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Melanie Cole (Host):  It’s estimated that 78 people a day die from overdose and overuse of opioids. Use of these drugs such as oxycodone, hydrocodone and fentanyl has skyrocketed in recent years. According to a recent study in the journal of the American Medical Association, more people die of heart and breathing problems caused by opioid use than accidental overdoses. My guest today is Dr. Jason Smith. He’s a cardiologist with Lourdes Health System. Welcome to the show. Tell us about what’s going on in the country with opioids today and addiction and how this relates to heart health. We hear about addiction and overdose, but heart health and heart problems because of these opioids is a whole different deal.

Dr. Jason Smith, DO (Guest):  Thank you. It really is an epidemic and it really has skyrocketed and spiked over the last 10 to 20 years. I think what we’re seeing now too is most of the deaths are because of opioid use – prescription medications – whether it’s legal or illegally obtained. It’s the opioids, the oxycodone or Percocet, hydrocodone or Vicodin some people may know it as. These are the most common drugs causing overdose, probably two fold that are current, but that depth is closing because there's a lot of government policies now to restrict access to the prescription opioid medications, and now people are turning towards the heroin more so than the opioid prescription medications. That’s very dangerous in the fact that there's not FDA regulation apparent, so the purities and impurities and what else may be in that drug is very dangerous, and every time they do an injection of heroin, they're getting a different amount of the active drug every time they do it, and they never know when that one time when they take too much is going to be. It’s very scary and very dangerous.

Melanie:  Opioids are one thing, heroin is another, and obtained illegally, but what about that legal dispensing of opioids for pain relief – someone’s had back surgery or neck surgery and they become addicted. What is going on with their heart and is there an issue with the re-prescribing of these medications? Do doctors say it’s been going on for six months, is this time? Are there some recommendations to look at when it’s time to say that’s enough?

Dr. Smith:  It’s very difficult. Number one, pain is very subjective so it’s hard to tell somebody that can't be in pain anymore. It’s a subjective thing but it is very critical that when you do prescribe opioid medications that you do understand that it usually should be temporary and there should be an end game. For me as a cardiologist, we have a lot of people who undergo open heart surgery, they have their chests opened up to replace valves, they do bypass surgeries, which can be very painful. Often times, opioids are used in the hospital to help with pain, and a lot of times, they leave with pain and have to leave on an opioid. It’s very important to have an end game and have that conversation with a patient about the addictive potential of the medication and that we need an end game.

The longer they're on it, the higher doses they're going to need. It's called tolerance – or tachyphylaxis –you need higher and higher doses to achieve the same effect over time because you saturated those pain receptors that give the sense of euphoria. But if use correctly and used for pain with an end game, we’re able to get patients to wean and come off of these opioids if they understand how they're supposed to take then and when they're supposed to take with an end game. If you keep prescribing them more and more, and they keep having more and more pain, you have to look into other resources perhaps. If you're not comfortable with it, there are many pain management specialists that you might be able to refer them to. It’s important that someone with expertise can take on the prescription of this type of medication because it can be very dangerous if you really don’t have an end game or know what you're doing and it can cause addiction in patients and they have trouble getting off.

Melanie:  As far as heart disease – and there have been some studies that on the cardiac effects of opioid therapy – we say that risk versus benefit for pain management and it is subjective, but the cardiac effects and the fact that heart disease can be the biggest risk from opioids, how do you weigh that? What do you tell people?

Dr. Smith:  In the short run, it’s relatively minor. Opioids can have some effects on the heart, but really the abuse of opioids with other types of medications increase that risk for instance. If you're just using opioids, some things that happen are the heart rate can slow, blood pressure can drop, so you get what's called bradycardia where the heart rate is very slow and you get blood pressures that can drop. It’s caused by the vasodilation of the arteries so they dilate, which will drop your blood pressure. This can cause people to pass out, this can overtime cause people who are prone to developing heart failure, cause fluid retention, edema – or swelling of the legs – and even pulmonary edema or congestive heart failure in a long span. These risk are increased when people use opioids with other medications or other drugs of abuse. Sometimes people are prescribed benzodiazepines like Xanax or Valium for anxiety – the combination of those two can lower the heart function, causing heart failure. Some people use alcohol, which will potentiate the effects of these types of drugs, so it’s the mixing of multiple drugs or somebody using cocaine on top – these are where these drugs of abuse become a problem.

I think we see a little bit more when the drugs are used illegally when somebody obtains an opioid who is not prescribed the medication, they get it on the street, and they pay money for illegally drugs and a lot of times they’ll crush up the pills – they crush them up because they can get a quicker high if they snort or even inject it. These drugs are not made to be inject into the bloodstream, so when you inject these types of inert material, they tend to clump, they can cause acute blockages of arteries, causing stroke and heart attacks. When these people can get these drugs anymore by prescription and they start to go out to look for other ways to get them and other ways to use them to get that high, there is where the real dangers come in.

Melanie:  What would you like listeners to know about opioid dependents and having to use them responsibly and physicians who prescribe them responsibly for pain management versus that risk for addiction and problems with that and the heart? Wrap it all up for us because what a timely topic. We’re hearing a lot about it in the media, but people don’t understand how it came to be and why this is such an epidemic right now.

Dr. Smith:  I just don’t think the physicians are having that conversation with patients. They're so easy to prescribe them but they're not really telling them that those drugs can cause dependence and addiction and to get a good history and physical and have that conversation with a patient about what the best experience is with other drugs have been – do they have problems with alcohol already? Do they have an addictive personality? Is there something that may lead them towards using these drugs for more abusive measures? As long as you're prescribing it for pain, a lot of times they will not have the addiction, but you have to have an end game.

You have to have a strict conversation with them and say “listen, we’re going to do this for the next two weeks and you're going to take less and less every day and you're going to wean yourself off before we have to start using higher and higher doses causing increase tolerance and then dependence and they lead to addiction, and then when you try to get off the medications, you'll actually withdraw from them.” You have to have an end game. I would say for those who are already addicted and have trouble getting off, there are resources out there whether it’s a rehab program. Unfortunately, many friends and relatives who had this type of problem has passed away from it, so the ones I've seen have the most success usually worked in Narcotics Anonymous. It’s all about people, places and things, so you have to get away from the things that are causing you to use the drug and abuse the drug. There are resources out there for people to tap into if they feel as if they're having trouble weaning off the drug or can't get off the drug or having effects of withdrawal. You need to talk to you doctor and the doctor needs to put you into the right position so you can get off the drugs before long term effects do occur.

Melanie:  Such important information. Thank you so much for being with us today. It’s great information for listeners to hear and understand. You're listening to Lourdes Health Talk. For more information, you can go to lordsnet.org. That’s lordsnet.org. This is Melanie Cole. Thanks so much for listening.