Janet Robishaw, PhD, Senior Associate Dean for Research and Professor and Chair of Biomedical Sciences at the Charles E. Schmidt College of Medicine, Florida Atlantic University, talks about the opioid epidemic and how genetics may play a role.
Interview conducted by Ivanhoe Broadcast News in September 2018.
Is the opioid epidemic as bad as we’re being told and how is it “shifting”?
Dr. Robishaw: The simple answer is it is as bad as we’re being told. What’s surprising is that a recent survey just came out last month where they actually polled the American public and asked if they viewed it as being a very serious health crisis. The surprising answer was no. They don’t seem to feel that it’s as serious as other medical disorders. They view it as kind of a second tier problem. And nothing could be further from the truth. We have somewhere around two million patients that are probably suffering from opioid use disorder which is usually called addiction, but we try to steer away from that. So, we have about two million Americans that are suffering from the opioid epidemic. It’s costing the U.S. economy almost eighty billion dollars a year. We have a huge outbreak of overdosed deaths either from prescription opioids or from heroin.
When we think of someone addicted to opioids or having the opioid use disorder, a lot of us think of either younger people, maybe lower economic, or people on the street. This is really not the case anymore, is it?
Dr. Robishaw: Correct. Even two decades ago the average person that died of a heroin overdose was a young male person, usually non-Caucasian, living in an urban city with poor educational status. Today, the average person dying of either a prescription opioid or heroin overdose is actually a middle-aged male or female, most likely Caucasian, of higher professional status and education.
Are you still seeing people being prescribed opioids for legitimate medical reasons becoming addicted and then eventually going to heroin?
Dr. Robishaw: We got into this problem over the last twenty years from a chronic pain management standpoint. As our population ages more and more, they suffer from chronic pain. Physicians decided that we really needed to start treating pain as a fifth vital sign. You may have noticed when you go to the doctor’s office they always ask, what is your pain level today? That came out of the fact that we know that chronic pain has a very negative impact on patients. We know that it affects their quality of life and it affects other co-morbidities that come along with it such as depression and anxiety. So, doctors were trying to do the right thing. They were trying to develop a way of treating patients who had suffered from chronic pain so all the right intentions were there. The problem was that there were a few papers that came out in the year 2000 that really were over-interpreted. Those papers were basically done on hospitalized patients in acute pain and what the conclusion was that those patients didn’t seem to show a high risk of developing addiction. That led to the supposition that opioids were not highly addictive. From there things went downhill because doctors started prescribing opioids to more and more patients that were suffering from chronic pain. And, as we now know, opioids are highly addictive to a portion of the population. So, now over twenty years what has happened is that these patients who went in to get help for their chronic pain and were prescribed opioids, through no fault of their own have developed an even more devastating condition which is opioid use disorder or addiction. That is a chronic relapsing disease that they’re going to have for the rest of their life.
So are there people who can take opioids legally for a specific medical purpose, like chronic pain, and not get addicted? Are there people who have a predisposition to addiction or abuse?
Dr. Robishaw: Absolutely. Our study is a study of about twenty five thousand chronic pain patients that are served by the Geisinger Health System in Pennsylvania. When we look at these patients, they have been prescribed opioids for longer than two months. In all cases, it’s for muscular skeletal pain, or most predominately some kind of back pain. When we look at these patients, we can tell that about eighty percent seem to be able to take opioids long term, meaning they don’t keep escalating their dose. They don’t show signs that they’ve developed addiction. For those patients, they get relief from the opioids and they’re able to function better. However, about twenty percent of the patients clearly showed signs that they’re developing addiction or opioid use disorder. One of those signs is that you will see they are doctor shopping. They’ll come in to the emergency room in the middle of the night saying they’ve lost their prescription and they need a refill. So, they’re showing clear signs that they are developing opioid use disorder which is really a craving of those drugs. That means about twenty percent of the population seems to have either a clinical or genetic risk of developing opioid use disorder. What we’re really trying to do with this NIH funded study is to be able to develop a predictive tool that looks at both clinical and genetic factors and say, okay if we could identify the twenty percent of patients ahead of time that are at high risk of developing addiction, we will not prescribe those patients opioids. We will do more interventional procedures to treat their pain and caution them that putting them on opioids is a very big risk. That also means that for the other eighty percent of patients that can take these opioids, if prescribed in an appropriate fashion, will still continue to get relief from their chronic pain.
From the standpoint of your research, this is not the medication that’s causing the problem? The medication is being given for what it’s supposed to do which is relieving or helping with chronic pain?
Dr. Robishaw: Not exactly. The medication is affecting the same receptor. A receptor is something that controls the function of your cells. The problem is this receptor is found both in the pain relieving regions of your brain, as well as in the pleasure seeking regions of your brain. So the drug is affecting both pathways. What it seems is that in about eighty percent of the population, the stimulation of the pleasure seeking part is not as great. So those patients don’t go on to develop opioid use disorder.
When you were in the lab, what were you looking at specifically?
Dr. Robishaw: With this research study, we’re really trying to address two types of questions. One is to look at your genetic profile and figure out if you have a genetic variation that’s going to affect your treatment response. The analogy I like to use is, if you sprain your ankle or you go out and play golf and you have that sudden pain in your back, the first thing you do is go to your shelf and you look for the over the counter pain reliever like Motrin, Aleve, Tylenol, Aspirin, and through trial and error you’ve discovered which one of those pain relievers works best for you. You’ll tend to take the same pain reliever whenever you have a transient pain. The reason you do that is you found through trial and error which one of those works best for you. The reason one will work better for you than another is because you have a certain genetic profile that determines how well that medication works. In about ten percent of the patients who have acute pain they will go on to transition and develop chronic pain. And if that chronic pain becomes moderate to severe you may go to the doctor and say, I need something stronger than my over the counter pain reliever and they may prescribe opioids. What we do first is we know that a lot of the opioids that you take have to be metabolized by your body. We know that there is a liver enzyme that can convert the opioid that you’re taking in to a more powerful pain killer. When it does, that’s a good thing because it’s giving you more analgesic relief. But, we know about ten percent of the population has a genetic variant in that enzyme. If you have that variant, then you can’t convert the opioid you’re taking to the more powerful pain killer. So compared to another person you’re not going to get the same pain relief. Therefore, you go to your doctor and keep saying I’m taking the drug but it’s not helping me. I’m not feeling enough pain relief. And if you do that often enough, your doctor is probably going to say that this person must be addicted and they’re just trying to get more drugs. The reality is if they did a genetic test, which is commercially available, they would know that patient has a real problem. They can’t metabolize that drug properly and they really need a much higher dose or they need a different class of opioid which are available. In our population, we have found those patients and can look at their clinical record and see this whole story play out. We can see them going back to the doctor time and time again and saying I’m not getting pain relief. Then, if they are returned with that information and you switch them to another opioid, you’ve solved that problem. That’s one kind of patient that we’re targeting. The other kind of patient we’re targeting is the patient that’s been on opioids for chronic pain for several months, but they’ve gone on to develop signs of opioid use disorder. Doctors are now very carefully screening these patients. They’re recognizing when they develop those signs they will refer these patients to an addiction specialist who will decide how to better treat both the opioid use disorder as well as their pain.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Gisele Galoustian, PR Florida Atlantic University
561-297-2676
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