Picking Painkillers: Treating What Hurts Without Triggering an Addiction

Here's one way you, or a member of your family with access to your medicine cabinet, could get high on the narcotic you were prescribed to treat pain: "You take your medication, you extract the active opioid, and you inject it," explains Dr. Nora Volkow, director of the National Institute on Drug Abuse. "Injecting opioids results in a much faster delivery into the brain, and that very fast delivery increases and enhances the rewarding effects."

Volkow wasn't recommending recreational drug use. Rather, she was describing exactly what certain prescription opioids with so-called "abuse-deterrent" properties are designed to prevent.

"You see different strategies -- these deterrent formulations, for example, rely on embedding the opioid in a formulation where you cannot extract it," she says. "So even if you crush it, you cannot extract it, and so you cannot inject it." Or snort it.

The reformulated OxyContin made by Purdue Pharma -- a drug once notorious for being an abused painkiller of choice -- was the first to earn abuse-deterrent labeling from the Food and Drug Administration in 2013. Still, while opioids are highly addictive, the majority of those prescribed don't come in abuse-deterrent formulations, for one simple reason: economics.

Though debate continues on Oxycontin's ability to deter abuse, drugs designed to do so provide a potential safeguard in the swelling storm of opioid abuse. But these specially made formulations typically cost far more than their more simply designed generic counterparts. As a result, health insurance plans, including Medicare Part D plans, tend to favor generics, which don't have abuse-deterrent formulations, as preferred medications in the lists of drugs they cover.

A study released in June by District of Columbia-based Avalere Health, a strategic advisory company that provides health care solutions, found Medicare Part D plan coverage for the now abuse-deterrent drug OxyContin decreased by 28 percentage points, from 61 percent to 33 percent, from 2012 to 2015.

By comparison, the generic Oxycodone Hydrochloride, which has no built-in mechanism to deter abuse, was covered by all Part D plans in 2015. Overall, the Part D coverage for all prescription opioids dropped 10 percentage points.

"The FDA had created new approval pathways in which products that are less likely to be abused can receive a special designation, but we're not really seeing health insurers adopt coverage for those products at a significant rate," says Caroline Pearson, senior vice president at Avalere and study co-author. "We're not really seeing an uptick in coverage of those products -- in fact, we're seeing decline."

The research, which was funded by the pharmaceutical firm Pfizer, did not look at three other drugs which received that abuse-deterrent labeling from the FDA in 2014, outside the study window.

Experts say higher drug prices and lower resulting drug coverage rates mean patients are less likely to be able to access -- and providers less likely to prescribe -- opioids specially made to deter abuse.

Pearson notes that the drugs are intended to stem intentional attempts at abuse, rather than keep patients from becoming addicted to painkillers in the first place. She adds that more real-world research is needed to determine how formulations translate into results, in terms of deterring actual abuse of the drug.

But some patients who aren't at high risk for abuse may still have cause to choose abuse-deterrent formulations, like concern that the drugs could fall into another person's hands.

"Mom or Dad is being treated with opioids, they're in the house and you've got a child ... [who] gets into it for the intention of potentially pursuing it for its high properties, for instance," Pearson says. "That is certainly a risk and a real scenario that we see take place."

Clare Krusing, a spokeswoman for the trade association America's Health Insurance Plans, says many plans do cover specially made painkillers that deter abuse, and if they don't, insurers would most likely have a process in place for patients to appeal.

"So it would be incorrect to say plans aren't covering these medications. But it does go back, in large part, to the drugmakers, who have a responsibility to look at what their pricing means for access as well." While a generic painkiller without safeguards against abuse can run less than $10 for a month's supply, brand name OxyContin, with its abuse-deterrent formulation, can cost more than $150 per month, depending on factors such as dosing, pharmacy and available discounts.

The hurdles to patients receiving abuse-deterrent formulations of painkillers serve as another stumbling block to taking on the prescription drug epidemic, blamed for an average of 44 overdose deaths daily, according to the Centers for Disease Control and Prevention. Another factor: stigma associated with addiction and drug abuse.

Despite this, Volkow says patients should not hesitate to have frank conversations with all their health providers -- doctors and dentists -- before filling a prescription for an opioid.

This should include full transparency about any and all other medications they're taking, including benzodiazepines for mental health conditions, as well as if they will be drinking alcohol. Both can depress breathing, and that increases risk of overdose. And however awkward or embarrassing it may be, experts emphasize that patients should disclose to their providers any history of substance abuse, whether involving prescription drugs or substances.

Doctors are required to keep such matters confidential, and Volkow notes that a patient's failure to disclose this information can undermine a physician's ability to safely prescribe powerful pain medication. She insists on the importance of full disclosure in addition to resisting the urge to take past opioid prescriptions to treat pain as it flares up, outside of recommended treatment protocols, since self-medication can increase the risk of becoming addicted to prescription drugs.

Experts also emphasize the importance of seeking counseling or other treatment for opioid addiction, as with any mental or physical health condition, rather than trying to resolve it on one's own.

Over time, patients develop a tolerance to opioids that requires taking more medication for the same level of relief. "The higher the dose, the greater the likelihood you can have adverse effects. And what are the adverse effects? One of them relates, of course, to addiction, and the other one relates to overdoses," Volkow says.

So what are some telltale signs a patient might be becoming addicted to a prescription opioid?

"If they start to feel that they are too preoccupied with the anticipation of getting this medication, they should actually discuss it with their physician," Volkow says. She compares it to looking forward to a nice dinner. "You know that you're going to have something that you like very much, and you start to think about it in an obsessive-compulsive way."

Patients may not recognize this, thinking only that they're looking forward to pain relief, so it's important to be on guard to untangle the nuances, in discussing concerns with a physician, she explains. Conversely, putting off taking needed medication because of its powerful effect may, counterintuitively, also signify an issue.

"[Some patients] may have pain and they say, 'I'm not going to take it, I'm going to last as long as I can to minimize the use.' But what they are doing by allowing the pain to be very, very intense is that they increase the value of the medication because they are anticipating the relief from this very intense pain," Volkow says. "So both of these behaviors can be early indications that the patient may be starting to be addicted to their medication."

In most cases, evidence does not support long-term use of prescription opioids. As a result, experts say it's important to discuss how long you'll be taking the medications, as well as talking about less powerful painkillers and alternative non-pharmaceutical ways to deal with pain, from exercise to biofeedback.

"People need to understand that these drugs are potentially addictive, even after short-term use in some people," says Dr. Andrew Gurman, an orthopedic hand surgeon in Altoona, Pennsylvania, and president-elect of the American Medical Association. He prescribes opioids to help patients deal with pain when they recover from surgery.

"When you look at the number of people who are dying of drug overdoses, primarily opioids, the number of people who are impaired by addiction -- these are the same kinds of numbers we were seeing at the height of the AIDS epidemic," he says. "It's frightening."

The AMA announced last week the creation of a task force to reduce opioid abuse comprised of 27 physician organizations, including the AMA, American Dental Association, American Psychiatric Association and seven state medical societies, with an aim to identify best practices to address the epidemic. The task force is the latest to join an all-hands-on-deck effort, which involves federal, state and local health agencies that are all scrambling to find solutions for the complex public health crisis.

Gurman does not serve on the AMA-led opioid abuse task force but is the AMA representative on the National Association of Boards of Pharmacy Stakeholders Group on Opioid Prescribing and Dispensing.

In addition to doctors looking at their prescribing habits and considering red flags, like patients seeking to obtain prescriptions for opioids from numerous doctors, health experts say it's important to discuss all options to deal with pain. Heat, ice and even holding one's hand above his or her heart, in the case of surgical patients at Gurman's practice, as well as dealing with the mental components of pain, can all help relieve discomfort.

That can ultimately reduce the need for prescription opioids. "Both patients and physicians need to think about and perhaps talk about alternatives to manage the pain," Gurman says.

Michael Schroeder is a health editor at U.S. News. You can follow him on Twitter or email him at mschroeder@usnews.com.