Acupuncture and the Opioid Crisis, Part I of III

Acupuncture and the Opioid Crisis Part I of III:
Angela Berscheid Registered Pharmacist, Registered Acupuncturist

Acupuncture and the Opioid Crisis, Part I of III, Hoku Integrated Healthcare in Westshore Colwood, Victoria BCPhoto representing addiction as hopelessness

I’ve been practicing pharmacy since 1988, serving mainly the South Island and the Lower Mainland of BC, and now as a consultant in my acupuncture practice in Victoria. From this time I have seen a great change in physicians’ prescribing of opioid painkillers. This blog will discuss the history of opioids, their use, and factors that have led to our current crisis.

When I graduated from UBC, we referred to these substances as “narcotics”—a term derived from Latin “narcos”—to sleep, and also a term used by Health Canada to regulate illegal drugs.

First, what is an opioid? An opioid is a substance derived from the Oriental poppy Papaver somniferum. The word “opium,” is derived from the Greek word “opion”, meaning “poppy juice”. It was first cultivated in Mesopotamia as early as 3400 BC, where its sap, was collected primarily for its pain relieving properties. It wasn’t until the 1500’s that opium was used for non-medical recreational use. Although cultivation started in Mesopotamia, both opium farming and trafficking moved to “The Golden Crescent” in the area of Afghanistan, and moved along trade routes to the “Golden Triangle” in Southeast Asia. Its use also spread when opium was carried along the Silk Road, a route that travelled from the Mediterranean, across Asia and then to China where the two Opium Wars commenced in the 1800s. To maximize trade, Great Britain sold opium grown in India to the Chinese. Where opium went, addiction followed. In retaliation to Great Britain’s wishes to continue trade, legalizing and taxing opium, the Chinese fought to ban all imports. In the first war, China gave up Hong Kong to Great Britain in order for the opium trade to stop. The second war ended with the legalization of opium. When the Chinese arrived to work on the railroads, its use spread to North America. Empty rusted opium containers have been found in the Nanaimo harbor, relics of those times.

Currently opium farms exist in many warm, dry climates, from the Golden Crescent and Triangle, to Thailand and Myanmar, as well as Mexico, and Columbia, where impoverished farmers, to support their families, sell opium on the black market. There are volunteers travelling to these countries, whose goal is to teach farmers how to grow other crops, but this is proving difficult as growing a legitimate crop has a lower profit margin, and the criminals involved in trafficking put serious pressure on the farmers to continue.

Opium is high in isoquinoline alkaloids, the most potent being morphine (from Morpheus, the God of dreams and sleep) and codeine. These two substances are referred to as “opiates.” All other derivatives are partially or totally synthesized from opium, and are called “opioids.” These compounds bind to Mu receptors to relieve pain and Kaffa receptors to induce sleep. Their Mu1 and Delta receptors cause dopamine, the pleasure and reward neurotransmitter to be released into the bloodstream. Our bodies produce our own natural feel-good and pain-relieving endorphins, but when these stronger drugs are used repeatedly, we can no longer produce, or bind enough of our endorphins to receptors to relieve pain and allow us to feel happy. When this occurs, generally only a small percentage of the population will actually become addicted. It was believed that most people could stave off opioid addiction until recently and I will go into this later in the blog.

Angela Berscheid offers Acupuncture in Westshore Colwood, Victoria BC
Photo of two opium poppy pods

Pharmaceutically opiumitself was made into powders and pills. Being more soluble in alcohol compared to water, opium tincture, or laudanum was widely used for pain, insomnia, cough, and diarrhea. Laudenaum was often prescribed to Victorian women for hysteria, and was misused by many, including Samuel Taylor Coleridge, who in his dreamlike state wrote the famous poem, “Kubla Khan.” Opium dens, where opium was smoked, were commonplace; it was also available in pharmacies, made by manufacturers such as Bayer in over-the counter remedies where no prescription was required.

Morphine was first isolated in 1805; in 1847, the potent opioid, diacetyl-morphine, under the trade name of Heroin, was synthesized to combat opium and morphine addiction. During the American Civil war alone, 400,000 soldiers became addicted to morphine. When it was discovered that Heroin was an extremely addictive substance, its use to treat addiction was stopped. Unfortunately Heroin powder was and is injected intravenously by young Americans to elicit intense euphoria. It was and is also smoked, and inhaled.

Over the years, several opioids have been synthesized for pain relief. They differ in potency and duration of effect.

Withdrawal from, opiates/opioids, though unbearable for many, is not life-threatening on its own, and includes often debilitating agitation, restlessness, sweating, drug craving, extreme anxiety, irritability, insomnia, depression, excessive yawning, tearing of eyes, fevers, chills or cold sweats, panting, retching, cramping, explosive diarrhea, and entire body aches and pains. The duration for acute Heroin withdrawal is approximately 7 days, the first 3 being the hardest to overcome. Some users will be tapered off more slowly to lessen the effects of “Cold Turkey”. For drugs with a longer half-life, withdrawal is longer. Symptoms can occur as soon as 6 hours after the last dose.  The prescription drug, clonidine, is used to lessen some of the effects of withdrawal.

In the late 1980’s Tylenol 3 was the top prescribed prescription medication in BC. I saw it frequently being used for both acute and chronic non-cancer pain, and some physicians would prescribe Percocet (oxycodone) for those who required a stronger medication. Cancer patients were often given morphine to control their pain. Sustained release products were not quite yet on the market. When they were introduced, the current thinking was that long-acting formulations of opioids, such as M-Eslon, or sustained relief morphine, provided around-the-clock pain relief, reduced common blood-level related side effects such as dizziness, drowsiness, sedation, nausea, and vomiting, as well as avoided the rush or high that potential addicts were seeking with the quick acting drugs. Long-acting strong narcotics with small breakthrough pain doses of their short-acting equivalent became the norm in cancer patients.

Hoku Integrated Healthcare in Westshore Colwood, Victoria BC
Photo of the markings on a Tylenol No. 3 tablet

          Fast forward to the mid to late 1990s.  Now patients with chronic non-cancer pain were being given the long-acting/short-acting opioid combination. A study by Katz et al has been referenced as a reason many doctors saw prescribing opioids for chronic non-cancer pain as being relatively safe. I saw patients not only on long acting morphine (M-eslon), but also on more potent drugs, such as fentanyl patches or Hydromorph-Contin, drugs that had before been reserved mostly for those with cancer. The vast majority of these patients were now getting adequate pain relief—from what I saw only a minority was showing signs of drug-seeking behavior.  Yes, some patients had slowly rising dosages, but that was attributed to either a) a worsening of their pain over time, b) tolerance and c) dependence.

          Many people don’t know the difference between “addiction”, “tolerance” and “dependence”. Addiction refers to actual compulsive drug seeking behavior. The addict’s mind is focused on how to get more of their preferred substance in order to “chill” or, in most cases, “feel normal.” Addiction to opioids is more common in people who are alcoholics, taking benzodiazapines such as lorazepam, and/or illicit drugs. Tolerance relates to how a person can “get used to” a certain dose. With repeated dosing of the opioid, the body starts to need more of that substance in order to get the same effect that was achieved with a lower dose. Although I haven’t seen any studies on this, I believe that long acting opioid formulations may contribute even more rapidly to tolerance since the substance is always in the body. Mu receptors get saturated, and the drug has a lesser effect. This phenomenon is also tragically seen in short acting drugs with repeated use. With Heroin, or even prescription oral drugs at high dosages, when the user goes without the medication for several days, they then overdose on what they believed was an amount they could handle. People would and do stop breathing and quickly die due to this phenomenon. Taking the drugs with other respiratory depressants, such as alcohol and benzodiazepines is an even deadlier combination. Here, people totally underestimate their previously tolerated amount and they can’t predict what effect these cocktails will have on their system. Dependence is what occurs when a person has reached tolerance. When this happens, they will go through some degree of withdrawal upon stopping taking the medication. The drug has become part of their “normal” body chemistry.  The effects of tolerance and dependence are often confused with addiction, as the patient would be asking their doctor for increasing quantities of that addicting substance. For most patients, normally supervised prescriptions for opioid medication have worked well and haven’t created a lot of addicts.

          I, like most pharmacists and doctors, however, did notice an alarming rate of abuse, first with long-acting oxycodone, prescribed as Oxycontin. Looking into this further, we discovered that people had started snorting, injecting, and even combining the crushed powder into various cocktails to get high. The street value of Oxycontin rose, and more pharmacies were being broken into. People were coming from outside of the province to try to fool the medical system to get more of this drug, only to find that we, in BC (and now in many provinces) have a valuable tool called “Pharmanet” that monitors all prescribed medications from any doctor to each specific patient. All it takes is one phone call to alert the doctor.

Even this wasn’t enough to stop the abuse, so the BC College of Pharmacists banned Oxycontin, and OxyNeo, a new sustained release formulation that was “snort-proof” and “injectable-proof” came on the market. This made a great impact on this wave of abuse.

Acupuncture and the Opioid Crisis, Part I of III, Hoku Integrated Healthcare in Westshore Colwood, Victoria BCPhoto of young woman with handful of pills

Now, however, we are faced with an opioid epidemic where countless people are dying each day due to overdosing on both prescription opioids and Heroin. Physicians are doing everything they can to not prescribe opioids to anyone. Their valid fear is that they will be the “well-meaning” physician that is responsible for getting one of their patients hooked on an opioid, and then get that 3AM phone call saying that their patient has died of an overdose. Walk-in Clinic doctors do not prescribe any opioids, and The BC College of Physicians and Surgeons has stringent guidelines regarding their prescribing. Still the epidemic worsens. You would think that random urine testing and the vigilant use of Pharmanet would have a stronger impact than it has had so far. I strongly believe that all pharmacies, physicians’ offices, and Emergency Departments should have access to a current online monitoring database. This would catch potential prescription drug abusers. The random urine tests would identify those that are using more than one substance, or none at all, as in those who are only selling or giving away the drugs.

          There are quite a few factors involved here.  First, there seems to be a relatively stable percentage of the population addicted to something—be it alcohol, cigarettes, sedatives, stimulants, opioids for recreational use, and other drugs.  This means that no matter what the interventions we have made so far, we will not have an impact on the percentage of addicts in North America. From 2002-13, heroin use has increased from 404,000 – 681,000 (number of users in the USA that have used heroin in the last year). When it comes to the use of prescription opioid pain relievers, people between the ages of 16-24 have the highest user rate, though not the highest overdose rate. Overall the percentage of people over the age of 12 using prescription recreational opioids was 1.9% in 2002, and 1.7% in 2013. No change. What is alarming is that most people who use opioids for recreational use get them from friends or family. In 2012-13, 53% got the pain relievers from a friend or relative. 14.6%, bought or took them from a friend or relative; 21% got them from their doctors, and 2.6% from more than one doctor. Only 4.3% got the prescription opioid painkillers from a drug dealer or a stranger.  

When these American statistics became known in 2013, prescribing habits of doctors had to, and did change. According to this data, friends and family are responsible for giving and/or somehow releasing over 3 times the opioid prescriptions compared to the doctors who originally prescribed the same drugs. We, as a society have to get smarter. This is not just a drug problem, it’s a societal problem, and because of this, doctors have practically shut down on prescribing opioids, to the chagrin of people who are in severe chronic pain, some of which will, according to these stats, turn to their friends and family for relief; if that is not available, then a small few do turn to the street, and these will likely die from overdose.  

Besides drug diversion, there is a greater reason why people are dying from opioids. Yes, Heroin use is on the rise. Why, though, would more Heroin users be dying of overdoses over a prolonged period of time? In the past, we would see waves of users overdosing on Vancouver’s streets due to more potent forms of Heroin becoming temporarily available when it made its way to the coast. Users would shoot up their regular dose, and die of respiratory failure. Once that more potent supply was gone, the overdose rate would normalize. This still occurs, but now we have fentanyl, and fentanyl analogue powders being smuggled to North America.   According to the University of Idaho, Fentanyl is 100 times stronger than morphine, and can be 100 or more times stronger than Heroin. Its derivatives, of which there are many, are up to 20,000 times stronger than Heroin. These powerful drugs are cheaper than Heroin, so they are often used to dilute, or “cut” it. Carfentanil, and W-18 are 2 examples. It should be noted, that when searching on the Internet, there are clearly some unknowns when it comes to estimating potencies. This is likely due to the many super-potent fentanyl derivatives of varying strengths that are on the market. Heroin can also be cut with an unknown percentage, and since some fatal dosages are invisible to the naked eye, minute variations in the weighing process can be fatal. Furthermore, potencies of these black market substances vary not only between illegal labs, but from batch to batch as well. It is agreed that a microscopic amount to a few grains of these derivatives are lethal, and stop breathing very quickly. Under the right conditions, the size of a grain of salt can kill 30 people! Many street drugs are tainted with these compounds, from heroin to Percocet, to benzodiazepines such as triazolam or diazepam, and people are dying of respiratory failure with alarmingly increasing frequency.

Angela Berscheid offers Acupuncture in Westshore Colwood, Victoria BCOn the left,a lethal dose of Heroin; on the right, a lethal dose of fentanyl. Photo courtesy of New Hampshire State Police Forensic Labs

This is likely the reason that heroin overdoses, according to the CDC, have quadrupled from 2010 to 2014. From 2014 to 2015, heroin overdose death rates increased by 20.6%, with nearly 13,000 dying in 2015. In the same year, men aged 25-44 had the highest heroin death rate at 13.2 per 100,000, which was an increase of 22.2% from 2014. This is American data, and anecdotally the stats are increasing.

Newest data for the city of Vancouver, BC in August 2017, according to Global News, shows that there have been 232 suspected "illicit" drug overdose deaths so far this year, more than the total for 2016. At this rate, it is expected that there will be 400 overdose deaths this year alone. First responders are getting, on average 135 overdose calls a week. 

Meanwhile, I’ve also been hearing several physicians referring to studies that suggest opioids do not work in chronic non-cancer pain, and that other drugs, such as NSAIDs (naproxen, diclofenac, etc), antidepressants (such as Cymbalta, amitripylline), anti-seizure medications (gabapentin, Lyrica, topiramate), muscle relaxants (cyclobenzaprine), topical NSAIDS with lidocaine, etc, especially in combination are more effective than opioids. These drugs however, are not free from side effects, such as gastrointestinal bleeding with NSAIDs, and varying degrees of sedation in many of the others. Though most side effects of these drugs are considered to be mild for most, some of the infrequent adverse effects of these drugs can be lethal, though more deaths have been recently attributed to opioids. These drugs are not considered to be addictive. Some patients respond well but others don’t.

Sometimes the synthetic opioid, tramadol, that is thought to have less abuse potential, is given for mild to moderate pain relief. Although it is a little less potent than codeine, it may be more effective in neuropathic pain, but it does have the potential for more serious side effects, drug interactions, and costs far more than codeine. It is my belief, that over time, we will see an increasing number of patients abusing tramadol.

When looking at meta-analysis of opioids in chronic pain, the consensus, if there is one, is that there is a lack of data for their use in chronic non- cancer pain. Some meta-analysis trials state that opioids are indeed effective, but physicians must be careful due to their addiction potential.

“More study is needed”. Accordingly, instead of being first line therapy, due to potential for abuse, opioids have become 2nd, 3rd (or “never”) choices for treatment. 

Since it is estimated that up to 40% of people are in some degree of chronic pain, an answer is needed. The drug combinations mentioned above do not work for everyone. We can’t just ignore those who are in urgent need of pain relief, but we cannot contribute to the epidemic.

This opioid crisis is real. It is killing not only strangers, but friends, and family too. Addiction and drug abuse cross all demographic borders, hitting the educated, the uneducated, those with high incomes, and those with low. Recent information in Canada reports that First Nations people are being struck with this disease relentlessly.

In the next blog I will be discussing overdose—ways in which we can prevent one, how to recognize the early stages, and how to quickly and correctly administer emergency treatment.

Part III will focus on non-drug measures in treating chronic pain, and how acupuncture treatments and Traditional Chinese Medicine philosophy can help people in chronic pain, who also suffer from fatigue, anxiety, depression, insomnia, and poor memory.

References:

http://www.ch.ic.ac.uk/rzepa/mim/drugs/html/morphine_text.htm

http://natoassociation.ca/opioids-in-the-golden-crescent-production-trafficking-and-cooperative-counternarcotics-initiatives/

http://www.webpages.uidaho.edu/psyc472www/PDF/6_1_Opiates_Opioids_Narcotics.pdf

https://www.acsh.org/news/2017/01/17/if-you-think-fentanyl-bad-10663

http://journals.lww.com/spinejournal/Abstract/1998/12010/Opioid_Therapy_for_Chronic_Noncancer_Back_Pain__A.14.aspx

https://www.cdc.gov/drugoverdose/data/heroin.html

https://www.deamuseum.org/ccp/opium/history.html

https://en.wikipedia.org/wiki/Golden_Triangle_(Southeast_Asia)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2711509/

http://annals.org/aim/article/2089370/effectiveness-risks-long-term-opioid-therapy-chronic-pain-systematic-review

https://harborvillageflorida.com/uncategorized/whats-difference-heroin-vs-fentanyl/

https://www.ncbi.nlm.nih.gov/pubmed/18443639

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1459894/

http://globalnews.ca/news/3685261/city-of-vancouvers-2017-drug-overdose-numbers-already-surpass-2016-total/