As a rural family physician I am working with the University of Washington Roam-echo telemedicine on chronic pain and opioid dependence.

I have presented 13 patients anonymously in ten months. That is, no patient names. UW has my name.

I am trying to bring information into focus, slowly but surely. With each presentation, another piece of information is added. And the picture is horrifying.

Here are some pieces:

1. People dependent on opiates can relapse long after the physical dependence goes away. Years, even.
2. Chronic opiates can change the receptors in the brain.
3. Six months of chronic opiates can change the brain. Or less than six months. I don't know how much less. Days? Weeks?
4. Chronic pain can also change the brain and they are classifying a number of the disorders where the pain seems much greater than the "tissue damage" as "disorders of central pain processing". Fibromyalgia, chronic fatigue, trigeminal neuralgia.
5. People who say they have 9/10 pain have proportionately more receptors light up in their brains on functional MRI scans than people who say they have 3/10 pain.
6. Some of the changes in the brain from chronic opiates at this point appear to be permanent.
7. More people in the US are now dying of correctly taken prescription medicine overdoses than die from either car wrecks or guns. Mostly prescription opiates with or without other prescription medicines or alcohol.

This does make me want to run around screaming in horror. Do you see the picture yet?

It's partly the bits we DON'T know.

1. The brain changes from fibromyalgia and other "disorders or central pain processing" are not the same ones as the opioids. What are the changes? UW: "We don't know."
2. Opioids are given to reduce pain. UW is saying that these permanent brain changes can happen after 6 months. But they can happen faster. One source said that the brain cells can permanently trim their dendrites after a month. Patients are telling me: heroin, once. Or: vicoden. "As soon as I tried it. A prescription." So how long does it take to change the brain?
3. Once the brain changes from opioids, the cells have pulled many of the mu receptors out of the cell walls and it takes more opioid to stop the same pain: tolerance. And then if the opioids are stopped, the person's natural endorphins are not enough to calm the cells down. Withdrawal. But those cells have changed, remember? So it seems to be that those brain cells, if they change, may be permanently hooked on opioids.

Uh-oh. I have never liked prescribing opioids, have always been stingy and strict, have used prescription drug contracts and refused to increase them, sending people to pain clinics. But this is different.

I've read that methamphetamines wipe out the dopamine in our brain, so that people quitting meth don't feel happy. For years. Two years later there is incomplete recovery of the brain, but some recovery. We don't know if the brain ever recovers.

But opioids may change the brain for longer, or for good. So for me the ranking of what is the worst addictive drug has suddenly changed.

Tobacco kills the most.
Methamphetamines damage the brain. I don't know if there is full recovery. They do lots of other toxic damage, the worst to small children in the care of users. The children tend to not get fed.
Alcohol is terrible as an addiction, can kill people, is destructive to families, but many people do quit. And the addiction rate, while higher than people admit to themselves, is not most people.

With opioids, I don't know. I don't know how many people become dependent, how many people have brain changes, or how fast. I don't know if it's days or weeks or months. I don't know if a low score on the "opioid risk tool" means that that person won't have brain changes if they are on opioids for 6 weeks or 2 months.

Don't give your pain medicines to friends. Don't sell them. Don't buy them. Take as little as possible .....

.... it might take over your brain .....

Prescription drugs kill more people than car wrecks.
Washington State Opioid prescribing guidelines
Brain changes with opioids.
Evidence that the brain changes may NOT be permanent

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