Episode 8 – What Is Misdiagnosis?
Dr. Ashish Bhatt ❘
Receiving the wrong diagnosis can impact the trajectory of someone’s life, but misdiagnosis still occurs. Dr. Bhatt explains why.
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Hayley: Hello, this is Hayley and you’re listening to Straight Talk With The Doc, a podcast on addiction, mental health, and treatment. We all know that addiction is dangerous and oftentimes deadly, but there’s one class of drugs that has killed hundreds of thousands of Americans and has become a major topic of conversation. Today we’re going to be talking about the opioid epidemic. And to help me break that down I’m joined by our medical content director, Dr. Bhatt. How are you doing?
Dr. Bhatt: Doing well, Hayley. How are you?
Hayley: I’m doing well. So, I want to jump right into it. I think some people know a lot about the opioid epidemic, but others may not really know the backstory. Dr. Bhatt, can you give a little background on the epidemic? How and when did it start?
Dr. Bhatt: That probably entails so much more than I’m going to be able to describe in the few moments that we have here today. The epidemic has been around, probably in waves over the last few decades, and it’s signified by the amount of deaths we are seeing in our country, and around the world, due to people using opioids. I think we saw this back in the 90’s, with an increased amount of prescribing that occurred amongst medical professionals. There’s a confluence of influences of why this all happened, and it had to do with recognizing pain more amongst people who were diagnosed with medical illnesses that had pain as a consequence, as well as overzealous marketing done by pharmaceutical companies. Physicians and clinicians having to first start out treating people who suffered with pain, and then probably not being educated as doctors on what direction prescribing somebody with opioids could do in terms of the physical dependency and consequences. And that probably was due to a lot of misleading marketing and studies that were probably embellished or magnified that did not show the true consequence of what could happen with long-term opioid abuse. It resulted in people diverting from prescription drugs to illicit substances when the prescription drugs would get regulated, and as a consequence we often saw people who were physically dependent, and then ultimately using drugs that were not prescribed and having negative effects of overdose and dying, and it’s blown out of proportion since then.
Hayley: I know there’s a lot of layers to why the opioid epidemic happened in the first place, but did people not really understand how addictive these drugs were?
Dr. Bhatt: Medically, there was knowledge that people can become physically dependent on it. But if I can be more specific, back in the 80’s there was a lot of recognition and even push by the World Health Organization that pain was being under recognized. And they were making us as doctors and health care practitioners recognize that and said, “look, there are people who are suffering with cancer, and other chronic pain conditions that need to be treated.” And so, there was this push to make sure that we weren’t under-treating individuals, that people weren’t getting neglected, that people weren’t suffering. And I think in that attempt, physicians and doctors went with it, but then, as I mentioned earlier, manufacturers of analgesic opioid medications- they picked and chose I believe what knowledge was going to be presented to physicians in terms of the drugs that they were giving. So, that combination of the need to treat, I believe and under-educated medical population and then an overzealous marketing campaign coming together led to people getting prescribed it and ultimately becoming physically dependent on it in a way that probably should’ve been recognized, but wasn’t.
Hayley: Can you explain how opioids work? How do they treat pain?
Dr. Bhatt: Opioids bind to a certain receptor in the body that basically creates a sense of analgesic, it blocks pain by binding to these neuro receptor sites and they have a tremendous benefit. They’re there, they’re indicated and they have utility for multiple conditions. When we are treated with pain medications for legitimate reasons, it allows us to not suffer. Imagine getting into an accident and fracturing bones and having operations as a consequence and not having the ability to control your pain. So, it works by basically binding to these pain receptors, blocking them so we don’t feel that level of pain that you wouldn’t be able to tolerate. That’s in essence the way that it works, binds to receptors that block the sensation of pain to the brain.
Hayley: I want to talk about what makes them so addictive. When somebody gets dependent on these drugs and then they stop taking it, what kind of effects do they feel?
Dr. Bhatt: What’s unique about opiates in general is that- and I’m going to clarify the terms, we see the words opiates and opioids, opioids tend to reflect synthetic man-made products, and opiates tend to be more natural, things that come directly from the poppy plant where opiates are produced. But, opioids in general, let’s just use that word, is basically when we take them for any reasonable amount of time they have a certain unique property that due to the mechanism of action and the physical nature, what we call the pharmacodynamic nature of the drug, and the way our body responds which is the pharmacokinetic response of how it handles the drug, they develop a physical dependency in as little as 2 weeks, and probably 50% of the population, even at therapeutic dosages. So, what I mean by this is that inevitably, if you take opiates even as prescribed for even a short amount of time, somebody will become physically dependent on this. And that’s because the neuro receptors change so quickly and adaptation occurs and tolerance occurs. And when you become dependent on something, even if you’re not abusing it, when you take that product away you’re going to have withdrawal signs and symptoms. With opiates it’s very, very uncomfortable to withdrawal from this. When people are using it, and they do not recognize or weren’t educated or might not be aware that they can become physically dependent, simultaneously because there is a- not just analgesic, people can get euphoric and feel happy. There’s a release of endorphins that occurs when people take them. So, you’re feeling good, which can have a positive reinforcement effect of it while taking it. Take away your pain, and also feeling a sensation of happiness or euphoria, but when you stop taking it, you feel this considerable withdrawal effect after you become dependent, where you can have body aches, chills, diarrhea, nausea, vomiting. This combination makes it more addictive as a whole.
Hayley: So, correct me if I’m wrong, but opioids are involved in the majority of drug overdoses, right?
Dr. Bhatt: Yeah. What we’re seeing now, there’s a pre-pandemic and post-pandemic situation where we have seen some additional increase of other drugs- cocaine, methamphetamine, a combination with benzodiazepines too. But yes, most recently, in the last 10-15 years, it has been opioids that we have seen that is the main drug causing these overdoses.
Hayley: Can you explain what causes someone to overdose?
Dr. Bhatt: It depends really on your situation, but often we saw it early on, where people who were prescribed opiates legitimately for a medical condition who become physically dependent on these agents, and often there were certain deregulations put in place, because opiates are not really indicated for chronic, long-term pain, that’s non-cancerous in origin, or not secondary to a real significant spinal cord or back issue, where the pain is so chronic and so severe in nature that like I mentioned before, you become physically dependent. And after this was recognized that people were becoming dependent, there was more regulation imposed. After that regulation imposed, people couldn’t get those medications, often they ended up due to the dependency, going out on the street and having to seek out illegitimate opioid medications and often this created a deficiency state. So, when somebody became dependent and then didn’t have it, their tolerance goes back down, they enter withdrawal, and then after periods where the tolerance goes down, then they go back to using it again, unfortunately because of the neuro adaptation that takes place, the body is not used to it. And then they go back to trying and taking the dose that they were accustomed to, and unfortunately due to the depressive nature of the opioids, it caused the brain to be flooded with these opioid drugs, causing respiratory depression, resulting with death.
Jeff: The fact that many of the people who are affected by the opioid epidemic were introduced through a medical prescription or something like that, has other effects too because traditionally opioids that people experimented with recreationally would be something like heroin, which would be something that, for the most part, only people who are really- I almost want to say committed to a drug using life would do. Because most people would not just experimentally try heroin just for the sake of trying it. With opioids, that is not necessarily the case, and many people who not otherwise have experimented with heavy drugs or exposed to very highly addictive substances.
Dr. Bhatt: Yeah Jeff, what you’re describing is the bigger conceptualization of this whole thing. We saw people being prescribed it, they become physically dependent, regulations being put in place that did not allow them to get it through their prescriber, and again physicians prescribing it for situations where people didn’t need to be placed on it long-term. And then due to pressure from those regulations, doctors cut back. And what did that leave? It left people dependent on these opiates and desperate. So, they went out and they did not necessarily only want to use heroin as you mentioned, or they often would use pills, and most of the sequence was going from prescribed opiates, to the pills from the street, and then when pills from the street got too expensive, they went to heroin which was cheaper after the fact. And unfortunately, due to how heroin is mixed and other things that it’s cut with, their bodies did not know how they were going to react, and unfortunately overdose was a consequence for all of this stuff, and it is very sad.
Hayley: You mentioned heroin. I also wanted to talk about fentanyl a little bit, because I know that has been a contributing factor in the opioid epidemic. Why is that such a dangerous drug?
Dr. Bhatt: Fentanyl is a synthetic product, it’s a man-made product, and it is just so much more potent than all of these other things out there. So, imagine the scenario that we’ve talked about just a few moments ago, people who are dependent on xyz class of opiate, a certain specific type, and then go out and their body doesn’t know how to adapt to it or adjust to it, and they’re going to go and take a product that might be cut with fentanyl, and fentanyl is 80, 90, 100 times more potent than this. And taking heroin for example, that could be cut with fentanyl, they don’t know what it’s going to do to their body. And unfortunately, because of its potency, people are overdosing because it’s just that dangerous that trace amounts of it can kill somebody who might be naïve or have never taken opiates before, it’s just that dangerous of a product.
Hayley: Before we move on from the topic of overdosing, I wanted to talk about what should somebody do in the event that someone is overdosing from opioids?
Dr. Bhatt: Unfortunately, often people are alone when they’re using, and if they’re alone there is no way to get help, and that’s why we have so many deaths. If somebody is with somebody who has overdosed, calling 911 is where you need to go. These people can go straight from, again, overdosing- they become drowsy, lethargic, then all of a sudden, their body’s respiratory systems shuts down, oxygen to the brain is diminished, then ultimately these people will die. Activating emergency services is really the way to go. Obviously, many people have heard of Narcan or naloxone which is a medication that is out there that can help reverse an overdose. If somebody has access to that and knows how to use it, that can be used as an intervention. We’ve seen it through public health programs and physicians prescribing it, people who unfortunately aren’t stable and are suffering with addiction to opiates, they’re even being prescribed rescue mechanisms, and having this naloxone on hand in the event they do overdose.
Hayley: You talked about that awareness earlier with doctors trying not to prescribe as many opioids in response. What kind of reform has been made due to the opioid epidemic?
Dr. Bhatt: When this was recognized, and again, now going back into all the confluence of causes that came together and caused this vicious storm. Once it was recognized that opiates are being prescribed overzealously and they were creating a physical dependency in individuals. A lot of regulations came down to just limiting the prescribing amount. They started developing systems of risk mitigation systems. The pharmaceutical companies that could be identified and the CDC, different agencies started providing recommendations on who to prescribe it for and what conditions you should prescribe it for, and for what duration you prescribe it for. Opiates really should be indicated for acute pain, for short-term, the lowest dose for the shortest duration, and that’s really how we should try and control this. And it should be done with a practitioner who is knowledgeable of the patient and keeps track of this. In addition to this control of how much we prescribe, there were data banks that were developed with prescription monitoring and managing programs that other physicians can see what other doctors have prescribed on their patients, so there’s a way to track the prescribing and dispensing of these things. Basically, the limitations on who, how much, and what for were introduced and guidance on how to go from short acting to long acting opiates, and encouragement to use non-narcotic, non-opiate based pain medications on individuals. Those things have helped in terms of reforming what we see was going on previously.
Hayley: In your opinion, are there things that you think still need to change? If so, what are they?
Dr. Bhatt: A lot of education on addiction training I think still is not as robust as it could be. Obviously, with the opioid epidemic and other addiction issues becoming more publicized, I think medical doctors need to be more trained in identifying addiction, prescribing certain controlled substances, and this needs to be regulated by the licensing authorities, and it’s happening. There’s more continued medical education requirements for physicians being licensed in certain states, and I’d like to just see it happen more in the medical school side in terms of this becoming a very, very important topic that physicians master. I’d like to see that continue to improve, not that it’s not being done, just continue to evolve. We have to continue to meet those standards, as well as continuing to ensure that these prescription monitoring programs and these limits and these regulations are being adhered to by the physicians, and figuring out ways that systems can be introduced to make sure that those are being used.
Hayley: You mentioned a little bit about who opioids are appropriate for. Should there be something like screening questions before a patient is prescribed opioids?
Dr. Bhatt: There are. There are many, especially doctors who are prescribing this, you have seen this evolution in many places where they do ask additional questions basically about underlying medical conditions and also risk factors for other addictive symptoms. They want to identify people who might be at an increased risk for developing a substance use disorder, and these things are happening and these things are done on various patients. And, it’s important. That’s one of the best things that’s happening out there.
Hayley: For those who would be considered high risk, are there other options to replace opioids?
Dr. Bhatt: You’ve got to divide it into two classes of individuals. There are people who are probably at risk, but have legitimate situations. Again, if I have a surgery, or if I’m in an accident, I don’t think there are many medications that are out there that might be able to control my pain, and at the time we would have to use opioid medications to help control the pain. We don’t want anybody to suffer. But at the same time, as long as those things are controlled and limited to time and situation, and for those people that are at risk using non-narcotic analgesics, non-steroidal anti-inflammatory drugs, people know them. I know people might hear this and say well that doesn’t control my pain, but often that’s the addicted mind that’s speaking. There is also a situation, a syndrome, where people develop this hyperalgesia or sense of heightened pain sensation after being exposed to long-term analgesic medications that control pain. So, it’s important to really look at the origin of the pain. So many people come to a physician and they’ll be like “I have this” and they want the doctor to give them something without actually having the doctor do the proper work up. Somebody’s pain might be coming from an inflammatory condition, so they should use an anti-inflammatory product. If somebody’s pain is coming from a muscle disorder or a muscle spasm, or muscle tension, you use an antispasmodic agent, a muscle relaxer. And if somebody is having pain from a nerve condition, well there are neuropathic agents. All of these agents that I just described are not narcotic, not opioid based medications and these are where we need to open the repertoire of treatment option.
Hayley: What are some of the signs, briefly, that someone is addicted to their prescription?
Dr. Bhatt: A lot of times people will- I know this sounds like a cavalier for doctor shopping, we do see that. People will go to one physician and they will bounce around to other doctors, and that often is a sign. Then people who are going through their prescription medications quicker than they should. If you’re given a month supply of medication, of any medication, not just opioids, and they’re finishing it quicker, this is a red flag. What are they doing, are they selling, are they using it, what’s going on? The burden falls not just on the patient but on the prescriber to make sure this is being monitored as well as the pharmacy that’s dispensing this. So, there’s multiple levels where checks and balances can occur. Also, people appearing intoxicated, and being that opiates are a significant depressant and also cause euphoria, if you see these behavioral changes where somebody is acting out of character or nodding off, or falling out as we say when prior to overdosing, they’re just looking like they passed out. Obviously, these are pretty apparent things that somebody has taken something or could have taken something or something medically is wrong with them. I think those are big ones. Using a lot, doctor shopping, behavioral changes that are common with other substance use disorders, craving, and obviously withdrawal signs and symptoms. Withdrawal signs and symptoms might be after the fact, but they happen. They happen as a consequence of becoming physically dependent, so these are all things to look out for.
Hayley: And what should someone do if they realize that they are addicted to their prescription?
Dr. Bhatt: I want to separate physical dependency from addiction. As mentioned before, the nature and character of an opioid product is one that can render you physically dependent even at therapeutic dosages. So, people who have been taking long-term opioid medications and they find themselves in attempt to stop or cut down and having withdrawal symptoms, and they’re not abusing, they need to speak with their doctor. They need to speak with them about how they can safely taper off and titrate down, and this should’ve been done upfront. Patients need to be given education, they need to be told and provided literature, they need to even potentially sign agreements on what and how long they should be using these for, and hopefully avoid the physical dependency in the first place. But those who are now abusing it in an addictive manner that aren’t suffering from any pain condition or the pain condition was treated and now resolved and now have gone beyond dependency and are using it to have an altered sensation, to get high, well, these people need to obviously get help. When you’re addicted, often you’re not in the right state of mind and often you’re not seeking out treatment, but obviously we’re here to encourage people who have a substance use disorder to seek treatment, because it is deadly. Opioids are a very deadly agent when they’re used in the manner that we’re speaking about. So, getting help, seeking treatment, asking for help, and hopefully if there’s family members listening, recognizing these symptoms, and keeping track of people who are at risk.
Hayley: Perfect. Thank you, Dr. Bhatt. And I also wanted to say that too, if you or someone you know is abusing opioids, it’s important to intervene and reach out for help because so many deaths are preventable. Addictioncenter.com has some great resources and our other episodes are also on there, as well as Spotify and Apple Podcasts. You can also write in a question to Dr. Bhatt on Addiction Center and check out some of the blogs he’s written. Thank you to everyone who listened and we hope to have you next time for another episode of Straight Talk With The Doc.
Dr. Ashish Bhatt
Addiction Center’s Medical Content Director, Dr. Ashish Bhatt, MD, MRO is an accomplished physician, addiction medicine specialist, and psychiatrist with over 20 years of medical and administrative leadership.