Opioid use disorder's treatments may include prescriptions, psychotherapy, support groups

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Opioid medications work well for people who need help controlling pain for a few days as they recover from injury or surgery. But opioids are not meant to treat chronic pain. People who take opioids can become dependent and misuse them. Here to discuss how opioid use disorder can be treated is nurse practitioner Theresa Baxter from addiction medicine at Upstate. Welcome back to "The Informed Patient," Ms. Baxter.

Nurse Practitioner Theresa Baxter: Thank you for having me.

Host Amber Smith: Can you first tell us what opioids are?

Nurse Practitioner Theresa Baxter: Sure. Well, so, interestingly, we have two different classes. We have opiates, and we have opioids. And some people don't know that there is actually a difference between that.

Opiates are chemical compounds that are extracted or refined from natural plant matter, such as from the poppy, sap, and fibers. Some examples of opiates is opium and morphine, codeine and heroin.

Then we have opioids, which is more commonly what we hear. Opioids are chemical compounds, so they're generally not derived from natural plant matter. They're usually made in a lab or synthesized in some way. There are some that are a combination of being synthesized in the lab and also natural, from nature. Some examples of opioids are hydrocodone, which you might know as Vicodin or Lortab, hydromorphone, which is Dilaudid, oxycodone, which also can be known as Percocet or Oxycontin. We've got Tramadol is an opioid. Oxymorphone, which is also known as Opana. Then we have methadone and fentanyl. Even some of the over-the-counter medications that contain dextromethorphan, like NyQuil or Robitussin, Theraflu or Vicks, they also have opioid properties, as well as Loperamide, which is Imodium.

Host Amber Smith: So a wide variety, it sounds like. How do they, I guess I wanted to understand how they work, like in comparison to acetaminophen or Tylenol or ibuprofen?

Nurse Practitioner Theresa Baxter: Sure, that's a great question. Opiates and opioids work by binding to specific opioid receptors in the brain and the body, to reduce the transmission of pain and to reduce the sensation and our perception of pain. They also cause a release of the nerve transmitter that you may have heard of before called dopamine, and dopamine contributes to feelings of pleasure and euphoria.

They do differ from acetaminophin or ibuprofen and some other commonly known pain relieving medications in that they are not opioids, and they don't bind to the opioid receptors. They work differently in the body to exert some chemical changes that normally take place wherever body tissues are injured or damaged. Changes at the site of the injury is where those medications typically work, as opposed to opiates and opioids, which actually work more in the brain and in the gut and in other opioid receptors in the body.

Host Amber Smith: So what makes the opioid addictive? And I guess part of the answer might be because they're affecting the brain. There's something in the brain that they work on, right?

Nurse Practitioner Theresa Baxter: Correct. And it's really multifactorial. So they make them addictive because of the release of dopamine. And we know that dopamine is really the "feel good" chemical in our body that keeps us continuing to do something or use something that just gives us that great feeling including having a nice meal, or being in a nice relationship. It's the most primitive part of our brain, part of the limbic system that keeps our species surviving. So the release of dopamine. And over time and over opioid exposure, the body's natural, the brain's natural ability to produce dopamine diminishes, which is what leads to a reliance on opioids for those pleasurable feelings.

Moreover, with continued use of opioids, the body develops a tolerance which happens when the body becomes less responsive to the drug, necessitating higher doses to get the same effect. The tolerance builds. People oftentimes will increase their dose. To recapture that initial euphoria, or pain relief, not only heightening the risk of overdose, but deepening the dependence on the drug, creating a very vicious cycle of increasing use and less satisfying returns.

Those are some components to it, but then there's also the physical dependence that makes them so addicting. Physical dependence comes, really, from any substance that we use, that creates a withdrawal syndrome when we stop using it. For example, I like to have a cup of coffee in the morning. I like to get that caffeine. If I don't have that, I am a crank. I really like to have that caffeine because it gives me energy, and it makes me feel good. And if I don't have it, then I'm tired, I'm grumpy, I may have a headache or another withdrawal syndrome. Also, chronic opioid exposure causes a neuro adaptation in our brain, meaning that actually the structure and the function of our brain can change as a result of prolonged opioid exposure.

Opioids also have very powerful effects on our mood regulation. So that's another thing. They can alleviate anxiety, reduce stress, and provide relief from negative emotions. So for people that have chronic pain or mood disorders, the psychological relief offered by opioids can be very, very compelling to them.

The rapid onset of opioid effects, especially when taken as an injection contributes significantly to their addictive nature, creating a quick and intense high that leads to a very strong reinforcement, making it difficult to resist the urge to take the drug again. So they act very quickly to give that dopamine release.

And then, of course, a genetic predisposition also places people at risk for developing an opioid use disorder.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. My guest is nurse practitioner Theresa Baxter from addiction medicine at Upstate.

So are opioids used today for acute pain, say, for someone recovering from surgery?

Nurse Practitioner Theresa Baxter: Absolutely. Opioid pain medication is a very important part of a multimodal analgesic regimen, which is what we always recommend for treating any pain condition. We don't use just one mode to treat it. So, what we do is we consider the acute pain condition that we're treating along with the patient and their individual experiences.

For example, if someone comes in with very serious injuries or had surgery, we do use opioid pain medications, but we always also use a multimodal regimen that could include anti-inflammatory medications, muscle relaxants, neuro modulating medications, topical medications. We oftentimes ask our anesthesia department to perform an interventional procedure that can help them with their pain.

And we also don't forget about our non-pharmacologic methods as well, such as heat or ice or positioning or reiki or companionship, spiritual care, just to name a few.

Host Amber Smith: How do you gauge a patient's pain level? I mean, do you just ask them how much pain they're in?

Nurse Practitioner Theresa Baxter: Well, so, we actually look at the whole picture. We do have a scale that we use. It's a one to 10. And I remember I used to ask patients when I was on the pain service, I used to say, "Can you please rate your pain on zero to 10, with zero being no pain and 10 being the worst pain you ever had?" And I personally had a very painful condition at one point, and I rated my pain as a 10. And I said, yep, this is a 10 because it's the worst pain I've ever had -- but I can still do the things I need to do, right?

So we really try to use more of a functional pain scale, which means that zero is no pain, you can go about all of your business, and 10 is the kind of pain where you can't do anything that you need to do to take care of yourself. You're not able to sleep, you're not able to eat, you can't participate with physical therapy and occupational therapy. So we really use it on what is the patient's functioning level. Ten means you cannot participate at all. You can't even speak to me. And for example, a seven means that the pain is intolerable, but you can still do some things that you need to do. So we try to gear more toward the functional pain scale instead of the standard zero to 10.

Host Amber Smith: That makes sense. Now, are medical providers able to predict which people are liable to become addicted to opioids before they start taking them?

Nurse Practitioner Theresa Baxter: Well, they can't really predict it per se, but they can use some screening tools. There are some validated screening tools that we are able to use before we start people on an opioid.

It's really based on several factors, developing an opioid use disorder. And when you're a provider working in the hospital, and you come upon a patient in pain and you want to start them on opioids, you don't necessarily have time to really take that all into consideration, which we'll talk more about that later.

But what we want to do is, we want to offer a comprehensive analgesic regimen and possibly opioid sparing whenever possible, providing patients with education on the risks of developing dependence and addiction, as well as other means of pain relief.

Host Amber Smith: Let's talk about who becomes addicted. Do you see more men or women?

Nurse Practitioner Theresa Baxter: Well, that is a tough one. So there's different groups I've seen of people that develop an opioid use disorder. And so people that have developed an opioid use disorder from prescribed opioid pain medications from a chronic pain condition tend to be older females. And illicit opioid use tends to be younger males. So, say for example, people that are using heroin or street fentanyl tend to be the younger population.

And then you have to think, too, what is their demographic? What's their culture? Like, people that have a culture of not really treating their pain as aggressively as we do here may have a less risk for developing an opioid addiction because they're not exposed to it.

Host Amber Smith: Interesting. Well, if medical providers are more careful about prescribing opioids today than they were when these drugs were new, and there's more restrictions today about opioid use, how do people still become addicted and keep using opioids of some sort, after their short-term prescription runs out?

Nurse Practitioner Theresa Baxter: Yeah, so some people have a predisposition to developing addiction. And in talking to patients, some of them do verbalize that exactly that the very first time that they took an opioid, that was it. They really loved that feeling. So that's one part of it.

But there are some providers who continue to prescribe long after the acute pain driver has ended for a number of reasons. Mostly it's due to their lack of education on treating pain and the development of an opioid use disorder.

Also it can be patient satisfaction. The patient has developed a dependence or a use disorder, the provider isn't able to recognize it, and so they continue to prescribe it. So I think the best thing that providers can do while they're treating pain and kind of curtailing the opioid prescriptions is to coach people through their pain and better support them to reduce risk for developing not just an opioid use disorder, but uncontrolled chronic pain.

Host Amber Smith: Well, let me ask you to talk to us about how opioid use disorder is treated.

Does treatment require the person to recognize the addiction and want treatment, or could a parent or loved one bring them for treatment reluctantly?

Nurse Practitioner Theresa Baxter: Well, they do have to agree to treatment, right? And that is really difficult sometimes for families to wrap their head around. We can't force someone into treatment. They have to really come to it on their own.

Host Amber Smith: Does treatment include medication? Are there other medications that help people get off of opioids?

Nurse Practitioner Theresa Baxter: Yeah, absolutely. There's a wide variety. So there's something called medication assisted treatments, used to be known as MAT, which basically it's a term that has been used to describe the addition of a medication as an adjunct to treat their opioid use disorder, which we now refer to it as MOUD, or medication to treat an opioid use disorder because that is, that can just be the treatment is the medication.

It's not assisted treatment. It's a medication. So depending on which medication is used, based on the patient, it's contingent upon what the patient is looking to achieve with their treatment. I don't know if you want me to talk about the FDA approved medications to treat an opioid use disorder.

Host Amber Smith: Well, are you as a provider concerned about, I mean, because they're ostensibly using the opioid because they have pain, and so that needs to be treated too, right?

Nurse Practitioner Theresa Baxter: Correct. Absolutely. It really depends on the patient. I always say, let's make individualized treatments really the gold standard for all patients. And especially patients that are living with chronic pain and an opioid use disorder.

So, when someone has an opioid use disorder, does that mean that they're not eligible to ever receive an opioid if they have a serious injury or surgery? No, not at all. We want to make sure that we treat the individual and the individual's pain based on what their condition is.

And there are some medications to treat opioid use disorder that actually do provide analgesia such as buprenorphine. Buprenorphine is a medication that we can prescribe and what it does, it helps people so that they're not having opioid withdrawal and it also can provide pain relief, which we do quite frequently in the hospital, we can dose it so that it helps people's pain more.

And then there's methadone, as you know, which is a pure opioid agonist that is the patient enrolls it to a methadone clinic so that they can receive their once-a-day dose of methadone, which is usually quite high, and it lasts for 24 hours. And it occupies their opioid receptors so that they're not having opioid withdrawal. And ideally they're not having opioid cravings.

Sometimes when a patient comes to the hospital with a pain condition, we can change that dose around as well to meet their analgesic needs.

Host Amber Smith: And so do they stay on the methadone or the buprenorphine? Do they stay on those long term?

Nurse Practitioner Theresa Baxter: It really depends on the patient. I always say as long as it's providing benefit to the patient and the patient wishes to continue it, we should do that.

And I get that question quite often, especially from other providers or family members wondering, how long does the patient have to stay on that? As long as it's benefiting them, right? It's a medication. Just like with, say, for example, hypertension or diabetes. There's not a predetermined amount of time that we're going to continue those medications. As long as they're helping the patient, we should continue them. And it's the same with medications to treat an opioid use disorder.

Host Amber Smith: Is psychotherapy ever used?

Nurse Practitioner Theresa Baxter: It is actually used. And again, that goes back to an individualized treatment plan. Some patients are agreeable to and participate in psychotherapy and other behavior management modalities. But again, that's up to the patient and what they're able to do.

Just like if I decide I want to get involved in an exercise regimen, and I make this really aggressive plan for myself, I'm going to get up at four o'clock in the morning. I'm going to go run three miles. I'm going to restrict what I eat. That's not feasible to me. That's not something I probably am willing to do.

So if we tell a patient, you are going to get on this medication. You are going to go to inpatient, you're going to go to group Monday through Friday, eight to five, and we set up all these things that we expect them to do to stay sober, unless that's what the patient wants to do and is agreeable to do, we're setting them up for failure.

So we really try to make it something that they're able to do. We do recommend that they participate in behavior therapies as well as medication for best results, or sober support meetings. Whatever's going to work best for the patient to reach their goals.

Host Amber Smith: So there could be support groups. You mentioned outpatient. Is there ever inpatient treatment?

Nurse Practitioner Theresa Baxter: Absolutely. There's inpatient, where they can go to a program that's anywhere from seven days to 90 days. There's sober supportive living, where they can go to live, sort of like a halfway house after they complete inpatient. There's outpatient. And there's a combination of both.

They can do some inpatient while they're going to outpatient a couple days a week. There's just a lot of variability to that.

Host Amber Smith: Constipation is one of the side effects of opioids. Is that treated too?

Nurse Practitioner Theresa Baxter: Absolutely. So we know that opioids cause constipation, so we always provide that education. "Hey, while you're using these medications, a natural side effect of them is becoming constipated, and we want to make sure that things keep moving. So we use medications to treat the constipation or prevent the constipation, and we also counsel on diet.

Host Amber Smith: Do people with opioid use disorder use, typically, other illicit drugs?

Nurse Practitioner Theresa Baxter: We do see this often. Polysubstance use is very common for many reasons. Sometimes it's to meet different needs of the person. For example, people sometimes use cannabis for anxiety and pain relief. Some use stimulants, some use hypnotics, which is really entirely a whole other talk.

We always try to do harm reduction. Harm reduction is really key when using any substances. One thing I do want to point out is that sometimes people develop opioid use disorder from unintentional exposure, meaning that they are, say, for example, recreational users and the cocaine has been laced with an opioid. And hence, if they don't have an overdose from being opioid naive, they could develop an opioid dependence from that.

Host Amber Smith: So this use of other drugs at the same time, does that complicate treatment for opioid use disorder?

Nurse Practitioner Theresa Baxter: It can complicate treatment for opioid use disorder, but the bottom line is that we treat it, and oftentimes when people are stable in their opioid use recovery, they're able to address the other uses. And so that's why we always also recommend behavior therapies and sober support groups as well.

Host Amber Smith: What is done to help with the underlying pain? And I know you mentioned buprenorphine also addresses pain, but if they wean themself off of that or stop taking that, what, I mean, they've still got this low back pain, for instance.

Nurse Practitioner Theresa Baxter: Yeah.

Host Amber Smith: Do they, do you have to funnel them to treatment for that at the same time?

Nurse Practitioner Theresa Baxter: Well, we do try to treat the whole person, which means that it's best to really simultaneously treat each condition, right? So while we're treating their opioid use disorder, ideally we're also treating their chronic pain.

But if they do decide that they want to come off of their medication to treat opioid use disorder, or they're still having that chronic pain while they're in treatment, there are so many things that we can offer to people. We use those multimodal analgesics, such as the muscle relaxers, the topicals, the anti-inflammatories, and things like that. But we also recommend physical therapy and occupational therapy, interventional procedures, massage, acupuncture, yoga. We really try to use everything we can so that people can tolerate their pain conditions and live their lives.

Host Amber Smith: You're listening to Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with nurse practitioner Theresa Baxter from addiction medicine at Upstate.

How do you gauge whether treatment is successful for a patient?

Nurse Practitioner Theresa Baxter: My opinion is that when someone is living their life, that's successful, right? So they're not suffering the consequences of active use, which could be, for example, loss of family and friends. Sometimes they have legal problems, problems with work, or fulfilling their other responsibilities, serious medical complications of active use.

I think it's really important to remember that having an opioid use disorder or, really, any substance use disorder is a chronic medical condition, which much like other chronic medical conditions, we should remain mindful of the risks of relapse because it does happen and what to do if that should occur. We don't graduate from treatment, right? Like, we may complete a phase of treatment, but we don't graduate from it. Like other chronic conditions, we may have periods where we're doing well in managing our condition, and we may have periods where we need a little bit of extra help or support.

Host Amber Smith: Does having this in your medical history make a person prone to other types of addiction?

Nurse Practitioner Theresa Baxter: It does. Co-occurring substance use disorder is very common, as are psychiatric comorbidities, which is another example of the importance of treating the whole person, not just their presenting condition.

Host Amber Smith: And are there medical problems that a person may develop that come from having had an opioid use disorder. I mentioned the constipation. Is that usually cleared up?

Nurse Practitioner Theresa Baxter: Well, it's something that a person will have to stay on top of because as long as they have that opioid exposure coming in, even if it's for a medication to treat their opioid use disorder, that still is an opioid. Methadone is still an opioid. Buprenorphine still has opioid. And so it still will lead to constipation. So it is something that is an ongoing problem to deal with. But it's treatable. It's preventable, and it's treatable.

There are plenty of other medical conditions that can come from having an opioid use disorder or prolonged opioid exposure in general such as hypoxia, which is a lack of oxygen to the brain due to slowed breathing, infectious diseases such as hepatitis and HIV (Human Immunodeficiency VIrus), problems with our lungs or nasal damage, which can increase the risk of pneumonia and tuberculosis. People with opioid exposure can become immunosuppressed, so they're more susceptible to those infections, can develop some heart problems, including low blood pressure, pulmonary edema, low irregular heartbeats, other abdominal dysfunctions, endocrine dysfunctions. Hypersensitivity to pain is a really big one, so they develop -- not everybody -- but it's pretty common to develop an opioid induced hyperalgesia, which is basically a very fancy way to say a heightened sensitivity to pain, which is a real conundrum for people.

Host Amber Smith: Oh, I imagine.

Nurse Practitioner Theresa Baxter: Yeah. And then, dependence and addiction, depression, anxiety, things like that.

Host Amber Smith: Well, this has been recognized as a crisis in America for several years now, and you're pretty much on the front lines of this. Do you see mostly success with your patients?

Nurse Practitioner Theresa Baxter: You know, interestingly, there is some changes. So we are seeing, and this is across the country, we're seeing, thankfully, a decrease in the number of people who are dying from an opioid overdose. And there's really many, many factors involved with that. What we are seeing, though, is a lot of the complications that come from prolonged opioid exposure and having an opioid use disorder.

So we have a lot of work to do with our opioid crisis epidemic that's going.

Host Amber Smith: Well, thank you so much for taking time to tell us about it. I appreciate it.

Nurse Practitioner Theresa Baxter: I think that what I really want to say, also, to wrap up is for people to really talk to their provider about alternatives to and the risk of taking opioid pain medications as well as safe disposal if they have extra ones and what to do if they find themselves having problems.

As medical providers, we want to make it safe for our patients to have that kind of open communication with us and decrease the stigma and shame that sometimes, and actually oftentimes, come with having a substance use disorder.

I also want to say that if you're someone who uses recreational drugs, please note that the entire drug supply is adulterated with toxic substances, and we don't know what's in the drugs. There's really no safe illicit drug use, and extreme care must be taken even if the person knows who they get it from. We always want everyone to get trained on and carry naloxone and use drug testing strips. There's other harm reduction measures as well.

Host Amber Smith: Well, that's good to know. Thank you again. My guest has been nurse practitioner Theresa Baxter from addiction medicine at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe with sound engineering by Bill Broeckel and graphic design by Dan Cameron. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please invite a friend to listen. You can also rate and review "The Informed Patient" podcast on Spotify, Apple Podcasts, YouTube, or wherever you tune in. This is your host, Amber Smith, thanking you for listening.