This article is a transcribed edited summary of a video Bob and Brad recorded in October of 2020. For the original video go to https://www.youtube.com/watch?v=39Vpffll5_s&t=1071s
Brad: Hi, I’m Brad Heineck, physical therapist.
Chris: I’m Chris, the pharmacist.
Brad: Today’s title of this video is Opioid Pain Meds; How They Stop Pain, Why They’re So Addictive and we’re going to get into recovery as well. This is going to be made easy to understand. Chris is going to explain it to us in a technical way but he’s going to also back off on that and show us in a good way that they lay person can understand this. Opioids, man. No matter what, you hear a lot about opioids. As a therapist, we see them used for pain meds and they’re widely used. But, their is this big problem of opioid crisis, which we'll get into but it’s a big problem. We need to know how to use these or understand these, so that we’re not afraid of them but we respect them and use them well. Doctors are very well aware of this. So, first of all, opioids, what are we talking about. What are the common names that we hear?
Chris: Well, there’s a whole bunch of them that can be used. The most common one’s are probably going to be oxycodone. Then we’re going to use hydrocodone with acetaminophen. You can use oxycodone with acetaminophen. You can use fentanyl patches and there’s actually sublingual lozenges. There’s a lot of different things. Most commonly, those are the ones you’re going to use the most, but you can use morphine. Morphine is a really common opioid as well.
Brad: That’s an opioid?
Chris: That’s an opioid as well. It’s kind of the grandfather one, soldier’s drug. So, it’s the first one that came out.
Brad: So, all of these opioid drugs fall into this opioid category and they have these names, which are very common. I know the Oxycontin, oxycodone is very common with total knee replacements in the past.
Chris: Very necessary.
Brad: Right, exactly. So, as far as the names, why do these work? How do they work, can you explain it in a lay person’s way?
Chris: Yeah, it’s kind of interesting. You have receptors that go through your brain, your spinal cord and even your gut. There’s actually, within those receptors, there’s a breakdown of those.
Brad: So, receptors, we’re talking about the nervous system.
Chris: Yeah, it’s just kind of like a little puzzle piece. You’ve got pain reliever up here, receptor down here. It locks in like a puzzle piece and the most important, there’s pretty much three receptors that are widely studied. The Mu is the one where it’s at. That’s the one that has most of the pain-relieving properties and then you have lesser ones that you would call Delta and also Kappa receptors.
Brad: So, the puzzle thing, we’re talking about these things coming together and that tells, or gets pain to our brain?
Chris: Yeah, so as soon as you take the medication, it goes into your gut, gets into your blood system, and in about 15-30 minutes, you’re going to start to get analgesia, which is pain relief.
And you still have that pain. Let’s say you broke your wrist. It still hurts like crazy; you just don’t care about it. That’s what pain relievers do.
Brad: You mean all are opioids?
Chris: Yep, any opioid. I guess I’ll use opioids and pain relievers synonymously. Just to keep it as simple as possible, but the problem with opioids and where we have the crisis is pills can lead to addiction and can lead to seeking some of the street drugs like heroin.
Brad: Okay let’s back up. Let’s go to knee replacement because they’re very common in my world. You’re on opioids, it hurts like crazy. You have to range it out, it hurts, but if you don’t get it moving, it’s going to contract, and scar tissue is going to be a problem. So, we have this connection of the puzzles come together, so that the pain goes in the knee, to the brain, it gets pain, the opioids, blunt that effect. So, that’s all good?
Chris: Yes.
Brad: So, we’re going to take those, we are going to get good therapy, you’re going to be walking again. So, where does the problem come from this less pain, or pain you don’t care about, into a problem, a crisis where you’re addicted to it?
Chris: Yeah, you know it’s kind of funny when you talk about that because especially like if you take a total knee. That type of therapy is going to take time to go from A to B. I mean, how often do you see your patients?
Brad: Typically, it’s a four-week regimen. It can go less than that and can easily go more than that, but we’ll use four to five weeks, whatever.
Chris: Yeah, and so the newer studies are very interesting. We had maximum prescribing of opioids that hit the peak in 2012. We’ve seen a very dramatic decrease to where we are today.
Brad: You’re talking about overall use?
Chris: Overall prescribing of these opioid painkillers. And so, it’s been fascinating and they’re harder to come by. You don’t see the forgeries; you don’t see the seeking behaviors as you do. So, to treat your patients, what doctors are doing now is there’s the number three and the number five that are very important numbers. A lot of surgeries, when you get doctors are only prescribing these kind of FDA guidelines. You get three days of narcotic pain reliever and then the doctor will review you and see what they need to do next because it seems like going up to five days, there’s a lot more continuation of the use of those opioid pain medications. It’s interesting when you have somebody that’s on a total knee, you want to transition from using something like hydrocodone or oxycodone for pain relief to getting over to like Tylenol and something like ibuprofen more rapidly, if you can.
Brad: Well, so where’s the problem? Why do people get addicted and why are people dying from it? How do they go from the prescription, medical use for it to this crisis of opioid addiction? Where does that happen?
Chris: Remember when we were talking about that puzzle piece? There’s one main puzzle piece that I went over, I said that weird word, Mu, kind of like a cow. Well, it hits that, not only does it give you the analgesic, but it also gives you a euphoric response.
Brad: So, you’re getting a buzz?
Chris: You get a buzz, basically when you’re in pain, you don’t notice this. Actually 97% of patients don’t have a problem. It’s that 3% that can get hooked.
Brad: Would that be like, an addictive personality?
Chris: Yep, and there’s a lot of factors. I mean, are you in a transitional stage in your life? The younger you are to start pain medications, or is there a family history of genetics? There’s a lot of things that build into addiction science that make it very very challenging. I mean, for the scope of what we’re talking about is what can we do to keep ourselves safe? It’s using them as prescribed by your doctor, what your pharmacist recommended you take it as and using it for the shortest possible period that you can.
Brad: So, if you’re on opioids for more than a month, that would be pushing the limit?
Chris: That’s pushing the envelope. I mean, you get up to using opioids regularly for a month, you’re going to have to have walk down because otherwise you’re going to go through withdrawal. At that point, you are at least physically addicted to the medication.
Brad: Even the prescription?
Chris: Yeah, even the prescription. So, if you’re taking, we’ll just, I’m going to pick on hydrocodone with acetaminophen. You’re taking, you know, one tablet four times a day, every six hours. If you do that for four weeks and I’ll send a note to say, “Brad, I’m not going to give you any more medication.” It’s going to be a bad day.
Brad: Just one day or is that going to take a while?
Chris: It takes about a week to flush out of your system. If we taper you off, going from four down to three tablets a day for a week and then maybe two tablets a day for a week and then finally one table a day and off, that exit is very clean.
Brad: Then you’re probably not going to feel addicted? You’re not going to want it anymore. Unless maybe you’re in that 3%.
Chris: Then there’s other stats that we can throw in too that make it even more confusing. I mean, for the most part, it’s that 3%.
Brad: I’ve heard this too, from doctors as well as patients, that they’re less likely to prescribe opioids and it’s governed, regulated. Is this worldwide or is this just in the United States?
Chris: The United States. It’s kind of funny, looking at the stats but right now in the United States, we use a thing called the PDMP, which is a website that helps us, The Prescription Monitoring Drug Program. When we get an opioid that comes in, we have to log on and look at that and then see what the prescribing history has been.
Brad: Of that person?
Chris: Of that drug and actually, prior to that, the doctor does the exact same thing. So, our stories will match each other. So, the doctor, before he can even prescribe it, and a lot of systems now around in our local healthcare area; they have to log on, look at the PDMP and then they can actually select the drug. If they don’t do that step, I believe the systems will not allow them to write for it anymore. It’s a safety check. Just to make sure they’re using it appropriately. There are cases: cancer, arthritis, I mean, you’re going to have people that may take these things forever. It’s tough and as long as they’re used the way the doctor intends it to; it’s not going to be a problem. When you use these long-term, you’re physically addicted to the medication but it’s not so much like a drug seeking behavior. If we remove it from you, you’re going to have withdrawal. That’s what I mean by addiction in that particular instance because there are also psychological addictions as well, where you just, the only way you’re going to feel comfortable is if you’re using the drug. It gets very confusing.
Brad: Where does the crisis become involved? If people are just using it with their doctor, the things get out of the system, through their high school kid, isn’t there some stats on getting into the medicine cabinet and taking it because these pain meds work well.
Chris: Yes, they do and that’s where the rush comes from. That’s what people want. When you finally go from using the medication for medicinal uses to using for recreational uses. That’s when we start to see this opioid epidemic taking place. You know, it’s a pretty easy problem to fall into. There are reasons why addiction occurs. Did you have a genetic predisposition to it? Were there family problems, did you have an alcoholic father or mother? Did you have a transitional period in your life where you start at a new school or you started a new job? Those things, just all of a sudden, you just want to try and escape and all of a sudden, taking the medication, you just feel a little bit better about everything and you just don’t care. That’s part of the problem with it. It’s very easy to slip into that. It becomes a very very ugly rabbit hole.
Brad: So, did you have some stats on who is getting addicted? Is it the patients? Is it their family members who get to it somehow?
Chris: It can be anything. That’s the thing. When you do the breakdown, if you look at across the board, the younger you start, and the longer you take the pain medication are strong predictors if you’re going to have a problem with opioids or even other substances in your life. We want to be really careful with that. We want to be upfront with our doctors. If there’s a problem, you want to talk to your doctor. When you look at some of the stats, high school, one in 12 high school seniors has tried opioids. Now, it could be heroin, which is a street drug, or it could be getting pills. When you look at the breakdown, it’s like, how did you get the opioid? It first comes from family members. So, they checked the medicine cabinet, somebody who said, “Oh, I’m done with these, you can have them.” Basically, they can get them from family members, 35% of them get them from the doctor but 53% get them from their family.
Brad: Now, you said heroin,so there is a black market?
Chris: There are black market opioids.
Brad: So, what are those opioids? Heroin and?
Chris: Well, heroin is the main one. It’s cheap, so that’s the problem. Back in the 90s, when I came out of college, we had a very different mindset for giving people pain relief. The dose was given to what they could tolerate. There’s no ceiling with opioids.
Brad: Prescription wise?
Chris: Yes. We started reigning things in after about 2012.
Brad: So, there was 10, 20 years where there was a lot of opioid prescriptions, high doses?
Chris: Wild Wild West. I can tell some pretty crazy stories about the involvement with the DEA and very particular uses for drug busts on bad doctors. It’s crazy. People will go to no end to get what they want once they are addicted to these things. The problem with heroin these days is, you start on pills, doctor won’t give you any more pills. I need something. I’ve just got this void in my body. I ignore my family, I ignore my job, I ignore my friends. I need to do something. Well, we find heroin. Heroin is cheap and it’s easy to use. You can snort it, or you can inject it, or you can smoke it.
Brad: Is it readily available in the street?
Chris: Unfortunately, it is readily available. It’s very dangerous stuff. One in four gets addicted to it right out of the gates. Why is it so addictive? It goes back to that Mu receptor again. It’s kind of creates this incredible intense pleasure for about one to two minutes after you ingest it. However, whether it’s in shooting, smoking, or snorting. After that two minutes rush, you have about four or five hours of just generalized contentment, kind of like you’re in a warm cocoon of happiness. For a lot of people, that’s very attractive. You just don’t care about anything else, you’re just kind of comfortable. The problem goes, after about that four hours, then you’re looking for your next fix. Eventually, the addictive psychology takes over and most people don’t even get the high. After that first high, on heroin specifically, or chopping up and shooting opioids of any sort, you never really get that initial high again. Now you’re just chasing it. You’re just trying to not feel like garbage. This is the withdrawal effect.
Brad: Like the hangover?
Chris: Yeah, so it’s a vicious cycle. It’s one of those things that you’re always chasing that. It affects the brain in such a way that when you go to rehab, they have to teach you how to think differently to break the cycle, so you can make the healthy choices, so you’re staying away from the people that can cause you to fall into these patterns, staying away from the situations that can cause it. It’s very complex and it’s very sad.
Brad: Is there any stats on how many people maybe start from the medical field, the prescription and get into that illegal street drugs?
Chris: You’ve got two million people right now, walking around in the United States alone, that are in what they call an opioid crisis. Basically, at that point, they’re hooked on it. Whether it’s pain medications or street drugs. That makes it really challenging to try and treat from that standpoint. There’s definitely avenues, you know, and the biggest thing is when you know you have a problem, you have to reach out to a doctor to get help. A lot of times family members will try to break through, and the addiction is just so strong that they don’t care. It’s tough stuff.
Brad: So, this is the kind of thing that can lead to death.
Chris: Absolutely and part of that problem is with some of the drugs that are available on the street. Heroin is cheap, pills are expensive. It’s $30-$80 for a prescription pill to be sold on the black market.
Brad: You mean one?
Chris: One tablet.
Brad: One tablet that you could get from your doctor would go for $30-$80 on the street?
Chris: Yes, versus a $10 bag of heroin.
Brad: They’re both going to give the similar type of high.
Chris: The advantage of the pills is you know what you’re getting. Things like heroin, you don’t know what you’re getting. They cut it with other things. One of the bigger dangers you have with drugs like heroin is what we’re seeing with the death rate rising so much. Last year alone, 67,000 people died.
Brad: 67,000 people?
Chris: 130 people a day die from opioids and heroin.
Brad: Both street and prescription?
Chris: Yes, they are kind of lumped together. The National Institute of Health has some real good graphs if you guys want to research it yourself. It shows, quite eloquently, the dangers of these drugs, but the big scary one right now, are the synthetics. Considering La Crosse, they just had a big fentanyl bust down by Gunderson. They’re cutting the heroin with fentanyl, which is an extremely potent; way more potent than heroin itself, and they mix it in with the heroin, so people that who melt it, shoot it or snort it or smoke it.
Brad: Fentanyl, where do you get that from?
Chris: You get it from your doctor, but this is a black-market fentanyl, so it’s coming from drug dealers. It’s a powder and you can’t really eat it. That’s why in prescription, you have a fentanyl patch or Duragesic patch, you wear it for three days: it’s great for cancer pain. It’s something where it’s a phenomenal painkiller but when you mix it with something deadly like heroin, the death rates get even higher. It’s actually outdoing straight up heroin death rates now.
Brad: Wow.
Chris: It’s scary stuff.
Brad: So, if you’ve got a family member or yourself, and you know you have this problem, you want help. Obviously, it sounds to me like to get through the withdrawal, as something to do by yourself, is extremely challenging.
Chris: You’re going to need help, yes. There’s a lot of different ways. Some of them are a little bit controversial. You can get a doctor, a medicated assist to get you off the drugs. You literally go to a hospital. They check you in. They give you special medications to help your body taper you down off the opioids until you’re clean. You’re basically in a medically induced coma to get to that. That’s the most controversial one, or they can try cold turkey but that’s 7-14 days of hell. Or you can get into a program. There’s lots of programs that doctors can lead you to and there’s things on the internet. Anywhere you want, help for the opiate addiction. You will see multiple sites come up. Basically, they want to keep you safe and healthy. A lot of those programs are incredibly successful. They have to place you on medications to help to get rid of the craving. Things like Suboxone is a drug that they use. It’s a special film that they dissolve in their mouth. It’s two drugs in one and one blocks the receptor, so that if you were accidently broke down and tried to use something like heroin, it doesn’t work. It doesn’t work at all and it gives another one to basically take the edge off so that you can function and feel normal. It’s amazing, when you see a functional addict. They can take a hit of heroin and you look at them and they’re talking to you and you wouldn’t even know it. It’s weird. Then there’s other ones that are all gorked out in left field.
Brad: Right. I wasn’t really aware of that myself. People can function while they’re on opioids and you wouldn’t know it. Could this go on for days or years?
Chris: Year.
Brad: Years? People could be using this for years.
Chris: Until they die.
Brad: As they are using this, is their body and their brain slowly decaying?
Chris: It causes brain damage. It’s just one of those things where, more than anything else, all your brain wants to do is seek that drug and nothing else exists. When you get to a doctor and you finally get to treatment, crisis management of all these things, they’re going to work with you psychologically to try and teach you behavioral patterns to help you to become safe and healthy again.
Brad: Do you recover? Say, your mind, it gets beat up through all this use. I’m thinking like your lungs; after you’ve smoked for 20 years, they get beat up but after a few years, when you quit smoking, it does recover. Maybe not to 100%, but you get through it. Is it the same thing with this?
Chris: You could say it is. I don’t think you’ll ever get back to 100% of yourself, but you might have to have medical help. As far as prescriptions go, they can try and help you. There can be chronic depression. There can be anxiety issues. There’s a lot of different things that have to be looked at. It’s a very complex medical condition that requires a doctor and regular check-in’s and visits. Sometimes, even weekly. Sometimes there are doctors in some of these programs that see people every other day.
Brad: Once you get further and further away and you’ve been completely free of using the drug, then you don’t have to go as often.
Chris: Exactly. Once we get to a point and your stable on the medication and then the goal after you get to a good point, hopefully then we try and pull you off of some of these things. Then you just check in counseling. You keep working on re-evaluating life choices and keeping in mind, a lot of folk’s relapse. It’s something that you have to realize that they can succumb to it. They can’t look at it like a failure. It’s just a disease.
Brad: They could be off of it
Chris: But then fall off the wagon, so to speak. But they can get help. They just have to re-evaluate and retrain the brain to try and avoid those and make better lifestyle decisions. Whether it’s going into an exercise program, where you’ve got to find something to fill that void. What happens is, when you get into that, you burn out all the receptors that help you feel normal. Then you have to retrain your brain. You have to come up with activities that are going to help you get back to that normal. What is your “new normal”.
Brad: Wow, we really went through a full cycle, through the whole idea of how does it work to get through that total knee with that painful rehab, medically, into the illegal drug portion, which it could lead to and then you have to get out of it.
Chris: It’s heavy.
Brad: Yep, and there’s help out there if you are in crisis mode. If you are taking it for a medical reason, a total knee replacement, shoulder problem, whatever it may be, you can do it safely. Be attentive to your doctors.
Chris: Work with your doctor. If you have a question to ask your pharmacist, we’re going to funnel you to the right people to try and help you to do whatever we can to keep you healthy and safe. Again, for most of us, it’s not a big deal. But there’s a small portion, it’s a huge deal to and it can kill you.
Brad: Again, the younger you start, the worse it is. So, pay attention to what your kids are doing.
Chris: Yes, and don’t be shy. Ask questions. If you’re a parent, you can’t be a buddy, you have to be a parent. Sometimes it’s not nice and those conversations are very unpleasant. But at the end of the day, it’s about the people you love, and you want to kind of help them as much as you can. There’s always help.
Brad: Outstanding job, Chris. I’m learning here. We talked about this before and I feel like I’ve learned something. I feel uplifted, so very good. I hope you feel the same way and good luck.
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