ADDICTION/ PAIN MANGAGEMENT/EUPHORIA
By Dr. Fisher



KEY POINTS

  • When treated with opioids, patients function better, addicts function worse, the distinction is not subtle.
  • Addiction is driven primarily by the urge to get high. Euphoria is an unusual response to opioids. You probably won't get hooked on something if you don't even like it.
  • The physiology of tolerance precludes pain patients from getting high. Mutually exclusive patterns of opioid use exist, between addicts and patients. If you can't get high, you probably aren't addicted.
  • Severe chronic pain is treated with dosages of opioids in an entirely different realm from what addicts use. This is dictated by divergence between the relatively low opioid levels required to stimulate the opioid receptors in the reward centers of the brain, compared to the much higher levels required to produce analgesia in the spinal cord.
  • We should know better than to fear opioid addiction. 23 million surgeries are performed each year in the USA. Millions of patients receive opioids, few get addicted. Clearly, addiction is not a property inherent to the drug.
  • The "hijacked brain" theory, promoted by addictionologists, doesn't hold water.



FISHMAN


It is of major importance to recognize the distinction between the dysfunction that marks addiction and the improved function that marks effective pain management. Thus, addiction and effective pain treatment have diametrically opposite endpoints and are distinguishable.

-Fishman, The Massachusetts General Hospital Handbook of Pain Management p. 499

"The signs of addiction are the signs of dysfunction. If I have a patient who is getting a drug and can't work anymore, is unable to keep appointments, their family says that their family life is breaking down, they appear disheveled, they're not organized anymore those are signs of dysfunction."

-Fishman, UC Davis Web site

Pain is an inherently subjective experience and treating it poses the difficulty of monitoring treatment responses without being able to observe objective proof. Thus, treatment of chronic pain should focus primarily on objective signs of functional improvement. In direct contradistinction, addiction is marked by objective signs of dysfunction. Thus, efficacy from treating chronic pain with opioids produces improved function while addiction does not.

-Fishman P. 310 of syllabus 2002


PORTENOY

For example, although it is widely believed that opioids produce the reinforcing experience of euphoria, surveys of cancer patients, postoperative patients, and normal volunteers indicate that elation is uncommon following administration of an opioid; dysphoria is observed more typically, especially in those who receive meperidine. (Demerol)

-Portenoy, Review article, P. 302


NATIONAL INSTITUTE OF DRUG ABUSE

The majority of healthy non-drug-abusing volunteers do not report euphoria after being administered opioids in the lab either with or without pain.

- Robert Mathias, NIDA NOTES Staff Writer, Research Eases Concerns About Use of Opioids To Relieve Pain, Volume 15, Number 1 (March, 2000)


SHAFFER DRUG LIBRARY GUIDELINES FOR OPIOID MAINTENANCE

The tolerance dose of oral methadone is reached through daily doses of 80 to 120mg a day in opioid tolerant people. The therapeutically necessary levels of methadone in the blood, of 150 to 600ng/ml are reached with daily methadone doses of 80 to120 mg/ day. (Dole 1988). Further increases in dose would hardly have an additional effect. Doses less than 70 mg/d are usually, in the long run, insufficient.

This empirical data indicates that the dosage range needed to saturate the opioid receptors in the reward centers of the brain are low, compared to dosages needed to treat pain within the dorsal horn of the spinal cord.


BONICA'S PAIN MANAGEMENT

Evidence indicates that the descending antinociceptive system, activated mainly by opioids in the periaqueductal gray of the brainstem, requires a much lower concentration of these drugs to produce analgesia than the analgesia elicited strictly by the activation of the receptors of the substantia gelatinosa of the spinal cord [17]. Therefore, opioids at low cerebrospinal fluid concentrations, such as those obtainable after oral, IM, or IV administration, act mostly through the descending antinociceptive system. After intraspinal administration, in which high cerebrospinal fluid concentrations are produced, the activation of opioid receptors in the substantia gelatinosa constitutes the major mechanism of analgesia [17].

Loeser: Chapter 84 of Bonica's Management of Pain, 3rd ed., Copyright 2001 Lippincott Williams & Wilkins p. 1690


The brain centers, which modulate pain require much lower doses of opioids than the dorsal horn of the spinal cord.


REWARD CENTER RECEPTOR TOLERANCE PRECLUDES ADDICTION

There is a discrepancy between the rate of opioid addiction in the general population (which run as high as 1/300, assuming 1 million heroin addicts in the USA), and the rate of opioid addiction in the pain population. This is because pain management with opioids requires a pattern of use of opioids incompatible with abuse (getting high). This phenomenon is determined by tolerance at the level of the opioid receptor in the reward center of the brain. Abusers allow their blood opioid levels drop, so that they can experience another flash of euphoria as the levels rise again, and receptors become occupied. This feeling can't happen when pain patients take opioids as prescribed, because constant opioid levels maintain tolerance. Opioid abusers often use much smaller amounts than required by patients with serious chronic pain.

In order for a patient to abuse Oxycontin he would have to forego his second daily dose and suffer through uncontrolled pain for about 12 hours. This would allow for 1 "high", lasting 1-2 hours, each day. Use of immediate release opioids allows for 2 or possibly 3 "highs" per day. In order to enjoy this dubious thrill, would be abusers who also suffer from pain, would have to spend at least 1/2 their lives in pain, waiting to lose their tolerance in order to get high again. The choice is a no-brainer.


THE "HIGH"

The reference point for the public is the runner's high. This is produced by endogenous opioids known as endorphins. The euphoria associated with opioids is best characterized as, the relaxed state of well being everyone experiences after exercise. Oxycontin is said to produce a "powerful heroin like high". Medically, the opioids are classified as narcotics, because they induce sleep. The opioid "high" actually better described as a low, and according to the DEA Web site, consists of euphoria followed by drowsiness.





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