Actor/comedian Dax Shepard has always been open about his past struggles with addiction and how he has been sober for the past 16 years. However, it was still surprising when, on the September 25th episode of his podcast Armchair Expert, Shepard revealed that he relapsed and has again been taking opioids.
About 6 months ago, Shepard broke his right hand, which required the temporary placement of a pin. Then in August, the avid motorcycle rider went over the handlebars of a bike during a race, breaking four ribs and shattering his shoulder. He again underwent surgery. Although he was prescribed hydrocodone/acetaminophen (Vicodin) for the pain, monitored by his wife, actress Kristen Bell, Dax began to “supplement” these pills with others that he purchased on his own.
As he told his podcast co-host, Monica Padman: “For the last 8 weeks maybe, I don’t really know … I’m on them all day … And I’m allowed to be on them at some dosage, because I have a prescription, and then I’m also augmenting that. And then all the prescriptions run out, and I’m now just taking 30 mil oxys that I’ve bought whenever I decide I can do [it].”
As he was still able to fulfill his daily responsibilities, including his twice-weekly podcast, he thought everything was under control. But then he started lying: “And I hate it, and I’m lying to other people. And I know I have to quit. But my tolerance is going up so quickly that I’m now in a situation where I’m taking, you know, eight 30s a day, and I know that’s an amount that’s going to result in a pretty bad withdrawal. And I start getting really scared, and I’m starting to feel really lonely. And I just have this enormous secret.”
Monica eventually called him out, and he came clean to her and Kristen. He immediately gave his pills to his wife and Monica to titrate down, began to go to AA meetings, and underwent withdrawal symptoms: “I’m sweating bullets; I’m jerky; my back kills. It’s terrible.”
Shepard went on to apologize to his friends, family, and his fans for deceiving them. He felt it was his responsibility to come forward and be honest about his struggles in the hope that others can also come forward and get the help they need.
Prescription opioids can be used to treat moderate-to-severe pain and are often prescribed following surgery or injury, or for health conditions such as cancer.
In recent years, there has been a dramatic increase in the acceptance and use of prescription opioids for the treatment of chronic, non-cancer pain, such as back pain or osteoarthritis, despite serious risks and the lack of evidence about their long-term effectiveness.
According to the CDC:
- More than 168 million opioid prescriptions were dispensed to American patients in 2018
- There is a wide variation of opioid prescription rates across states; healthcare providers in the highest prescribing state, Alabama, wrote almost three times as many of these prescriptions per person as those in the lowest prescribing state, Hawaii
- Studies suggest that regional variation in use of prescription opioids cannot be explained by the underlying health status of the population
- The most common drugs involved in prescription opioid overdose deaths include methadone, oxycodone (such as OxyContin), and hydrocodone
- The total “economic burden” of prescription opioid misuse alone in the U.S. is $78.5 billion a year, including the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement
The National Institute on Drug Abuse (NIDA) states that roughly 21-29% of patients prescribed opioids for chronic pain misuse them, and that 8-12% develop an opioid use disorder (OUD).
Anyone who takes prescription opioids can become addicted to them. In fact, as many as one in four patients receiving long-term opioid therapy in a primary care setting struggles with opioid addiction. Once addicted, it can be hard to stop.
Symptoms of Misuse/Abuse
In addition to the serious risks of addiction, abuse, and overdose, the use of prescription opioids can have several side effects, even when taken as directed:
- Tolerance — meaning you might need to take more of the medication for the same pain relief
- Physical dependence — meaning you have symptoms of withdrawal when the medication is stopped
- Increased sensitivity to pain
- Nausea, vomiting, and dry mouth
- Sleepiness and dizziness
- Low levels of testosterone that can result in lower sex drive, energy, and strength
- Itching and sweating
Opioid withdrawal symptoms can begin as early as a few hours after the drug was last taken. Although these symptoms can be extremely uncomfortable, they are usually not life threatening.
Early symptoms of withdrawal include:
- Muscle aches
- Increased tearing
- Runny nose
Late symptoms of withdrawal include:
- Abdominal cramping
- Dilated pupils
In May 2018, the FDA approved the non-opioid drug lofexidine (Lucemyra), an oral tablet, to manage the symptoms of opioid withdrawal. Methadone and buprenorphine are also approved for this purpose.
Treatment of OUD
OUD is a chronic, relapsing, remitting condition for which there is, currently, no cure. It causes significant, persistent changes in the brain’s chemistry and function. As a chronic illness, it needs to be treated like other chronic illnesses — i.e., with long-term treatment and follow-up.
Effective prevention and treatment strategies exist for opioid misuse and use disorder but are highly underutilized across the U.S. Fewer than half of private-sector treatment programs offer medications for OUDs, and of patients in those programs who might benefit, only a third actually receive it.
Overcoming the misunderstandings and other barriers that prevent wider adoption of these treatments is crucial for tackling the problem of OUD and the epidemic of opioid overdose in the U.S.
The treatment of OUD requires the intervention of a team of providers that include behavioral, psychiatric, socioeconomic, and individual/group support services, as well as medical care.
Medications combined with behavioral counseling for a “whole patient” approach is known as medication-assisted treatment (MAT). Research shows that MAT decreases opioid use, opioid-related overdose deaths, criminal activity, and infectious disease transmission, and also increases social functioning and retention in treatment.
There are three medications used as maintenance treatments for OUD: methadone, buprenorphine, and naltrexone (Vivitrol, Revia).
Methadone is a synthetic opioid agonist that eliminates withdrawal symptoms and relieves drug cravings by acting on opioid receptors in the brain. Methadone occupies and activates opioid receptors more slowly than other opioids, and treatment doses do not produce euphoria. Methadone has been used successfully for more than 40 years to treat OUD and must be dispensed through specialized opioid treatment programs.
Buprenorphine is a partial opioid agonist — meaning that it binds to the same opioid receptors but activates them less strongly than full agonists do. Like methadone, buprenorphine can reduce cravings and withdrawal symptoms in a person with an OUD without producing euphoria, and patients tend to tolerate it well.
Research has found buprenorphine to be similarly effective as methadone for treating OUDs, as long as it is given at a sufficient dose and for sufficient duration.
The FDA approved buprenorphine in 2002, making it the first medication eligible to be prescribed by certified physicians through the Drug Addiction Treatment Act. This eliminates the need to visit specialized treatment clinics and expands access to treatment for many who need it.
Buprenorphine is available as a tablet, a sublingual film, a 6-month subdermal buprenorphine implant, and a once-monthly injection. These formulations are available to patients stabilized on buprenorphine and eliminates the treatment barrier of daily dosing for these patients.
Naltrexone is an opioid antagonist, which means that it works by blocking the activation of opioid receptors. Instead of controlling withdrawal and cravings, the drug treats OUD by preventing any opioid drug from producing rewarding effects such as euphoria.
The use for ongoing OUD treatment has been somewhat limited because of poor adherence and tolerability. However, in 2010, an injectable, long-acting form of naltrexone, originally approved for treating alcohol use disorder, was FDA approved for treating OUD. Because the effects last for weeks, the long-acting form of naltrexone is a good option for patients who do not have ready access to healthcare or who struggle with taking their medications regularly.
In 2018, National Institutes of Health Director Francis Collins, MD, announced the launch of the HEAL (Helping to End Addiction Long-term) initiative, an agency effort to speed scientific solutions to stem the national opioid public health crisis. The goals include:
- Translation of research to practice for the treatment of opioid addiction
- New strategies to prevent and treat opioid addiction
- Enhanced outcomes for infants and children exposed to opioids
- Novel medication options for OUD and overdose
- Clinical research in pain management
- Preclinical and translational research in pain management
Michele R. Berman, MD, and Mark S. Boguski, MD, PhD, are a wife and husband team of physicians who have trained and taught at some of the top medical schools in the country, including Harvard, Johns Hopkins, and Washington University in St. Louis. Their mission is both a journalistic and educational one: to report on common diseases affecting uncommon people and summarize the evidence-based medicine behind the headlines.