December 6, 2017

Opioid Abuse and Hepatitis C Virus (HCV)

More than 3 million people in the U.S. are estimated to have long-term Hepatitis C virus (HCV) infection. Most people do not know they are infected. Injection-drug users are at high risk for Hepatitis C Virus. In fact, injection drug use is the most common way to catch HCV in the U.S.[1]

  • How is Hepatitis C spread?

HCV can be spread when blood from an infected person enters the body of someone who isn’t infected. Sharing needles or other injection drug equipment can spread HCV. Sharing needles with a person who seems “healthy” doesn’t protect from infection, because most people who have HCV don’t look or feel sick and don’t know that they are infected. Each injection-drug user who is infected with HCV is likely to infect 20 other people in their lifetime.[2] Injection of opioids like heroin not only spreads HCV but also weakens the body’s natural defenses against infection and can worsen the infection.[3]

  • Symptoms of Hepatitis C

Many cases of HCV are asymptomatic. This means that the infected person doesn’t feel sick and doesn’t know that he or she is infected. People can live with HCV for decades without signs of infection. About a quarter of people infected with HCV will experience only an “acute” (short-term) illness, similar to a case of the flu, which occurs within the first 6 months after someone is exposed to HCV. Over time, about 75%–85% of people who are infected with HCV develop a “chronic” (long-term) infection that can last a lifetime and lead to serious liver disease.[4] Symptoms of liver disease include fever, tiredness, loss of appetite, nausea, vomiting, dark urine, grey stools, joint pain, and/ or jaundice (yellow color).

  • Current and past injection drug users are at risk for Hepatitis C infection, and should be tested and receive treatment if necessary.
  • To learn more about Hepatitis C testing and treatment, visit the CDC’s website: http://www.cdc.gov/knowmorehepatitis/
Opioid Abuse and HIV
  • Risk of HIV with Injection Drug Use

Heroin use involves a lot of risks. Dangerous “side effects” of heroin addiction often include involvement in criminal behavior, buying and selling illegal drugs, and risk of infectious disease through sharing drug supplies. One of the most dangerous “side effects” of injecting heroin is the increased risk of being exposed to HIV and other diseases. In 2010, about 10% of new cases of HIV in the US were among injecting drug users.[5] Sharing needles, syringes, or other injection equipment may expose drug users to the blood or body fluids of other users who may have HIV. Drug use can also lead to unprotected sexual contact, which can also transmit HIV infection. Using non-injection drugs often does not eliminate the risk of being infected with HIV/AIDS, because people under theinfluence of drugs still often engage in risky sexual and other behaviors that can lead to exposure to these diseases.[6]

  • Addiction Treatment Can Reduce the Risk of Contracting HIV

Use of MAT like buprenorphine or methadone has been shown to reduce the risk of contracting HIV through risky behavior related to illicit drug use. Participation in methadone or buprenorphine treatment programs can dramatically reduce a patient’s likelihood to share needles or and participate in risky sexual behavior related to illicit drug use.[7] The National Institute on Drug Abuse recommends that drug abuse treatment be combined with HIV prevention, education, and community outreach that addresses the risk factors for HIV that especially affect drug users, like sharing needles and unsafe sexual practices.[8]

Chronic Pain and Opioid Abuse

Chronic pain can be defined as pain that continues more than three months beyond the usual recovery period for an illness or injury, or as pain that may continue for months or years due to a long-term illness or condition. However, definitions vary: some define chronic pain as pain that last more than six months beyond a usual recovery period, and define pain that lasts only a few weeks more than expected as a “subacute” pain syndrome.[9] Chronic pain is usually not constant, but it can interfere with daily life at all levels. [10] For more information on chronic pain, resources can be found at the American Chronic Pain Association’s website, theacpa.org. Chronic pain affects a quarter of people seeking primary healthcare in the U.S.[11] Opioid pain medications are commonly used to treat chronic pain.

  • Opioid medications commonly use for chronic pain treatment include:
  • Codeine
  • Oxycodone (OxyContin, Oxyfast, Percocet, Roxicodone)
  • Fentanyl (Actiq, Duragesic, Fentora)
  • Hydrocodone (Lorcet, Lortab, Norco, VIcodin)
  • Morphine (Avinza, Kadian, MS Contin, Ora-Morph SR)
  • Hydromorphone (Dilaudid, Exalgo)
  • Meperidine (Demerol)
  • Methadone (Dolophine, Methadose)

Long-term use of these opioid medications has become a common treatment for chronic-pain. However, opioid painkillers’ strong effects in the brain sometimes lead to opioid misuse and abuse.

A “Perfect Storm”: Chronic Pain and Long-term Opioid Use

Chronic pain with long-term opioid use can lead to a “perfect storm” for the development of opioid use disorder and addiction. 

  • Chronic Pain causes changes in the brain.

Chronic, long-lasting pain is often associated with anxiety, depression, problems in learning and memory, and reduced quality of life.[12] For example, a part of the brain called the hippocampus decreases in size in chronic pain patients. These changes may be the underlying cause of learning and emotional problems that chronic pain patients often experience.[13] Though things like attention and general intelligence are unaffected by chronic pain, research has shown that long-term pain can impair a patient’s everyday behavior- especially in risky or emotional situations or decisions.[14] Patients with chronic pain also may have trouble with “prospective memory,” the process involved in remembering to do things at some future point in time. Examples include having difficulty remembering to keep an appointment, such as a visit to a clinic, or to pay a bill on time.[15]

  • Prescription opioids may also have adverse effects on cognitive functioning, a risk that is rarely evaluated in chronic pain patients.

Though chronic pain itself has been shown to impair some cognitive functions, long-term opioid therapy in addition to chronic pain has been shown to add further impairment. Chronic pain patients treated with long-term opioid therapy may have reduced spatial memory, less flexibility for change, and impaired working memory compared to chronic pain patients not treated with opioids.[16] 

  • Chronic pain can increase a person’s risk for opioid abuse.

Researchers have found that chronic pain can “prime” the brain for the effects of opioids. Both chronic pain and opioid drugs share a pathway in a part of the brain called the central amygdala, which regulates emotional responses to pain as well as the “reward” effects of opioid drugs. Research in mice found that persistent pain can increase the brain’s sensitivity to the “reward” effects of opioids like morphine. [17] Chronic pain patients may also develop other risk factors for opioid use disorder and addiction, like trouble with decision-making. [18] A significant percentage of chronic pain patients (3-19%) treated with long-term opioid therapy suffer from drug or alcohol dependency or addiction. [19]

How can individuals with chronic pain avoid opioid use disorder?

1) Can pain be managed without opioids? Other treatments for chronic pain: Opioids may be effective for short-term pain relief, but the evidence is mixed for long-term therapy with opioids for chronic pain.[20] The World Health Organization and American Pain Society recommend non-opioid pain medicines as first-line agents for the management of chronic pain. Many patients will experience pain relief with non-opioid pain medicines or alternative treatments, without the need for long-term opioid use. 2) Are risk factors for opioid abuse present, such as a history of opioid or substance addiction? If so, what are safer options for pain management? Transitioning to other pain medication.Patients on opioid pain treatment for a long period of time may eventually develop tolerance, or the need to take more medication to achieve the same pain-relieving effects. Over time, an opioid medication may no longer provide effective pain relief.

  • Buprenorphine: Long-term opioid users who want to transition away from strong opioid medications may choose to transition to sublingual buprenorphine. Buprenorphine is only a partial opioid agonist, and formulations often include naloxone, a built-in safety measure against abuse by injection. Opioid-tolerant patients who transition to use of buprenorphine/naloxone may experience significant reductions in pain.[21]

Buprenorphine/ Naloxone has great potential as a safe and effective pain-relieving medication in chronic pain patients who abuse opioids.Buprenorphine/ Naloxone can reduce pain and manage withdrawal symptoms in chronic pain patients with long-term opioid use, as well as make use/abuse of other opioids less likely in at-risk patients with a history of opioid abuse.[22] Doses of Buprenorphine/ naloxone are safer to use than other stronger opioids like methadone, but may need to be dosed more than once daily to relieve chronic pain in pain patients seeking treatment for opioid addiction.

  • Methadone treatment is often not the best choice chronic pain patients. Methadone treatment not only requires daily clinic visits, but also maintains a patient’s dependence on strong opioids. One danger of taking methadone for pain is that its pain-relieving effects wear off many hours before the blood levels drop, so people may take extra doses and end up at risk for accidental overdose. Methadone can provide long-lasting pain-relieving effects, but should not be used until other options have failed. Other opioids are safer to use in pain management than methadone.
  • Naltrexone: Chronic pain patients who wish to transition away from long-term opioid treatment may also choose to remain abstinent from opioids altogether. These patients may benefit from long-acting naltrexone doses to prevent relapse after detoxification. Although long-acting naltrexone treatment prevents all opioid medications from acting in the brain, patients can still use non-opioid pain medications during treatment.
Opioid Detoxification in Chronic Pain Patients

Chronic pain patients with opioid addiction may be especially reluctant to undergo detoxification from opioids, for fear that their pain will become unmanaged. However, many chronic pain patients may be able to receive effective pain management from non-opioid pain medications, both during and after the detoxification process. 

Chronic Pain with Other Psychiatric Disorders

Chronic pain often occurs along with other common psychiatric disorders, like depression and anxiety. Patients with mental health and substance abuse disorders are more likely to receive long-term opioid therapy for chronic pain. However, these patients are also more likely to have adverse outcomes from long-term opioid use. Opioid pain medications have temporary anti-anxiety and antidepressant effects, and are sometimes used by patients to “self-medicate” emotional and physical pain. These benefits rarely last for long, and instead may lead to dependence and addiction.[23] Psychiatric Care for Chronic Pain Patients: Opioids are commonly believed to be the ‘de facto’ and only treatment for patients with chronic pain. However, patients with chronic pain should also be screened for common psychiatric or mental health issues, and receive treatment if needed. The prescription opioid abuse epidemic is a symptom of a serious, unmet need for better recognition and treatment of common mental health problems in patients with chronic pain.[24] — [1]Hepatitis C FAQs for the Public. (n.d.). Centers for Disease Control and Prevention. Retrieved June 30, 2014, from http://www.cdc.gov/hepatitis/c/cfaq.htm#cFAQ23. [2]Magiorkinis, G., Sypsa, V., Magiorkinis, E., Paraskevis, D., Katsoulidou, A., Belshaw, R., Fraser, C.;,Pybus, O.G., & Hatzakis, A. (2013.) Integrating phylodynamics and epidemiology to estimate transmission diversity in viral epidemics. PLoS Comput Biol 9(1), e1002876. [3] Moore, K. & Dusheiko, G. (2005). “Opiate Abuse and Viral Replication in Hepatitis C.” Am J Pathol 167(5): 1189–1191. [4]Hepatitis C FAQs for the Public. (n.d.). Centers for Disease Control and Prevention. Retrieved June 30, 2014, from http://www.cdc.gov/hepatitis/c/cfaq.htm#cFAQ23 [5] Broz, D. et al. (2014). HIV Infection and Risk, Prevention, and Testing Behaviors Among Injecting Drug Users – National HIV Behavioral Surveillance System, 20 U.S. Cities, 2009. Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, Georgia. MMWR Surveill Summ. Jul 4;63 Suppl 6, 1-51. [6]Why does heroin use create special risk for contracting HIV/AIDS and hepatitis B and C? (2014). From: http://www.drugabuse.gov/publications/research-reports/heroin/why-are-heroin-users-special-risk-contracting-hivaids-hepatitis-b-c. [7] Saxon, A. J., Hser, Y. I., Woody, G., & Ling, W. (2013.) Medication-assisted treatment for opioid addiction: methadone and buprenorphine. J Food Drug Anal. Dec 21(4), S69-S72. [8]Why does heroin use create special risk for contracting HIV/AIDS and hepatitis B and C? (2014). From: http://www.drugabuse.gov/publications/research-reports/heroin/why-are-heroin-users-special-risk-contracting-hivaids-hepatitis-b-c. [9] Apkarian AV, Baliki MN, Geha PY. Towards a theory of chronic pain. Prog Neurobiol. 2009;87(2):81–97. [10]American Chronic Pain Association – FAQs. (2014, July 30). Retrieved August 19, 2014, from http://theacpa.org/faqlisting.aspx [11]Toblin  RL, Mack  KA, Perveen  G, Paulozzi  LJ.  (2011.) A population-based survey of chronic pain and its treatment with prescription drugs. Pain. 152(6), 1249-1255. [12]Apkarian AV, Sosa Y, Krauss BR, Thomas PS, Fredrickson BE, Levy RE, Harden RN, Chialvo DR. (2004). Chronic pain patients are impaired on an emotional decision-making task. Pain. Mar;108(1-2), 129-36. [13]Mutso AA, Radzicki D, Baliki MN, Huang L, Banisadr G, Centeno MV, Radulovic J, Martina M, Miller RJ, Apkarian AV. (2012.) Abnormalities in hippocampal functioning with persistent pain. J Neurosci. Apr 25;32(17), 5747-56. [14]Apkarian AV, Sosa Y, Krauss BR, Thomas PS, Fredrickson BE, Levy RE, Harden RN, Chialvo DR. (2004). Chronic pain patients are impaired on an emotional decision-making task. Pain. Mar;108(1-2), 129-36. [15]Ling J, Campbell C, Heffernan TM, Greenough CG. (2007.) Short-term prospective memory deficits in chronic back pain patients. Psychosom Med. Feb-Mar;69(2),144-8. [16]Schiltenwolf M, Akbar M, Hug A, Pfüller U, Gantz S, Neubauer E, Flor H, Wang H. (2014.) Evidence of specific cognitive deficits in patients with chronic low back pain under long-term substitution treatment of opioids. Pain Physician. Jan-Feb;17(1), 9-20. [17] Zhang, Z., Tao, W., Hou, Y. Y., Wang, W., Kenny, P. J., & Pan, Z. Z. (2014). MeCP2 Repression of G9a in Regulation of Pain and Morphine Reward. J Neurosci. Jul 2;34(27), 9076-87. [18]Apkarian, A.V., Sosa, Y., Krauss, B. R., Thomas, P.S., Fredrickson, B. E., Levy, R. E., Harden, R.N., & Chialvo, D. R. (2004). Chronic pain patients are impaired on an emotional decision-making task. Pain. Mar 108(1-2), 129-36. [19]Fishbain DA, Rosomoff HL, Rosomoff RS. (1992.) Drug abuse, dependence, and addiction in chronic pain patients. Clin J Pain. Jun;8(2), 77-85. [20]Trescot AM, Helm S, Hansen H, Benyamin R, Glaser SE, Adlaka R, Patel S, Manchikanti L. (2008.) Opioids in the management of chronic non-cancer pain: an update of American Society of the Interventional Pain Physicians’ (ASIPP) Guidelines. Pain Physician. Mar;11(2 Suppl), S5-S62. [21]Daitch J, Frey ME, Silver D, Mitnick C, Daitch D, Pergolizzi J. (2012.) Conversion of chronic pain patients from full-opioid agonists to sublingual buprenorphine. Pain Physician Jul 15(3). [22]Roux P, Sullivan MA, Cohen J, Fugon L, Jones JD, Vosburg SK, Cooper ZD, Manubay JM, Mogali S, Comer SD. (2013.) Buprenorphine/naloxone as a promising therapeutic option for opioid abusing patients with chronic pain: reduction of pain, opioid withdrawal symptoms, and abuse liability of oral oxycodone.Pain. Aug;154(8):1442-8. [23]Howe, C. Q., Sullivan, M. D. (2014.) The missing ‘P’ in pain management: how the current opioid epidemic highlights the need for psychiatric services in chronic pain care. Gen Hosp Psychiatry. Jan-Feb;36(1), 99-104. [24]Howe, C. Q., Sullivan, M. D. (2014.) The missing ‘P’ in pain management: how the current opioid epidemic highlights the need for psychiatric services in chronic pain care. Gen Hosp Psychiatry. Jan-Feb 36(1), 99-104.