Turning the Narcotics Epidemic Around

Medical treatments, recovery groups key to stopping addiction

By William D. Tumlin, M.D.

Over the last few years, the problem of narcotics abuse and addiction have spiraled out of control in the United States. More citizens are dying now from narcotics overdose than from motor-vehicle accidents.

Increased narcotics use got a boost a few years ago when doctors were accused of undertreating pain. We were urged to make pain “the fifth vital sign” and docs were even sued for undertreating pain. Prescriptions for narcotics compounds, especially hydrocodone and oxycodone, increased dramatically. At the same time, more opiates were imported as products of poppy production surged.

As our Drug Enforcement Agency recognized the problem, efforts were made to restrict the flow of legal and illegal drugs in the country. When the legal drugs (especially oxycodone) were restricted, persons already dependent on these legal compounds found that cheaper substitutes were available on the streets.

A dose of heroin can be purchased for as little as $5, whereas street oxycodone (30 mg) is about $25 a dose. At the same time, young people have become much bolder in recreational use of these chemicals. The result is that there are a great deal more addicted individuals now than before.

When addicts use prescription drugs, they know the dosage they are receiving, but when an illegal powder is purchased, they do not. Too much of any narcotic produces respiratory depression or respiratory arrest. The person takes the dose and simply stops breathing. If he or she has some alcohol or tranquilizer in his or her blood, the effect may be much greater, to the point of synergism. That is, 1+1 = 3, not simply an additive effect. Respiratory arrest and death are much more likely.

Added to this is the increasing likelihood that dealers are using a synthetic narcotic, fentanyl, to cut the heroin. Fentanyl is 30 to 50 times more potent than heroin, making respiratory depression extremely likely. Injecting heroin today is truly a game of Russian roulette. Death rates are soaring. If the addict has someone nearby to inject him or her with naloxone to block the dose, he or she may live; otherwise, CPR until an ambulance arrives is the only hope.

We rescue these patients from the addiction with a drug called buprenorphine. This is an agonist-antagonist drug. It is bound at the mu receptor but blocks the kappa receptor. This mixed effect causes the drug to replace ordinary narcotics yet rarely produces any euphoria or “high.” It also has a “ceiling effect,” in that the receptors are loaded at 16 mg daily and a higher dose produces very little effect and no more respiratory depression. Added to this is the fact that it binds the mu receptor more tightly than other narcotics. This means that use of ordinary oxycodone or heroin produces very little effect when on this drug.

The half-life of buprenorphine is 30 to 37 hours, indicating that it takes that long to metabolize one half of it. It takes another 30 to 37 hours to burn half of that, and so on. All of this makes for a very smooth and stable effect when the drug is administered. There is no drowsiness or euphoria when the dose is correct. Our intention is to get addicts stabilized and involved in addiction recovery programs and then to taper them off the buprenorphine as is appropriate. Gradually tapering off the compound is usually not difficult.

At the last step in the detox, we utilize the blood pressure medication clonidine. This drug also blocks symptoms of narcotics withdrawal. At this point, because our natural endorphins have been suppressed by the previous use of narcotics, they do not usually return to normal quickly. If left untreated, the individual continues to feel listless, tired and somewhat depressed for up to six months. This can be treated with a very small dose (4.5 mg) of naltrexone at bedtime. Naltrexone causes the pituitary to signal endorphin-producing tissues to produce normal or greater-than-normal levels. A sense of wellbeing returns to the recovering addict, decreasing the likelihood of relapse.

All of these chemical manipulations must be combined with activity in recovery groups so that the addict can learn normal living skills. Twelve-step programs teach the addict new coping skills that help prevent him or her from falling back into the old pattern of using drugs to deal with the difficulties and stresses of everyday life! These support groups encourage a spiritual life as part of this recovery. Additionally, the presence of other group members with common goals is very encouraging.