Summer House

Public Opinion Online — How does a doctor wean a patient from a legally prescribed painkiller that has brought on an addiction?

Doctors are trying to answer that question through a new type of addictive substance.

Opioid dependency — addiction to a substance that contains opium — is a big problem that’s prevalent even in rural communities such as Franklin County.

Opium, an addictive narcotic drug that comes from the dried juice of a poppy, is an ingredient in many prescription-strength pain relievers, such as OxyContin, Percocet and Tylenol with codeine, as well as heroin and methadone. This group of drugs is called opioids.

Specially trained physicians, including Dr. Bridget Hilliard of Antrim Family Practice in Greencastle, are having success in treating opioid-dependent people with a partial-opioid medication called Suboxone.

One of Hilliard’s patients, a Franklin County woman in her early 20s who was addicted to heroin, tried several times to get off the drug herself.

She went to a methadone clinic for a year, but then found it more difficult to quit methadone than heroin. While on methadone she felt tired and in a haze all the time, falling asleep during college classes. She had to go to a clinic six days a week to get her daily supply of methadone, which cost $12 a day. She felt so ill on the drug that she returned to heroin.

Now that she’s taking a drug called Suboxone, she feels well, is back at college and working. She expects to be weaned off Suboxone within six months and has lost the desire to take opioids, she said.

"The Suboxone has been a miracle," she said.

In her class at Greencastle-Antrim High School, the patient said that at least half the students had taken some sort of opioid for recreation at least once and about 10 percent of the students at the time of graduation were addicted to one of those drugs.

Research shows that unlike methadone, which is a full opioid and extremely addictive, Suboxone changes the brain chemistry on a long-term basis, Hilliard said. This gives addicts a better chance of staying off illegal opioids after stopping their use of Suboxone.

Hilliard has been prescribing Suboxone since last fall, and strongly encourages her patients to have drug counseling while taking it.

In order to prescribe Suboxone, doctors must acquire a Drug Enforcement Agency license. They do this by getting additional training about the chemical. Even after becoming licensed, a doctor is limited in the number of patients he or she can treat at a time, Hilliard said.

How people become opioid dependent

For half of those addicted, Hilliard said, the addiction started when they were prescribed a painkiller, such as Percocet, Vicodin, OxyContin or Tylenol with codeine. The other half initially started using the painkillers in their teen years to get a euphoric feeling.

She has talked to people who took an opioid for the first time for a migraine and got such a euphoric feeling they continued taking it because it made them feel good.

"Your body can build up a tolerance for the medication, so you need to take more to get the same effects," Hilliard said, adding extremely high levels can cause breathing problems as well as the other problems that accompany addiction. "People of any age can get addicted."

Some people can use these medications appropriately and not get addicted, but there’s no way of knowing who they are, Hilliard said, adding that doctors need to monitor their patients’ use of the drugs. Doctors also must be very detailed when charting why they are prescribing the medications, how much is being prescribed and if the patient is showing signs of psychological dependence, she said.

Those who have a history of substance abuse are more prone to becoming addicted to another substance, Hilliard said.

It isn’t foolproof, but Suboxone may be the best chance some people have.

Xanax is a Central Nervous System (CNA) depressant known as benzodiazepine, which is commonly prescribed by physicians to treat panic attacks, nervousness, and tension. Xanax, also known as alprazolam, is considered to be a Schedule IV controlled substance under the Controlled Substance Act (CSA). Xanax has been used as a tranquilizer since the 1960s. With strong opposition to the use of benzodiazepines in the 1970s, there was a 25 percent drop in the number of prescriptions written and today, with approximately 3 million Americans (1.6% of the adult population) having used benzodiazepine on a daily basis for at least 12 months, they are the most controversial of all psychotropic medicines.

According to the United States Department of Justice Drug Enforcement Agency (DEA) and under the CSA, all controlled substances are rated on a five-schedule system. Schedule V, the lowest, for the potential for abuse and dependency and I, the highest. Xanax is a Schedule IV. All Schedule IV controlled substances have the following attributes: a low potential for abuse, a currently accepted medical use in treatment in the United States, and if abused, may lead to limited physical dependence or psychological dependence. Other examples of drugs included in schedule IV are Darvon®, Talwin®, Equanil®, Valium®, and Xanax®.

Although there are many benefits to taking Xanax and other Schedule IV drugs, many patients are becoming addicted and therefore require an intervention and drug treatment program to overcome their addictions. The patient’s body can also build up a tolerance to the drug and require larger doses if taken for long periods of time. With these increases in Xanax use come physical and psychological dependencies. Xanax is not drug to quit cold turkey. The Journal of Postgraduate Medicine stated that up to 25 percent of patients who stop taking their medication experienced withdrawal symptoms such as: nausea, vomiting, dizziness, headache, anxiety, irritability, insomnia, chills, lethargy, fatigue, moodiness, crying, dystonia, paresthesia, tremor, vivid dreams, and myalgias.

The National Institute on Drug Abuse found during a two-year treatment outcome study that 15 percent of heroin users also used benzodiazepines daily for more than one year, and 73 percent used benzodiazepines more often than weekly. Studies also indicate that from 5 percent to as many as 90 percent of methadone users are also regular users of benzodiazepines. With this information in mind, the Xanax abuse treatment involves careful monitoring and counseling in an in-patient or outpatient treatment facility. The American Psychiatric Association’s (APA) report on benzodiazepines revealed that 11 to 15 percent of the adult population has taken a benzodiazepine one or more times during the preceding year, but only 1 to 2 percent have taken benzodiazepines daily for 12 months or longer (4). However, in psychiatric treatment settings and in substance-abuse populations, the prevalence of benzodiazepine use, abuse and dependence is substantially higher than that in the general population. Treatment encompasses a patient’s thought process, behavior, and helps them to cope with everyday life. Patients suffering from Xanax addiction should be tapered off gradually. There are basic outpatient plans available for discontinuation of the drug including: gradual discontinuance over a six to 12 week schedule, monitoring and helping the patient to feel in control of their dosage, and supplying a helpline when the patient needs reassurance. Other plans include inpatient treatment centers and 12-step programs such as Narcotics Anonymous, and drug treatment exchanges such as, Clonidine, propranolol, or carbamazepine. Although these substitutes can be dangerous, an inpatient setting where dosages can be physician monitored until the patient can reach a zero dose of the benzodiazepine is recommended.