These days, opiates — and opioids in particular — are primarily prescribed to treat pain, but there is a long history of these drug classes being used to treat depression and other mental illnesses. In the 8th century, Arabian cultures used opium in mental hospitals and in the Victorian era, “tincture of opium” was used for depression, hysteria and as a way to soothe small children, with 25 drops selling for merely a penny.
As physicians began to better understand the risk factors associated with these drugs, they fell out of favor in the medical establishment, resulting in strict regulation and essentially prohibition in the early 1900s. The regulatory environment eventually eased up though as time passed, and we find ourselves currently in the throes of the worst opiate and opioid epidemic ever.
How People Get Started on Opiates
More people died from opiate or opioid overdose than from homicides in 2015, with 91 Americans dying from overdose every day. The current national epidemic was born largely out of misguided attempts to treat pain by freely prescribing these narcotic drugs. Besides, pain, and particularly chronic pain, can be hard to treat because it is poorly understood and frustrating to both patients and practitioners. Medical students receive little training in pain management; PCPs are limited to 10 minutes, preventing a more in-depth discussion of other options; insurance companies often don’t cover other pain management procedures moving pills to the forefront and reimbursements are notoriously low. Then there’s the curiosity component, as well as rogue doctors and pharmacies setting up a quid pro quo arrangement — opiates for sex, money or favors. The most common pathway to opiate use however, is acute or chronic pain secondary to physical maladies, injury, accidents, or neuropathies.
Opiates vs. Opioids
Opiates come directly from the opium poppy, whereas opioids are laboratory-created substances in the opium poppy. Common opiates are morphine and codeine under their various brand names, along with the kingpin in this group — heroin.
The opioid group includes methadone; oxycodone (Percocet, OxyContin); hydrocodone (Vicodin) and fentanyl — a transdermal patch which is 50 times as potent as heroin.
Clinical Uses of the Opiates and Opioids
- Pain relief. In the presence of pain, their analgesic properties are generally very good; in the absence of pain, they produce euphoria and induce a dissociated state
- Anesthesia. Utilized in surgery or any procedure where general sedation is warranted
- Cough Suppression. Codeine is one of the best cough suppressants ever.
- Diarrhea Suppression. Opiates and opioids are notoriously constipating, thus are effective antidiarrheals
- De-Addiction. Think Suboxone here. Suboxone aids in ameliorating withdrawal from these substances and blocks their euphoric effects
How They Work
All opiates and opioids target corresponding receptors in the brain. Activating these receptors stimulates endorphin production. These drugs supply an endorphin “rush” and with the brain as the instigator, trick the body into thinking it is pain-absent. This lasts only as long as it’s time for the next dose. Ramifications of opiate and opioid use include tolerance, withdrawal, physical dependence and possible addiction – a chronic, relapsing brain disease characterized by compulsive drug-seeking and use despite harmful consequences.
Pain Management
Since the most common pathway to opiate or opioid use is pain secondary to some physical malady, it is important to understand under what circumstances these agents are appropriate pharmacological choices and when they’re not. Short-term use for acute pain due to an injury or circumstance where a progressive healing process will likely occur is quite acceptable. These drugs however are no longer considered first line agents for the treatment of chronic pain. With an eye toward long-term drug use for pain, the most effective medications are the antidepressants Cymbalta and Effexor — dosed at the high end of their respective therapeutic range.
Final Point
It’s imperative to approach pain patients — particularly those with chronic situations — from the perspective that they would rather be healthy and living a gratifying life, than sick and living in a demoralized way. Help them find their way to functionality, which may not mean being completely pain-free.
Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.
To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.