Scientific approach drives substance abuse conference

The annual Update on Psychiatry at the Medical University of South Carolina started on a tragically timely day. As substance abuse experts gathered to talk about trends in their field, news broke that the musician Prince died of an opioid overdose.

The singer, who stood out for most of his life, was unfortunately part of a crowd in his death: Almost 19,000 Americans die a year from prescription painkiller overdoses.

That stark reality, the high toll opioid use can take, drove much of the discussion at the MUSC conference. Talks included “Stemming the tide of prescription opioid misuse, diversion and overdose” and “Prescription opioid use, misuse and abuse in pregnancy.” 

New approaches to older problems were on tap too, including the latest treatments for alcohol use disorders and gender differences in substance abuse.

Opioids

MUSC psychiatrist Kelly Barth, a doctor of osteopathic medicine, specializes in treating people with chronic pain who are using prescription opioids. Her talk, “Stemming the tide of prescription opioid misuse, diversion and overdose,” showed the difficult position both doctors and patients are in.

“Chronic pain is complex and poorly understood,” the associate professor in the Departments of Psychiatry and Internal Medicine said. It’s also widespread. About 11 percent of Americans, or 25 million people per year, suffer from chronic pain.  

The United States is the largest consumer of prescription opioids in the world, with about 200 million prescriptions for opioids each year in a country with about 242 million adults, Barth said. She reviewed the recent CDC guidelines for the use of opioids in the treatment of pain, and emphasized that as the medical field struggles to find effective treatments for chronic pain, the most important step doctors can take immediately to prevent opioid overdose deaths is to recognize and treat addiction. More than two million Americans have opioid use disorder, and life-saving treatments are available, Barth said. 

Doctors also need to recognize the risk of the combination of prescription opioids and benzodiazepines. More than 50 percent of people who die from opioid poisoning have been using other drugs as well, Barth said, including benzodiazepines such as Klonopin and Xanax and in some cases, cocaine and heroin.

Although Barth said more research is needed to learn how to best treat chronic pain, there are already alternatives to opioids and ways to help chronic pain patients cut down on or end their opioid use. They include psychological and physical therapy, anti-inflammatory medications, anti-convulsants and anti-depressants.  

Opioid use in pregnancy

The other talk that focused on opioids, “Prescription opioid use, misuse and abuse in pregnancy,” was given by psychiatrist Constance Guille, M.D. She’s an assistant professor in the Department of Psychiatry and Behavioral Services and director of the MUSC Health Women’s Reproductive Behavioral Health Clinic.

Guille described the challenges facing some of the women she treats: mothers-to-be who are taking opioids. Their babies are at risk of being born addicted and having to go through a very painful withdrawal in the weeks after birth. Opioids can also cause preterm birth and low birth weight.

“Fourteen to 23 percent of pregnant women will fill an opioid prescription during pregnancy. Over the last decade in our country, there’s been a five-fold increase in neonatal abstinence syndrome in South Carolina. Every 25 minutes in the U.S., a baby is born going through withdrawal,” Guille said.

“In addition to pregnant women’s opioid use, we need to address their pain conditions. Our job is to help women cope better with their pain events and use alternative non-opioid strategies to reduce their pain.” 

Substance abuse in women versus men

Women are more likely than men to abuse prescription drugs, according to another speaker, Kathleen Brady, M.D., Ph.D. Not necessarily opioids, she said – women and men are about neck and neck in that category – but prescription drugs more generally. 

In her talk, “Sex and drugs: Gender differences in substance abuse disorders,” the psychiatry professor said more than 20 million Americans have substance abuse disorders. It’s worth examining gender differences, she said, because different factors are leading men and women to substance abuse, and addressing those factors should be part of treatment.

“In general, women with substance abuse disorders are two to three times more likely to have depression or anxiety,” Brady said. The professor, who also directs the South Carolina Clinical and Translational Research Institute and serves as vice president for Research at MUSC, cited a study that found women who suffered from major depression were eight times as likely as women without depression to suffer from an alcohol disorder at a 5-year follow-up visit, suggesting that depression can be a risk factor for the development of alcoholism for some women.

“For males, depression did not seem to be a risk factor for the development of alcoholism” Brady said. 

Another gender difference involves the speed with which people move from using to abusing to seeking treatment. Women lead the way in that area, too. “This has been shown prominently in the alcohol area. Women use smaller quantities of substances for fewer years before seeking treatment.”

There are physiological reasons for that, Brady said. “For every sip of alcohol, a woman’s blood alcohol concentration is going to be higher than a man’s.” Women tend to be smaller, they have more fatty tissue but less body water and their stomachs don’t have as much of an enzyme that breaks down alcohol. That means more ends up in their blood.

Men lead the way in two other categories Brady covered. They are two to three times as likely to be dependent on alcohol as women are and almost twice as likely to be addicted to illegal drugs.

Gender differences should also be considered when it comes to treatment, Brady said. “Certain men and women with substance abuse disorders may prefer single gender versus mixed gender settings.” They may feel able to speak more openly around people of their own gender, she said, and deal with gender specific issues such as the effect of substance abuse on reproductive health.

Takeaways

Substance use disorders can sneak up on people. The trouble can start with a pain pill prescription following surgery that keeps being refilled well past its useful point. Or it may be an evening drink to reduce anxiety that leads to several drinks a night. Biology, psychology and personal history take it from there.

But as the Update in Psychiatry made clear, science is finding new ways to understand substance use disorders and treat the people suffering from them. 

Robert Malcolm, M.D., raised a fascinating possibility. “In the future, vaccines are going to be very important in the addiction area.”

For now, mental health counseling, medication and more unusual treatments such as brain stimulation are key, the experts said. So is exploring ways of improving those treatments, honing them to take into account the many layers that underlie substance use disorders.