PROTECTING NATUROPATHIC PHYSICIANS

Opioid Misuse and Addiction: How Naturopathic Can Help

News stories about the opioid crisis abound. Here is a case study about opioid misuse and addiction, as well as guidance for naturopaths as they strive to combat the crisis.

By Kristina L. Petrocco-Napuli, DC, MS, FICC, with naturopathic perspective added by Fraser Smith, ND

Thirty-five-year-old Megan presented with chronic neck and upper back pain. Megan's pain began four years earlier, following a car accident where she injured her cervical spine and upper thoracic spine.

The pain became a daily part of Megan’s routine. When she became pregnant with her first child, she was taking opioid pain medication daily, but she was able to stop during the first trimester.

After her first pregnancy, Megan continued to have pain and began to take opioids again. Pregnant with her second child, Megan struggled to stop the medication. Seeking help, she found support from her husband, family and friends. However, the pain continued to rule her life, making stopping difficult.

Naturopathic care—or any other complementary therapy—was never provided as an option to Megan for her chronic neck and back pain.

Chronic Pain Is a Widespread Problem

Megan’s story is not an unfamiliar one. Stories about the opioid addiction are frequently in the news. It is a major problem throughout the U.S., and it does not discriminate. We live in a society that is in pain.

According to the American Academy of Pain Management, 100 million Americans suffer from chronic pain.1 In addition to the reports of chronic pain, opioid medications have been overprescribed. Intended for pain associated with cancer and the end stages of life, opioids are less effective to treat noncancerous, chronic pain.2,3

The opioid crisis is not new. Its usage in the U.S. can be traced back to the late 1800s when morphine and heroin became readily available. During that time, the most commonly addicted were white females. In the early 1900s, opioids, such as heroin, were used as cough suppressants, and not much was known about the drug’s long-term effects.

As usage became widespread, it became apparent that opioids were addictive. In 1914, the Harrison Narcotics Act was initiated, and a tax was imposed on anyone making, selling or importing any type of opium. In 1924, heroin became illegal.4

In the 1980s, published articles attested to the safety of long-term morphine usage. An escalation of usage began, resulting in a significant impact on the country.

As a Practitioner, Are You Opioid Aware?

A wide variety of opioids can be prescribed within the following categories:

  • Natural opioids like morphine, which is derived from the poppy plant
  • Semi-synthetic like hydrocodone and heroin
  • Fully synthetic like tramadol or fentanyl

When opioid prescriptions are no longer accessible, many individuals begin using heroin, due to its low cost and availability.5

Prescription rates vary across the country. The highest overdose rates are found in West Virginia, New Mexico, New Hampshire, Kentucky and Ohio.6 Women are twice as likely to use prescription opioids as their male counterparts, and they tend to be between the ages of 25-54. A correlation between deaths due to opioid misuse and benzodiazepines has been found.Many patients are simultaneously prescribed both drugs.

One study found that women have been prescribed opioids for low back and pelvic pain during pregnancy even though the long-term effects were well known.The prevalence of low back pain and pelvic pain is common and ranges between 68 and 72 percent of pregnant women.9,10 For chronic pain in pregnancy, the American Pain Society guidelines11 suggested that women be counseled regarding the risks and benefits of opioid therapy, with the recommendation that there should be little to no use during pregnancy.

The American College of Obstetricians and Gynecologists makes numerous recommendations to minimize opioid use and highlight non-pharmacological options for chronic pain.12 For those who are addicted, abrupt discontinuation of opioids during pregnancy can lead to preterm labor, fetal demise or fetal distress. Opioid agonist therapy with methadone or buprenorphine is the standard recommendation.

Infants exposed to opioid use may develop neonatal abstinence syndrome (NAS), which was first described in the clinical literature in the 1970s. In 2012 alone, 21,000 infants were diagnosed, a five-fold increase from the previous 12 years.

There is a high correlation between opioid exposure and death from birth to five years of age.13,14 Opioid exposure tends to be accidental, such as a child accidentally ingesting a pill, being stuck by a heroin needle or having skin contact with Fentanyl. Since infants and small children have a low body mass, even a small amount of exposure can have long-term and damaging effects.

Exposure tends to decline before it starts to elevate beginning at age 12 and increasing until ages 17-18, where it plateaus. Opioid use in adolescents is much different than in the younger counterparts, as it tends to result from leftover prescriptions found in medicine cabinets.13,14

The Role of Naturopathic Medicine

Naturopathic Physicians  have a very important role to play in assisting with the chronic pain crisis, as well as with addressing the public health concerns associated with opioid misuse, including:

  • Public awareness: Build knowledge on how naturopathic medicine can help with chronic pain as an alternative to medications.
  • Education: Inform other practitioners about non-opioid treatment options for patients. This will become increasingly important, given the recent focus on non-pharmacological care.
  • Reduce misuse: Help patients locate drug drop boxes for opioid disposal, drug take-back programs, medication lock boxes and testing programs.
  • Prescribe with the utmost care: In jurisdictions where NDs have a DEA number, prescribe opioids conservatively and only after providing patients with the best education.
  • Screen patients: In a practice, identify patients at risk and help them find treatment options if they do have opioid addiction. 
  • Teach patients a new outlook: Patients, as well as physicians, have been sold a bill of goods that opioids are non-addictive or that all pain has to be aggressively managed. Of course, pain has to be treated, and sometimes opioids are appropriate. However, there are many situations, such as osteoarthritis in the elderly or sports injuries in teenaged athletes, which do not require opioid treatment.

In the case mentioned previously, perhaps naturopathic care could have helped Megan avoid using opioids had it been offered as option for her chronic neck and back pain.


ND Insights is published for NCMIC policyholders. Articles may not be reprinted, in part or in whole, without the prior, express consent of NCMIC. Information provided in ND Insights is offered solely for general information and educational purposes. Names and events are created for illustrative purposes only. It is not offered as, nor does it constitute, legal advice or opinion. You should not act or rely upon this information without seeking the advice of an attorney.

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Kristina Petrocco-Napuli, DC, MS, FICC, began a postdoctoral fellowship in technique at New York Chiropractic College. She also achieved a master's degree in Instructional Design, Development and Evaluation from Syracuse University. She is an adjunct faculty member at NYCC and Logan University. For the past two decades, Dr. Petrocco-Napuli has been actively involved in research related to female pelvic pain and has centered her practice and authored clinical and educational articles on this topic.

Fraser Smith, MATD, ND, is a naturopathic physician, professor, and assistant dean of naturopathic medicine at National University of Health Sciences in Lombard, Illinois. His interests are botanical medicine and cardiovascular health. He holds his ND license in Vermont. Dr. Smith is currently president of the Association of Accredited Naturopathic Medical Colleges.

References

1 Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education: Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research. The National Academies Press, 2011.

Trescot AM, Glaser SE, Hansen H, Benyamin R, Patel S, Manchikanti L. Effectiveness of Opioids in the Treatment of Non-Cancer Pain. Pain Physician. 2008; 11. 181-200.

Chou R, Deyo R. Devine B. The Effectiveness and Risks of Long Term Opioid Treatment in Chronic Pain. Agency for Healthcare Research and Quality. September 2014

Kolodny A, Courtwright D, Hwang C, Kreiner P, Eadie J, Clark T, Alexander G. The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction. Annual Review of Public Health. Vol 36 (2015) pp559-574

Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers – United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. 2013;132(1-2):95-100.

CDC https://www.cdc.gov/vitalsigns/opioid-prescribing/

American Society of Addiction Medicine. Opioid Addiction Fast Facts(2016)https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf

Maeda A, Bateman BT, Clancy CR, Creanga AA, Leffert LR. Opioid Abuse and Dependance During Pregnancy: Temporal Trends and Obstetrical Outcomes. Anesthesiology 2014. Dec;121 (6):1158-65

Wang SM, Dezinno P, Maranets I, Berman MR, Caldwell-Andrews AA, Kain ZN. Low back pain during pregnancy: prevalence, risk factors, and outcomes. Obstet Gynecol 2004;104(1):65–70

10 Mogren IM, Pohjanen AI. Low back pain and pelvic pain during pregnancy: prevalence and risk factors. Spine 2005;30(8):983–991

11 American Pain Society Guidelines:Guideline for the Use of Chronic Opioid Therapy in Noncancer Pain: Evidence Review: http://americanpainsociety.org/uploads/education/guidelines/chronic-opioid-therapy-cncp.pdf

12 Committee on Obstetric Practice American Society of Addiction Medicine August 2017: American College of Obstetricians and Gynecologists https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Opioid-Use-and-Opioid-Use-Disorder-in-Pregnancy

13 Patrick S and Schiff D. A Public Health Response to Opioid Use During Pregnancy. American Academy of Pediatrics. Pediatrics. Vol 139/Issue 3 (2017)

14 Allen J, Marcel C, Spiller H, Thiphalak C, Hodges N, Smith G. Prescription Opioid Exposures Among Children and Adolescents in the United States: 2000-2015. Pediatrics. Vol 139. No 4(2017)