The Next Wave of Drug Abuse : The Opioid Crisis Continues

(Throckmorton, et al 2018) warns of shifting trends in the addiction landscape. They note that the Gabapentinoids (Gabapentin and Pregabalin) are approved in treatment of seizures and certain forms of neuropathic pain. However, US rates of Gabapentinoids use tripled between 2002-2015 and Pregabalin ranked as one of the  10 best selling drugs in 2017. Increased prescription rates have raised concerns about possible abuse of Gabapentinoids. Cannabinoids are linked to dependency in individuals. Cannabis use disorder has long been noted in DSMV. Gabapentinoids have been increasingly dispensed with opioid analgesics and benzodiazepines.

Kratom, a botanical substance is available via online commerce and retail outlets specializing in tobacco and cannabis paraphernalia. Although Kratom has no approved use in the United States, it has been widely discussed in the media as an alleged treatment for opioid use disorder and pain. Many lay coalitions advocate for its availability. Kratom has been widely used as a recreational drug. The CDC report calls to poison control centers citing Kratom exposure rose 10 fold between 2010- 2015. The FDA has expressed concerns. Recently, Kratom was found to have opioid pharmacological properties and being used in place of approved opioids. FDA researchers found that more than 20 specific compounds within Kratom are predicted to bind to the mu- opioid receptors. Analysis of data from social media shows the use of Kratom to treat pain, lessen opiate withdrawal symptoms and for recreational use often with no regard for its safety or addiction potential and despite the lack of clinical studies involving this substance. The same applies to Cannabis, a schedule II drug, not approved by the Institute of Medicine or the FDA. New disorders are emerging for Cannabis such as hyperemesis syndrome. Neuropsychological deficits in learning potential and executive function are related to cannabis use among teens.

An addiction trend is the dramatic increase in abuse of loperamide a common over- the – counter product. Loperamide in approved doses is noted to be a safe, effective treatment for diarrhea, but individuals are reported to be using Loperamide in overly high doses to self manage opioid withdrawal or achieve euphoric effects. Serious health concerns have been reported including Torsades de pointes and death in individuals taking high doses of Loperamide. The FDA recently has been working with the manufacturer of Loperamide to reduce the amount of the drug packaged.

(Throckmorton et al. 2018) reports a shift away from use of prescription opioids towards plant based materials containing unrecognized opioids in OTC products with potentially lethal opioid effects.

New drugs of abuse can emerge (eg, tinneptine) and patterns of use and abuse can change, (eg, Gabapentinoids). (Throckmorton et al. 2018) notes that a system of pharmacovigilance is proposed along with new epidemiological data. The goal is to identify emerging trends earlier. However, this writer proposes greater education of the public in  non-pharmacologic treatment of chronic pain and addiction, as well as increased access for patients to these treatment modalities. Cognitive behavioral therapy is the gold standard in non- pharmacological treatment of chronic pain. It assists patients with management of chronic pain and restructuring of thought processes to effectively manage anxiety and depression. Biofeedback teaches patients to increase skin temperature and thus reduce pain. Patients are taught to acquire voluntary control of normally automatic bodily functions.

A great starting place with treatment of chronic pain and addiction is a comprehensive assessment by a skilled, highly trained healthcare professional. An important distinction in deciding appropriate treatment is where one falls in the following categories:

Primary Addiction Dual Diagnosis

Primary problem is addiction to a Addictive Disorders co-occur with

Substance with Medical and depressive anxiety and bipolar

Psychological treatments applied disorders; treatment focuses on both

To Primary addictive disorder . disorders simultaneously and how

they reinforce each other.

It is puzzling as to why methadone clinics and maintenance treatment are mainstreamed but effective non-pharmacologic approaches are not.

UCLA dual diagnosis program emphasizes a comprehensive diagnostic assessment. An accurate diagnosis is challenging in the context of an addictive disorder and co-occurring psychological condition. Patients frequently are given conflicting and inaccurate diagnosis not informed by psychological testing. Many patients are seen in recovery programs and no psychological testing is conducted. Thus, an objective study of diagnostic issues is neglected at patient’s expense. The treatment plan subsequently is flawed. Medication management, education and cognitive behavioral group therapy are all part of a quality targeted dual diagnosis treatment program.

The FDA is currently convening a group of professionals to evaluate epidemiological  signals that may preface new usage trends. The public needs protection from risks that may emerge as the nation’s opioid problem is confronted. Consumers need nothing less than this!

Bibliography

Throckmorton, Douglas, Gottlieb, Scott, & Woodcock, Janet (2018), The FDA and the next wave of Drug Abuse – Proactive Pharmacovigilance in New England Journal of Medicine, Vol. 379, No: 3