News broke this week of what the Department of Justice is calling the “largest-ever prescription opioid law enforcement operation.” Authorities have charged 60 medical professionals for their involvement in the illegal prescription of more than 32 million pain pills. Some of the charges announced against these individuals include Medicare fraud and the unlawful distribution and excessive prescription of controlled substances.

This bust is another wake-up call for doctors who prescribe opioids as part of a pain management plan and a reminder that they have clear duties for assessing, treating, and monitoring patients. As the opioid crisis continues, we are likely to see more lawsuits initiated by patients who develop debilitating addictions to pain pills. Providers of care must ensure that all records pertaining to patients clearly reflect the medical and relevant social history, physical examination, diagnoses and treatment.  The effects of opioids on the physiology of the brain, systemic and behavioral symptoms, tolerance and addiction, and risk factors of abuse should all be understood and considered.

The Effect of Opioids on the Brain

Opioids include prescription drugs such as oxycodone, hydrocodone, codeine and morphine, synthetic opioids such as fentanyl, and illegal drugs such as heroin.  The body’s own opioids are the neurotransmitters endorphin and enkephalin.  These neurotransmitters attach to opioid receptors in the brain, spinal cord and digestive tract and are involved in stress response, mood, learning, memory and immune functions. The binding on the opioid receptors in the reward regions of the brain inhibit the perception of pain and increases the feeling of pleasure.  These receptors in the brain can also decrease alertness and slow respiration and those in other tissues can cause constipation and cardiac arrhythmias.

When an opioid drug is used, the chemicals attach to mu opioid receptors on neurons, which triggers biochemical brain processes that give feelings of pleasure and relieve pain.  Continued use of opioid drugs results in decreased production of the body’s own opioids, causing the brain to function abnormally when the drug is not taken.

The areas of the brain directly impacted by opioid use, and the resulting effects, include:

• The basal ganglia which plays a role in motivation, socializing, sex, and the formation of habits and routines. This area is part of the brain’s “reward circuit” which releases dopamine and becomes overactivated by the use of drugs.
• The extended amygdala is involved in anxiety, irritability and unease. This area becomes more sensitive with drug use.
• The prefrontal cortex controls thinking, planning, problem solving, decision making and self-control. Drug use impedes impulse control, resulting in drug seeking behavior to secure the euphoric feeling.
• The brain stem controls basic functions such as heart rate, breathing and sleeping. Overdoses of drugs depress breathing, resulting in death.

Tolerance, Withdrawal and Addiction

Tolerance occurs when the person requires a higher dose of opioids to achieve the same response.  Repeated use of opioid drugs desensitizes the brain’s natural opioid system, which results in symptoms of withdrawal when the drugs are discontinued.  Changes in neurotransmitter production during withdrawal causes nausea, anxiety, itching, muscle cramps, diarrhea and overall difficulty in functioning normally.

Drug addiction is defined as an irresistible craving for a drug, out-of-control and compulsive use of the drug, and continued use of the drug despite repeated, harmful consequences.  Opioid drugs produce large surges of dopamine, which essentially teach the brain to seek drugs, no matter the cost.  Cues in the person’s environment can trigger these uncontrollable cravings, which the brain can remember for decades.

Opioid dependence and addiction are considered chronic medical disorders.  The reward system of the brain appears to be central in the development of tolerance and addiction.  Other abnormalities that produce addiction are complex and may involve environmental effects and genetic predispositions in the form of abnormal brain pathways.

Risk Factors for Opioid Addiction

A thorough review of a person’s social history can reveal known risk factors for opioid misuse and addiction. Records should be assessed for documentation of risk factors prior to the prescription of an opioid drug including:

• Poverty / Unemployment
• Family and/or personal history of substance abuse
• Young age
• History of criminal activity or legal problems including DUIs
• Regular contact with high-risk people or environments
• Problems with past employers, family members and friends (mental disorder)
• Risk-taking or thrill-seeking behavior
• Heavy tobacco use
• History of severe depression or anxiety
• Stressful circumstances
• Prior drug or alcohol rehabilitation

As noted in a previous Excelas blog post, CDC guidelines, state specific rules, and professional organizations provide extensive resources for the appropriate content of medical record documentation related to prescription opioid use.

About Excelas

Excelas provides medical record services to organizations nationwide.  Our team of credentialed health information managers and medical analysts have the experience and expertise to gather, organize and analyze the complex information in cases involving opioid abuse and overdose.

References:

• Mayo Clinic Staff. How Opioid Addiction Occurs. February 16, 2018.
• Volkow, M.D., Nora. What Science Tells Us About Opioid Abuse and Addiction.  January 27, 2016.
• National Institute on Drug Abuse. Drugs, Brains and Behavior: The Science of Addiction.  July 2018
• Kosten, M.D., Thomas R. and George, M.D., Tony P. The Neurobiology of Opioid Dependence: Implications for Treatment. July 2002