Opioid Use Disorder

Dr. Reid Finlayson, Medical Director of the Vanderbilt Faculty and Physician Wellness Program and Associate Professor in the Department of Psychiatry, discusses risk factors, signs and symptoms, and treatment approaches for opioid use disorder.

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Shaina Farfel:  Welcome to this edition of the Vanderbilt Health and Wellness wellcast.  I'm Shaina Farfel with Occupational Health.  Today, we are speaking with Dr. Reid Finlayson, Medical Director of the Vanderbilt Faculty and Physician Wellness Program, Associate Professor in the Department of Psychiatry, and Medical Director of the Vanderbilt Comprehensive Assessment Program for Professionals.  Welcome, Dr. Finlayson.  Thanks so much for being with us today.

Dr. Reid Finlayson:  Glad to.

Shaina Farfel:  So, as most of our listeners are aware, the U.S. is in the midst of an opioid overdose epidemic, making it all the more important to have ongoing conversations about the scope of this problem and how we can increase awareness and access to treatment for those who need it.  Can you start off by defining opioid use disorder for us and how this may differ, or not, from physical dependence to opioids?

Dr. Reid Finlayson:  An opioid use disorder is defined as a problematic pattern of opioid use that leads to serious impairment or distress.  Doctors use specific sets of behavioral criteria to determine whether a person has a substance use disorder.  Other terms that can be used include misuse.  Misuse means using a medicine other than for its directed or indicated use.  Abuse is the use of an illegal drug or intentionally using a medication for a nonmedical purpose, such as getting high.  Addiction is a primary chronic disease that involves the brain systems for reward, for motivation, for memory, and some related circuitry that leads to potential for relapse and progressive intensification of the symptoms.  Tolerance is an adaptive state in which exposure to the drug results in a diminution or lessening of its effects over time or the same dose isn't as effective as it used to be.  Physical dependence engenders abstinence syndrome.  In other words, when the drug is stopped, a characteristic pattern of physical and mental symptoms occurs, especially if it is stopped abruptly.   The withdrawal symptoms are just the opposite of the initial effects and include pain, anxiety, diarrhea, and very intense craving for the drug, and they last until the brain recovers.  The recovery time can vary from a few days to many weeks, depending on the amount of opioid and the length of time the brain is exposed to it.

Shaina Farfel:  How common is an opioid use disorder?

Dr. Reid Finlayson:  Well, the latest figures from 2017 suggest that 11.1 million Americans misused opioids in that year and 10.5 million used only pain pills, whereas 886,000 people used heroin, and of those who used heroin, 324,000 used only heroin, and some, of course, misused both pain pills and heroin.  .  The main reasons that were given by people who were abusing the drugs were roughly 63% were using them for relief of pain, 13% were using them to feel good or get high, 8% were using them for tension relief, 5% were using them for sleep, and there were a number of other smaller categories.

Shaina Farfel:  So, this is a nationwide issue.  It is affecting a lot of people.  When we look closer, are there  risk factors that put certain people at increased risk for developing an opioid use disorder?

Dr. Reid Finlayson:  Yes, people who have a history of substance abuse and even more so, if it is combined with mental illness, or people with a variety of mental illnesses, seem to be more susceptible to opioid use disorder.  It also leads to a family history of substance use disorder being a risk factor.  Young people seem to be more prone to developing dependence and use disorder and we know that people who have adverse childhood experiences that are devastating as young people tend to have a higher frequency of opioid use disorder.  

Shaina Farfel:  And for an individual who is using or a family member of someone who is using, what might be the signs and symptoms that they would look out for of an opioid use disorder?

Dr. Reid Finlayson:  The Diagnostic and Statistical Manual, the 5th Edition, lists 11 specific symptoms, and I like to group them into four sets of symptoms, the first being impaired control.  In other words, the person winds up taking more opiates than they intend to use, and that can be a higher dose or for a longer period of time than they originally intended.  The second indication of impaired control is trying to stop and being unable to. .  And then, the third thing is sacrificing normal daily activities - family, work, school, hobbies, playtime, etc. to obtain and use drugs..  And the fourth one in that category is craving or intense desire to use opioids.  The second category amplifies my comment earlier about social impairment.  People who abuse opioids can run into failure to fulfill major role obligations at work, at school, or at home..  They can have persistent and recurrent social and interpersonal problems that are made worse by the opioids. .  And then, the last thing in the social impairment category, is giving up important obligations of a social nature, work, or recreational activities because they are using opioids.  The next group of symptoms involve risky use and that means using opioids in physically hazardous situations. The last category helps us to distinguish between a use disorder and a simple dependency. Tolerance is a diagnostic criteria, but if it is developed using prescribed opioids for a specific purpose, that doesn't really count.  Tolerance, again, means using more opioids to get the same effect or having a diminished effect from using the same amount.  And then the other pharmacological property is withdrawal and that is specifically symptoms that are generated when opioids are absent or reduced in the brain or if people are taking opioids in order just to relieve or avoid having symptoms of withdrawal, that would be considered a criteria for diagnosis.

Shaina Farfel:  Now that we know a bit about risk factors and signs and symptoms, let's talk about treatment.  What are the different kinds of treatment that may be available for folks suffering from an opioid use disorder?

Dr. Reid Finlayson:  The ideal of treatment would to be able to stop and abstain from using them.  We are finding that with many of the very potent drugs that are available now, that some people just are unable to do that, and fortunately, some very effective medications have been established and are shown to be effective to treat opioid use disorder and help patients get into recovery.  The oldest one of these is methadone and methadone is an opioid which is dosed daily in specialty clinics but has a remarkable ability to stabilize the lives of opioid-dependent people, particularly people who are injecting heroin.  Buprenorphine has been around since 2000 and I think it is a significant advance in methadone in the sense that it is not so dangerous to use and it can be prescribed when a person is stable, say, for a month at a time, and they can take the medication and remain free of cravings. There is, unfortunately, a lot of misinformation and bias that stigmatizes medically-assisted treatment.  I prefer to call it medically-assisted recovery, but many people feel like it is just trading one drug for the other, but administered properly, methadone and buprenorphine are very, very helpful in saving lives and allowing people to live normal lives, and I think as people can come to see that and see the terrific results that we get with them, that the stigmatization will diminish.  Naltrexone is another drug, which displaces opioids off the mu opioid receptors in the brain, and precipitates withdrawal.  So, it is not a drug that we can use acutely, but when somebody is detoxed from opioids, it can be administered either by mouth or preferably by monthly injection, and it does a terrific job of reducing the cravings associated with opioid use.  Naloxone is well known and becoming generally available to help reverse the respiratory depression and coma and death, which all too often, accompanies overdoses to opioid drugs.  And I should mention, too, the presence of synthetic opioids like fentanyl, carfentanil, and many others on the horizon, are combined with heroin on the streets and it is a really dangerous situation for people who are dependent.  I think it is a disease, I think it is an illness, and I think we have good treatment for it.  We just need to educate the people that need the help and also their families and their communities that it is possible to help them.

Shaina Farfel:  And that leads straight into my next question.  So, if there is an individual who does want to seek help for themselves or a loved one, what are the resources out in the community or here at Vanderbilt that may be available to them?

Dr. Reid Finlayson:   I would, first of all, recommend the Tennessee REDLINE.  It is a toll-free telephone information and referral line that is funded by the Tennessee Department of Health Substance Abuse Services.  The purpose of REDLINE is to provide accurate, up-to-date information on addiction and referral and coordination of treatment for Tennessee citizens, and REDLINE can provide referrals for co-occurring addiction and mental health disorders.  I think, in an acute situation, that is the first thing I would suggest that people do.  In an emergency situation where somebody has overdosed, take them to the nearest hospital or administer naloxone.

Shaina Farfel:  Thank you so much for your time today.  I think this information will be invaluable to our listeners and hopefully help to spread awareness for this ongoing nationwide problem.  We appreciate your time.  Thank you.

Dr. Reid Finlayson:  Thank you, Shaina.

Shaina Farfel:  Thanks for listening.  If you have a story suggestion, please email it to us at health.wellness@vumc.org or you can use the "Contact Us" page on our website at www.vumc.org/health-wellness.