid - morphine, hydromorphone, or something else - and you'll see increasing effects. So we tell our students, our medical students and others, that there's no healing effect with opioid. You can keep on giving it until someone finally has relief. Whereas you can only give, as I mentioned Tylenol, and then you only reach this threshold or this ceiling. So that's the good side of opioids. The bad side is something many cultures have known for thousands of years, and that is these substances can be addictive, they come with many side effects, and I think the most problematic issue that we've learned here in the last twenty years or so, is that these medications actually make you more sensitive to pain over time.
Bill: So why can't some people stop taking opioids? You just said they are very effective, they do work, but the problem is people become opioid dependent. Why is that?
Dr. Naidu: Alright, so I want to first start out by saying that every individual is different. So even though on the whole, I did say opioids are effective, there are individuals in this world who do not see much, if any, effects from opioids. Similarly, when we talk about the adverse effects, as you just pointed out, there's a sub-population of individuals who will become addicted, and our theory behind that is that the opioids in those individuals rev up their resistance so that when they take an opioid, whether it's the first time or the first few times, it might have been used for appropriate reasons like to dull pain, but they got really reinforced into that behavior of taking that substance, so they may go on to continue to use that substance, and use it despite consequences, and have cravings for that substance, and that would lead them down the road to addiction. Let's separate though addiction from dependence. Dependence is when your receptors are expecting to see that molecule again. So addiction if you will is sort of the mental aspect, the reward aspect, the behavioral aspect, and the dependence is the physical aspect. So if you take an individual who is not addicted, and you give him an opioid every four hours for a week, and then you stop, they're going to go through withdrawal symptoms and that suggests they are dependent on that opioid, but they may in fact not be addicted at all.
Bill: Alright so as you mentioned, there are certain people that have a higher risk factor for becoming opioid dependent. Do we know what those risk factors are?
Dr. Naidu: Well, let me back up. So almost anyone can become dependent physically, meaning after a specific period of time if they've been taking it continuously and they stop, they may have withdrawal symptoms, and that might then suggest they are dependent, but that is separate from the addiction aspect. And yes, there are some individuals who have that risk factor. Why that is probably comes down to genetics, it probably comes down to their societal factors and cultural factors, and we certainly know that there's some correlation with the family history. So if there's a family history of alcoholism, or other substance misuse, abuse, and addiction, there may be a higher propensity for that individual to have the same issues. And many, many children of those who have parents who are addicts will say, "I'm going to stay away from that stuff because I don't want to go through what my mom did or what my dad did," and so they basically say no to any of this stuff as a form of abstinence.
Bill: Okay so if someone's listening to this right now and is on opioids for pain management, and they're like, "Oh man, I've heard so much about this stuff, I just went in for my bad back, and I don't want to get addicted to this! No!" Are there signs of opioid dependency? Are there things people should do so they don't become addicted?
Dr. Naidu: Right, so as I mentioned it may be inevitable. If you're using an opioid for over a week that you're going to be dependent on them, and like I said, the way you'll know is you stop it 'cold turkey,' and you start feeling the chills, the sweats, the hair on your arm stands up, you feel sick, you're nauseous, you may have diarrhea; those are withdrawal symptoms and that suggests you are dependent on that drug. But again, that might not mean they're addicted. An individual may come to the conclusion if they have insight into their addiction, when they start to realize bad things are happening, consequences are happening because of their use, or they're using the substances in an illegal or elicit manner, like they're going to the street, or they're stealing, or they're taking it from friends and family, or they're using it far more than they're supposed to be doing it the way they were prescribed. So that kind of behavior or that way of using the drug starts to make you wonder, "Is this person addicted?" And the individual themselves may not notice it. It may be a family member or a friend who picks up on it and says, "Hey, what's going on here? Why is it going on this way?" And I think that's the most important thing, is really helping individuals identify when they may be at risk for addiction.
Bill: Right, so for self-aware individuals that feel that may be happening to them, I could see them going, "I've got to get help." But what about the people who are blind to it? They're like, "I'm not addicted. I'm fine, leave me alone. I'm good," and your family member is struggling going, "No, you're not fine. We need to get this under control." How does a family member deal with someone that by all signs is addicted to opioids?
Dr. Naidu: This is where culture, society, and family is so important. The addict that worries me the most is the addict who's isolated, who's alone, he doesn't have that social support. When I get approached by families, that's when I really feel hopeful about how this individual will do. So if you are a family member or a friend who sort of is worried about someone close to them having maybe an addiction issue, it's not an easy subject to approach, you may have to do it in various ways depending on that person's personality, but get help. We're seeing more and more resources available in communities across this country because of this epidemic, where there are hotlines, there are groups, and there are ways of addressing it. For some individuals, it takes a shock, meaning like a major catastrophic event, maybe a major side effect from an opioid, or a near death experience, for them to really realize this is a problem. Or it takes the individual who finally after enough cajoling, or enough rationale to say, "Hey there's a problem here, and we need to do something about that." And I see these individuals in all sorts of ways, you know? I see the individuals who have a near death experience, I see the individuals where their wife or their children say, "Hey, there's a problem," and I see the individuals who have the insight to say, "I need help, doc. I need something to help me get through this." And what I'm really pleased to hear, and I feel really fortunate about, is that over the last four to five years we've seen more and more resources to help these individuals.
Bill: Absolutely, and it's so important, and I know Marin is on the forefront of helping people with that. Dr. Naidu, such an important topic, thank you so much for your time today. And if you would like more information, please visit www.RXSafeMarin.org. That's www.RXSafeMarin.org. This is The Healing Podcast brought to you by Marin General Hospital. I'm Bill Klaproth, thanks for listening.
The Use – and Misuse – of Opioids
Bill Klaproth (Host): The misuse of and addiction to opioids has become a public health crisis, so when it comes to opioids and pain management, what do you need to know? Well here to talk with us about this is Dr. Ramana Naidu, Medical Director of Pain Management at Marin General Hospital. Dr. Naidu, thank you for your time. So let's start at the very beginning, I guess. What is an opioid?
Dr. Ramana Naidu, MD (Guest): An opioid is any substance that binds to receptors in our body that are called opioid receptors. So a lot of the medications that we commonly use in medicine include morphine, hydromorphone also known as Dilaudid, anesthesiologists use fentanyl, and then of course the more notorious substance is heroin or other drugs that are used illegally.
Bill: Dr. Naidu, let me ask you this then, how are they different from other types of pain relief, like over-the-counter aspirin that we would take to try to manage pain?
Dr. Naidu: Sure, so each pain medication has a certain mechanism of action. And so the opioid family, as we just talked about, are specific medications that work via those receptors. If you look at medications like aspirin, or ibuprofen, or Naprosyn, also known as Aleve, they work by inhibiting specific enzymes that's involved in inflammation. And then separately, Tylenol, or acetaminophen, works by a completely different mechanism, and in fact, we don't know exactly how it works. We have many theories, but it works very differently than the other two classes I mentioned. And there are many, many other receptor types or mechanisms to other types of pain medications.
Bill: So these were supposed to be a breakthrough in pain management. Well something happened along the way, in fact making things much worse for some people through dependency. What happened? Why did we not see this coming?
Dr. Naidu: Some would argue we've always known it was coming, but I think there are many, many factors as far as why this has become such a problem in our country. And I have to point out, this is a relatively unique issue we're dealing with for this country. And yes, there are some other developed countries such as Canada, Germany, Denmark, and others who are sort of seeing some of the same problems, but we're leading the way when it comes to this, and I'll go into some of those issues. So firstly, opioids are effective for pain. There's only so much you can get out of pain management from a Tylenol, or from ibuprofen. And what's unique about opioids as far as comparing all the medications we have here in 2018, you can give more and more opioid - morphine, hydromorphone, or something else - and you'll see increasing effects. So we tell our students, our medical students and others, that there's no healing effect with opioid. You can keep on giving it until someone finally has relief. Whereas you can only give, as I mentioned Tylenol, and then you only reach this threshold or this ceiling. So that's the good side of opioids. The bad side is something many cultures have known for thousands of years, and that is these substances can be addictive, they come with many side effects, and I think the most problematic issue that we've learned here in the last twenty years or so, is that these medications actually make you more sensitive to pain over time.
Bill: So why can't some people stop taking opioids? You just said they are very effective, they do work, but the problem is people become opioid dependent. Why is that?
Dr. Naidu: Alright, so I want to first start out by saying that every individual is different. So even though on the whole, I did say opioids are effective, there are individuals in this world who do not see much, if any, effects from opioids. Similarly, when we talk about the adverse effects, as you just pointed out, there's a sub-population of individuals who will become addicted, and our theory behind that is that the opioids in those individuals rev up their resistance so that when they take an opioid, whether it's the first time or the first few times, it might have been used for appropriate reasons like to dull pain, but they got really reinforced into that behavior of taking that substance, so they may go on to continue to use that substance, and use it despite consequences, and have cravings for that substance, and that would lead them down the road to addiction. Let's separate though addiction from dependence. Dependence is when your receptors are expecting to see that molecule again. So addiction if you will is sort of the mental aspect, the reward aspect, the behavioral aspect, and the dependence is the physical aspect. So if you take an individual who is not addicted, and you give him an opioid every four hours for a week, and then you stop, they're going to go through withdrawal symptoms and that suggests they are dependent on that opioid, but they may in fact not be addicted at all.
Bill: Alright so as you mentioned, there are certain people that have a higher risk factor for becoming opioid dependent. Do we know what those risk factors are?
Dr. Naidu: Well, let me back up. So almost anyone can become dependent physically, meaning after a specific period of time if they've been taking it continuously and they stop, they may have withdrawal symptoms, and that might then suggest they are dependent, but that is separate from the addiction aspect. And yes, there are some individuals who have that risk factor. Why that is probably comes down to genetics, it probably comes down to their societal factors and cultural factors, and we certainly know that there's some correlation with the family history. So if there's a family history of alcoholism, or other substance misuse, abuse, and addiction, there may be a higher propensity for that individual to have the same issues. And many, many children of those who have parents who are addicts will say, "I'm going to stay away from that stuff because I don't want to go through what my mom did or what my dad did," and so they basically say no to any of this stuff as a form of abstinence.
Bill: Okay so if someone's listening to this right now and is on opioids for pain management, and they're like, "Oh man, I've heard so much about this stuff, I just went in for my bad back, and I don't want to get addicted to this! No!" Are there signs of opioid dependency? Are there things people should do so they don't become addicted?
Dr. Naidu: Right, so as I mentioned it may be inevitable. If you're using an opioid for over a week that you're going to be dependent on them, and like I said, the way you'll know is you stop it 'cold turkey,' and you start feeling the chills, the sweats, the hair on your arm stands up, you feel sick, you're nauseous, you may have diarrhea; those are withdrawal symptoms and that suggests you are dependent on that drug. But again, that might not mean they're addicted. An individual may come to the conclusion if they have insight into their addiction, when they start to realize bad things are happening, consequences are happening because of their use, or they're using the substances in an illegal or elicit manner, like they're going to the street, or they're stealing, or they're taking it from friends and family, or they're using it far more than they're supposed to be doing it the way they were prescribed. So that kind of behavior or that way of using the drug starts to make you wonder, "Is this person addicted?" And the individual themselves may not notice it. It may be a family member or a friend who picks up on it and says, "Hey, what's going on here? Why is it going on this way?" And I think that's the most important thing, is really helping individuals identify when they may be at risk for addiction.
Bill: Right, so for self-aware individuals that feel that may be happening to them, I could see them going, "I've got to get help." But what about the people who are blind to it? They're like, "I'm not addicted. I'm fine, leave me alone. I'm good," and your family member is struggling going, "No, you're not fine. We need to get this under control." How does a family member deal with someone that by all signs is addicted to opioids?
Dr. Naidu: This is where culture, society, and family is so important. The addict that worries me the most is the addict who's isolated, who's alone, he doesn't have that social support. When I get approached by families, that's when I really feel hopeful about how this individual will do. So if you are a family member or a friend who sort of is worried about someone close to them having maybe an addiction issue, it's not an easy subject to approach, you may have to do it in various ways depending on that person's personality, but get help. We're seeing more and more resources available in communities across this country because of this epidemic, where there are hotlines, there are groups, and there are ways of addressing it. For some individuals, it takes a shock, meaning like a major catastrophic event, maybe a major side effect from an opioid, or a near death experience, for them to really realize this is a problem. Or it takes the individual who finally after enough cajoling, or enough rationale to say, "Hey there's a problem here, and we need to do something about that." And I see these individuals in all sorts of ways, you know? I see the individuals who have a near death experience, I see the individuals where their wife or their children say, "Hey, there's a problem," and I see the individuals who have the insight to say, "I need help, doc. I need something to help me get through this." And what I'm really pleased to hear, and I feel really fortunate about, is that over the last four to five years we've seen more and more resources to help these individuals.
Bill: Absolutely, and it's so important, and I know Marin is on the forefront of helping people with that. Dr. Naidu, such an important topic, thank you so much for your time today. And if you would like more information, please visit www.RXSafeMarin.org. That's www.RXSafeMarin.org. This is The Healing Podcast brought to you by Marin General Hospital. I'm Bill Klaproth, thanks for listening.