 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. Hi everybody and welcome to today's presentation. Opiates, what's the problem? In this presentation we're going to take a look at this new epidemic. Over the next 20 or 30 minutes we're going to examine what opiates are. We're going to learn about endogenous opiates, how opiates and endogenous opiates work. What are the effects and side effects of opiates? Then we'll discuss the concepts of tolerance and withdrawal and addiction. We'll also look at why so many people are overdosing recently. And we'll take a brief little examination of medication-assisted therapy. Now this is not a comprehensive presentation designed to help you self-identify if you have an addiction or to really go into medication-assisted therapy. We're really looking at just generally what are opiates and what is the problem that we're facing today. We're going to start out with endogenous opioids. These are your natural pain management chemicals in your brain. They're wonderful and everybody has them, which is why we have what we call a pain tolerance. Some people have more, some people have less, which is why some people can tolerate more pain than other people can. There are basically three natural opioids and it's not important to understand what they are right now. But it is important to understand that opioids reduce pain, which may be an expression of a broader function to counter stress. So what do we mean here? When we're under stress, our body sends out the fight-or-flight reaction that says, you know, you either need to deal with this or get the heck away. When we're under pain, you know, think about real primitive animals. When animals are in pain, they don't want to show it because if they show it, then they might become food for another animal. So in essence, pain is a type of stress. Pain is a stressor because it signals a physical threat and elicits the stress response, which includes increased arousal, increased heart rate and respiration and anger, irritability or fear. If you want to test this, get a bucket full of ice and put some water in it and then put your hand in it. And after about five minutes, check your respiration rate, check your heart rate and check your attitude. Most people, at least if they're not used to ice baths or ice packs, you know, because they're long-term athletes or something. But most people, during that initial phase of icing before it goes numb, pain really makes us a little bit crabby. So understanding that and understanding how pain works, because your body's saying, okay, this hurts, we need to get rid of the pain. Pain's not okay. Your endogenous opioids basically serve as an anti-stress activity. And they specifically are going towards the mu-opioid receptor. And that's going to become a little bit more important when we start looking at some of the synthetic opiates that we're going to be talking about. Because remember, you have three different types of receptors. And of those three types of receptors, all three mitigate pain. But your mu-opioid receptor is the one that not only mitigates pain, but also is involved in the stress mitigation reaction. So it's sort of an anti-anxiety and anti-pain. Medications that can be made from natural or synthetic substances bind opioid receptors blocking the perception of pain. So this is what we're talking about when we're talking about oxycodone, hydrocodone, Percocet, any of those things that your doctor might prescribe to you when you're in a lot of pain. Although these drugs mimic brain chemicals, they don't activate nerve cells in the same way as a natural neurotransmitter. And they lead to abnormal messages being transmitted through the network. These opioids not only do they block the pain reception a little bit, but they also target the brain's reward system by flooding dopamine in. Now dopamine is your, oh, I want to do that again, chemical. It's your reward chemical. They found that if you stimulate the dopamine system in rats, they will do whatever it was that got that stimulation until they die. They will forget eating, they will forget sex, they will forget whatever it is. They'll press that lever if pressing the lever gets them the dopamine. This is important because dopamine is extremely powerful. It's one of those things that your body secretes to help you learn what you're supposed to do again. And it's like, that was really good. Let's do that again. Synthetic opiates target only, for the most part, the mu receptor. So we're looking at like 80% target for the mu receptor, which means you're having a lot of anti-stress, a lot of anti-anxiety, and a lot of dopamine. So, you know, you can imagine if you're starting to not feel stressed and you're feeling really, really good, you're going to want to do it again. Many people are drawn to synthetic opioids for their anti-anxiety properties as well as their pain relief. So this is important to understand if you're taking opiates, and you know, I'm not saying opiates are bad. Opiates are needed sometimes. But if you're taking opiates, let's look at why you're taking them. Is it physical pain? Or is it the anti-anxiety, anti-stress, and the dopamine rush? Or a combination of all of them. Side effects of opiates. Well, reduced pain is the main effect. You can also have the side effect of reduced stress or anxiety because the opiates activate the GABA system. And GABA is sort of your chelax, if you will, kind of neurotransmitter. So it goes in there, you're not only getting dopamine, but you're getting GABA, and you feel pretty darn good. The negative side effects, if you will, or the ones that can be more problematic, slow breathing, slow heart rate. You slow those down enough, you don't survive. You die. And constipation. And constipation is just another example of how everything kind of slows down in your body when you take opiates. When we're talking about opiates, we also need to talk about tolerance because like some other drugs, but not most, opiates have a really rapid, really rapid onset of tolerance where the body starts saying, I need more in order to get that same pain killing effect. I need more to get that same euphoria. The brain wants to maintain what's called homeostasis or balance. It's used to having this much endogenous opioids. When you give them synthetic opioids, it doubles. So you have a whole lot more going in there. And the brain goes, there is such a thing as feeling too good. We need to balance it out. We need to not be dumping all this dopamine and basically dumping all this GABA because we need to reserve it for when we really need it. So the brain adjusts and it says, okay, we can't have that much coming in and going through the doors and getting into the body. So we're going to kind of shut down some of those receptors. So more opiate is required to achieve the same euphoria or relaxation and pain management. I've worked with a lot of patients who have had chronic pain that, you know, there really isn't anything that doctors can do for it at a certain point. There's some pain that's just intractable. And do they develop tolerance to opiates? Yes. Because that's the way the body works. Do they need the opiates? Yes. Are they addicted? Are they addicts, if you will? And I don't like that word, but are they addicted in a negative sort of way to opiates? Not necessarily. And we're going to talk about the difference in a couple of slides. Withdrawal. Remember, I said the body wants to maintain homeostasis. So when it was getting too much, the brain shut down some of those receptors. So not so much dopamine and not so much GABA could get out into the system. Well, when you take away that flood, the body doesn't automatically go, oh, okay, we need to open those doors again. It waits to see if there's going to be another flood. And it takes a while. Withdrawal usually only takes a few days, though. So the body starts adjusting and starts producing more endogenous opiates really quickly. Why is this important to understand? When people overdose, a lot of times it's because they quit using, they had been tolerant and they were taking this really big dose, and I'm intentionally not using numbers, this really big dose of opiates. And that was what they needed to maintain their pain-free-ness or maintain their lack of anxiety. And then they decided they weren't going to take it. So they detoxed and they hadn't been taking it for a few days. And then they decide they need it again and they start back out with that really big dose. Well, the body can't handle that big dose anymore. The body can only handle what you would consider the prescribed dose because it's already readjusted the balances, which can lead people to having suppressed respiration, stopping breathing, and dying. Okay, but when you're withdrawing, the endogenous opioids don't build up quite as quickly. So when you're withdrawing from painkillers, especially if it's a fast withdrawal, you just decide you're not going to take them anymore, your pain is going to increase. And when I worked in a mother-baby unit, the mothers needed to be maintained on methadone while they were pregnant because it's harmful. It can cause the fetus to die if you take the mothers off the opiates or the methadone right away while they're still pregnant. But once they give birth, then the tapering would begin. And the first few weeks, I mean, not only did they just have a baby, but the first few weeks the endogenous opioids hadn't really kicked back into full bore. So these mothers were feeling achy all over and things that normally wouldn't hurt, things that normally wouldn't bother them, bothered them a ton. So getting through the day felt like drudgery. Anxiety increased because, again, you know, balance and the body doesn't know it's not going to get the synthetic rush to tell it to dump GABA. So the person starts to feel more anxious. Now, if you're in pain, you're achy all over and you're anxious, you're probably not going to sleep very well, which means there's going to be a desire to make that stop. And during this period is when people are at greatest risk of relapse. But it's also, again, when people are at greatest risk of overdose because they go back to a dose that's too high for their body. So let's talk about taper for people who have become physically dependent and everybody who takes opioids for a long period of time. And this can be, you know, anything longer than a few days will start to develop a physical dependence, which means over time they will need more of the same substance to get the pain relief. Again, that's not necessarily avoidable in certain circumstances. So we're going to really talk about what addiction is in a few minutes. When somebody tapers, they gradually reduce their dose of opiates under medical supervision to allow for what I call changing of the guards. It allows for the body to build up those endogenous opioids. So when they go down to the next level, they're going to be uncomfortable, but not wickedly uncomfortable for a few weeks. And then the body is going to catch up and then the doctor decreases their dose a little bit again. And again, they go through a period where they're a little bit uncomfortable, but it's not horrible for a few weeks. And the step down process goes on for a lot of patients that I've worked with the step down process takes anywhere from six months to 18 months. It's a slow process. But it can be achieved and the body can, you know, rebalance itself. So when you're finally off opiates completely, the pain doesn't come back. Now that doesn't necessarily mean all the anxiety is gone either because you have to address whatever's causing the anxiety, but we'll get there. This can be achieved, this tapering can also be achieved with medication assisted therapy. And I'm just going to briefly go over the two main options, methadone and suboxone. And methadone we'll talk about in a few minutes is something that's really highly controlled and you've got to go to the doctor ever to go to the clinic every day to get your dose and then eventually you can get take home doses that up to a week at a time. Suboxone is a little bit more loosey goosey. And you can get it from a regular physician who has the ability to prescribe suboxone. But it still is one of those things that is pretty tightly controlled. So overdosing tolerance decreases quickly. And if you use the same high dose you were using a week ago, you can cause respiratory arrest. Okay, we've gone over that one. Synthetic opioids are not standardized. So these things that people are making in their backyard, they're making in their sheds, they're making in their bathtubs, they're making wherever they're making them. You don't know exactly how much of the good stuff you're getting versus the fillers. So that's one thing you could get something that is more potent than you expect. Heroin, which we all know is is a popular street drug can be cut or diluted with something called fentanyl, which is one of those opiates that people make in their sheds, which is 30 times stronger than heroin. And I use the word shed sort of generically, people can manufacture fentanyl. And it's very, very cheap. So dealers who have a little bit of heroin can make it go a really long way if they cut it with fentanyl, but if fentanyl is 30 times stronger, and you take the same dose of heroin that you would take for pure heroin, you can see why people overdose. Combining opiates with other depressants like alcohol or benzodiazepines. Both depressants, so they don't act in a one plus one equals two, it's more like one plus one equals 22, and they can really act to suppress respiration and heart rate. Benzodiazepines are your anti-anxiety medications, Xanax and Valium are the two most people are really familiar with, but if a medication has on the label that it could cause sedation, you know that there's some sort of a depressant effect in it and even antihistamines have a little bit of a depressant effect. Changing methods of administration can also lead to overdosing due to faster and more direct action. When you inject, it goes to your brain a whole lot faster than when you take it orally. Likewise, if you take something orally, if you're taking oxycodone and you take a pill, about 25 to 30% of it is going to be lost in the digestion process. So you're not getting the full dose. If you inject that same amount into your veins, even if it's oxycodone, you're basically increasing your dose by 25 to 30% right off the bat. Which is why, you know, if you switch methods of administration, you can really overdose really, really easily. So it's important to understand all of the reasons that people are overdosing so much. And I really believe that the majority of it is accidental. So what is addiction, and this is I told you we would go here and we are addiction is a physical and a psychological issue. Remember a few sides back. I said that people can be physically addicted. When you're physically addicted you have tolerance and withdrawal symptoms, and you can be physically addicted to a lot of different medications. That just means your body has adjusted to it. It doesn't necessarily mean that you have an addiction. So what's an addiction. Addiction is the use of addictive behavior or substance to provide pleasure when it doesn't exist otherwise. And I tell people kind of think your, you know, it's just all gray. Nothing's really happy. Nothing's really sad. And you're just going through the motions of life and some people really crave having some happy. Or to escape from pain either emotional or physical so you're grieving trauma, anything that's causing some kind of pain people can use the substance to escape. Now when you're using it, because you've got physical pain, you're treating physical pain. So you're not necessarily escaping from it and and when we go into the second part of the definition you'll see kind of what I'm getting at here. The use of this substance continues despite negative consequences in one or more areas of life. So if you're using opiates to treat a chronic pain, and your doctor increases your level and you keep taking it at that level, and then you have to increase your level again and you keep taking it that level. And you're under physical, a physician's care. That's one thing. If it's not causing you problems in other areas of life, you know, that's one thing. But an addiction is when you keep using it despite the fact that it's causing a lot of problems in other areas of life. Mainly, you're spending more time or money than intended, planning on how to get it, getting it, using it and or recovering from it. So, you know, that's that's a lot there or and or you're neglecting other areas of life because of use. So if you're spending a lot more time, then that time's got to come from somewhere and it may come from spending time with your family. You may start neglecting duties at work, or you may give up your hobbies and eventually it may be all of the above. And it causes problems in one or more areas of life. It's a little bit different than neglecting things because you can neglect things and it may not start causing problems right away. But if you neglect your job long enough, or you neglect your spouse long enough, or you neglect your finances long enough, it's going to start to cause problems. And that's when, you know, anxiety is going to go up because guess what? You know, you've got all this other crap going on in addition to the physical pain and, you know, you're trying to deal with it and you're feeling overwhelmed. And what's your brain going to tell you you want to do? You want to escape? You want that dopamine? You want that GABA? So people may tend to start craving the the substance or another substance like alcohol, which, as I said, you don't want to combine with opiates. So what about methadone? Methadone is very controversial. Always has been probably always will be. It lessens the painful symptoms of opiate withdrawal and blocks the euphoric effects of opiate drugs. So when you're taking the when you're taking methadone, you're still getting that same relief, if you will. And other drugs aren't going to work because if you think of a lock and key, the methadone's already in that lock. So another key can't go in there. So that helps a little bit. It's what we call a full agonist and it provides the full opiate effect. So you're you're feeling pretty good. It can be used in a controlled taper. So like I talked about earlier, six months to 18 months, a lot of opiate clinics or methadone clinics work to help people wean off of the opiates and find something that's more effective for them or usually define something that's more effective for them. In some cases, it may be used for maintenance. It is more tightly controlled than any of your pills. It is more tightly controlled than even suboxone. So, you know, the people have to go to the clinic a lot. They've got to urine test a lot. They've got to go undergo a lot of different steps in order to maintain keep their methadone. And this is all in order to prevent methadone from getting diverted, but it gets diverted and that's where methadone gets the bad rap. So then on the scene came buprenorphine. Buprenorphine is what we call a partial agonist, meaning it activates those same opioid receptors, including the mu receptor. That's your anti anxiety receptor, but to a much lesser degree than the full agonist. So it's kind of like turning the burner on medium instead of high. It's a sealing effect with buprenorphine no matter how much you take. At a certain point, you're not going to feel any more euphoric or any better. So people who have been addicted to opiates often refer to this as feeling, you know, calm or okay, or mildly relaxed. It's not that euphoric effect that you get from a full agonist, but it can definitely help with the taper. If you're trying to get off of opioids. So what's suboxone? Suboxone was introduced because they found that people were taking buprenorphine and crushing it and injecting it or finding a way to get it into their system faster, which, you know, kind of defeats the purpose. Suboxone is a combination of buprenorphine and naloxone. Naloxone is an opiate antagonist, which basically if you take naloxone, it's going to make you go into opiate withdrawals to sweet. That's kind of nasty. Naloxone is included in the suboxone formulation in order to prevent the drug from being injected, but it's not absorbed orally. So if people are taking suboxone orally, they actually can. If they haven't developed the ceiling effect yet if they haven't reached that ceiling they can take enough to where they get to that ceiling effect and they feel pretty darn good. Which is why suboxone also gets diverted in on the streets a lot. So these are important things to understand when we're talking about different opiates. So you can also understand why they are controversial, if you will. So remember that addiction is about escape escape from intractable pain or from a life devoid of pleasure. You know, it's just all graze or all stress all the time. If you've got PTSD you might be flooded with flashbacks a lot. And the opiates sometimes take the edge off the anxiety, take the edge off the fight or flight reaction when those flashbacks occur. So people with PTSD are at a higher risk in some cases of developing an addiction to opioids. Stopping the substance doesn't change addiction. It just means you're not using the substance. If you are addicted to something because you have an addiction, not just because you've developed a tolerance to it and that's the difference. You're using it for something besides a medically prescribed purpose. When you stop the substance, whatever was causing you to want to use is still there. So the underlying issues that led you to want to use need to be addressed. So if you've got high levels of anxiety, it needs to be addressed. One of the patients I worked with, not terribly long ago, was a performer and told me that she felt so much more energetic and so much more enthusiastic and could perform so much better when she was on opiates. And most of this was because it reduced her anxiety that desire to go out there and please and always be on and always be available to fans was taking a toll on her. And so becoming addicted to opiates ended up being how she dealt with that anxiety over time. Relapse on opiates is much more dangerous because of how rapidly tolerance decreases. Yes, I know I've said that's like six times, but it's important. Opiates cause the brain to dump dopamine, producing pleasure and blocking and they also block physical pain. So if you're feeling euphoric and you have no pain, I can see where you might want to go there again. But it's a slippery slope. Opiates provide the relief from pain and anxiety and activate the dopamine system. So if you had preexisting mental health stress or pain issues, you might start self medicate. Opiates also alter the brain chemistry. Remember I said the brain seeks home homeostasis or balance. So when the opiates wear off, just like when cocaine wears off or methamphetamine or any other drug, the person may feel a whole lot worse because the brain is adjusted to having the synthetic drug in the system. When that synthetic drug's not there, the brain's going, I'm out of balance again, you need to balance me out, which may cause people to crave whatever drug that is that is now maintaining the balance. It's also easy to crave that dopamine rush. If you are what some people call an adrenaline junkie, you know what this is. Things that you do that are high risks that produce that adrenaline rush. A lot of times that's dopamine and norepinephrine just surging through your brain going. Wow, what a rush. Let's do that again. So you understand what that feeling might be like and just take that and multiply it times 10 and you can kind of understand what high levels of opiates can do in the brain. Many people use opiates to deal with anxiety, stress or fear. This fear can be fear of failure, you know, like I talked about my client being afraid of going out there, disappointing fans, being afraid that they would, you know, turn on her. She never knew which was going to be her last hit record. Fear of rejection or abandonment. Some people fear this in their day to day life from their relationships and anything else and they're just constantly stressed and afraid that something's going to go wrong. Fear of the unknown and fear of loss of control. So these are our basic fears. These are the basic things that our body says, fight or flee, fight or flee. You have to understand what triggers these fears for you and start addressing those in order to address anxiety, which will help you not crave the elimination of anxiety through opiate use. It's important to understand and address what's causing the fears in order and some of the things that you can do our work on emotional regulation and distress tolerance. If you Google dialectical behavior therapy or D as in dog be as in boy T is in table self help. You will find a lot of resources on emotional regulation and distress tolerance that can help you kind of stop the peaks and valleys. So it's more of a gentle rolling of stress and anxiety and stuff because we all have it is just figuring out how to manage it. And if some of the anxiety goes around fears of rejection or abandonment or fears of failure, sometimes self esteem work can help because it helps people focus on what they are doing well, what they are succeeding at and why they are worthy of love and acceptance. Opiates can start causing tolerance after only a few days. So I'm going to say that again after only a few days. Think about when you have surgery. I had surgery last year and my doctor gave me 30 days worth and I still have 90% of the medication that's in there. So a lot of times doctors prescribe a lot more opiates than you necessarily need to manage the pain. But if you have to take them for a long period of time for some reason, understand that tolerance does start, you know, really quickly. If you're not weaned off the opiates, the initial few days of being without them can be characterized by a greatly reduced pain threshold. So if you took all those pills for 30 days every four hours for 30 days. And then you ran out and you're like, okay, well, don't have that anymore. The next few days you could feel a lot more achy and you could have a lot more anxiety. So it's important to understand that that's the brain rebalancing itself and it will work its way out. But if it's too unpleasant, that's something a doctor can help you manage. The body will eventually start producing those endogenous opioids again. I remember my father had cancer and he was on opiates a lot and they tried to wean him off of opiates when he went into remission. And the first month that he was being weaned off were kind of touch and go because he was pretty uncomfortable. Endogenous opioids did not produce the same euphoric anti-anxiety effects that the synthetic ones do. So remember these are the ones that we have every day that keep us from feeling like we need to be bedridden all day if we stub our toe. These are the things that your body just goes, okay, let's block that pain receptor, not a big deal. But it doesn't produce the anti-anxiety and euphoria to nearly the same level that the synthetics do. If a person is truly addicted, the drug is not their only problem. It's helping them survive their problem until they find another more effective option. It's helping them survive. We want to survive. We can only be miserable for so long. We can only be in pain, emotional or physical for so long before we need some relief. So in addiction treatment, a lot of what we work at is helping people identify why is it that you're using? These underlying factors that are causing you the anxiety, the depression, what's the trauma? And help people work on those and develop stronger, more effective coping skills so they don't feel the need to turn to the opiates again. If the person was using opiates to self-medicate anxiety, these issues will need to be addressed in treatment. That is a really quick summary of what opiates are, why people are overdosing, how it's really easy to become physically and or psychologically addicted to opiates. But I also wanted to help you see that there are options. There is hope for people who are whatever the reason for using the opiates, there is hope and there are interventions that people can use that can help them find a method of managing their pain and living a happy, healthy life. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. 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