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Forum Name: Pharmacy & Drug Topics
|DC-Angel - Thu Nov 13, 2008 7:33 pm|
My sister-in-law has been addicted to pain meds for several years and I believe she is going down hill again.
A few years ago she was given morphine(patches) she was addicted and after a year or so came off of it cold (told a friend stole all her meds, but I believe she just really abused them and couldn't get refilled for a few weeks). She said she would never take it again, and it was the worst thing she ever went through. WELL, 2-3 months ago she was fired from her job, which was at a hospital (catering/food dept.). She had gone in and from the way she was acting (bouncing off the wall, from what I am told) her boss (or someone) escorted her to the ER side and she had to submit to a drug test. WELL she tested positive for morphine and alcohol, and she was fired and escorted out. The alcohol I believe made up as failing, so it would seem that the morphine was not true. She drinks only 2 times a year (new years & annivers. if even then). She swears to my brother, me & everyone else there is NO way she had morphine and even I believed her UNTIL yesterday. While my brother is in the hospital, we went to get something to eat and she tells me she has on a fentonal patch (her friend gave her) I asked what it was and she said a pain med that is awsome??? Well I didn't know what it was, and hadn't heard of this med. and she tells me her friend is sending her some fentanol lollipops, so I learned yesterday from her.I decided to research this med on line today because of the way she was acting last night it had me thinking if this may have been the med she took when she was fired, if it was along the same lines of morphine???? So my question is... if she was taking fentanol that day, would a drug test show positive for morphine? I am stuck, with watching her go down hill again, and my brother having many health issues this year. If he knew she was taking this fentanol he would be done with her. The morphine a few years ago had them separated, and with her getting fired, my brother being self employed and can't work much recently the bills are growing. If my brother found out for sure she was fired for that, or this med, and that she is taking this stuff, and falling downhill it would be the end of their marriage, and her 3 kids would be done with her as well.
I have my own medical issues, and have actual caught her stealing my meds (right after getting out of the hospital) but never told my brother because I didn't want to get in the middle. But this I have to know if it could be so I can decide what to do for my brother and his 3 kids.... PLEASE HELP.... as soon as possible...
|Marceline F, RN - Sun Dec 14, 2008 9:05 am|
Substance addiction can be a real tragedy to a family. There are so many possible underlying issues that can lead a person to fall into the trap of substance addiction. I don't know why your sister-in-law started on the morphine to begin with, it possibly was for an acute injury, or for a chronic pain issue, and the starting reason is actually less important than why she stayed on it for a year (such as intractable pain - real or imagined) which very easily led to her addiction. It seems, on the surface, that your surmise is correct, and that she overused the patches, ran out of them, and was unable to get them reissued. The doubling up of the patches not only depleted her supply early, but also increased her dependence on them sufficiently to contribute to a hellacious withdrawal. Sometime after that, it may be that she used her original justification for the need for a narcotic pain medication, whether it was an "acute injury", or "chronic pain", contacted a new MD, and requested strong medicine. Fentanyl is an extremely powerful synthetic opioid: a classification of drug that includes morphine. Standard lab testing looks for the opioid metabolites that are found after the use of both morphine and fentanyl - as well as after other medications. The fentanyl patches most commonly used are known as Duragesic and are supplied in a variety of strengths. These patches are so strong that even disposal of them needs to be tightly controlled. There have been cases when people have taken used patches and chewed on them to get the residual drug. Fentanyl lollipops are very quick releasing suppliers of the drug, and have been useful for people who are afraid of pills, or cannot swallow them, or are not able to receive the medication in an injection form, and do not need the long-lasting release of a patch. They are also given for breakthrough pain for Cancer patients who are already on the fentanyl patch. If your sister-in-law was using either the Fentanyl patches or the lollipops, she is technically telling the truth that she is not using morphine. HOWEVER, she is only lying to herself in a way, because Fentanyl is still in the opioid family, is considered 50 to 100 times more potent that morphine, and will test positive as an opioid just as morphine does with lab serum or urine testing. Opioid tolerance is easily developed - and patients are considered tolerant if they are receiving morphine at about 60 mg/day, fentanyl patches of 50 mcg/hr or more, or on an equivalent dose of another opioid for a week or longer. Chances are very high that she has been receiving some form of opioid for quite some time.
I feel for your anguish on behalf of your family and the children. A whistleblower is a very difficult position to be in. At the same time, if your sister-in-law is lying to herself and to her family, the lie will catch up to her and to them sometime, and then she may be found incidentally guilty of serving as a role model for the children for inappropriate and inadequate coping. You will need to decide for yourself, and with your immediate family as to what the family priorities are, and weigh the consequences of discussing - and NOT discussing - the concerns about her and her unfortunate addictions. There are mental health professionals and substance addiction specialists in most major cities that may be of value in getting her help to both get clean, and to address the underlying issues - whether physical pain, or emotional distresses, that seem to be causing her to seek self destructive methods of narcotic relief.
|Dr. E. Seigle - Sun Dec 14, 2008 10:50 am|
I will assume that the medication that you have referred to that your sister-in-law has said she was taking is Fentanyl. This drug is in the same family as morphine, known as Opioids, which refers to the class of medications either derived from the poppy plant or made to act in the same way by drug companies. So, this would show up on drug tests as positive for opioids, and could be further determined to be Fentanyl. It workds in a similar way and has a similar risk of addiction and abuse as morphine and a number of other opioids.
One way to look at addiction is that it is an illness, and people who have an addiction are at risk for relapses in abusing their drug for the rest of their life. With motivation and good treatment, your relative can recover from this episode of illness. She may need ongoing treatment over a long period of time.
I would encourage that she consider getting re-evaluated for her substance abuse problem and any other problems that may be contributing to it, and that she receive appropriate treatment.
Good luck! -E. Seigle MD
|Jeffrey Junig MD PhD - Sun Dec 14, 2008 10:57 am|
Addiction to opiates is so destructive-- people who have never been addicted find it hard to understand why the addict keeps returning to such destructive behavior, blaming it on 'weakness' or 'immorality'. While there are certainly 'poor choices' at the start of opiate addiction, one the addiction is in place there is little possibility for the addict to stop without aggressive treatment. I encourage opiate addicts and their families to understand that addiction is a disease. Such a view should NOT take responsibility away from the addict, or serve as an excuse-- just the opposite; the addict has the RESPONSIBILITY to keep their disease under treatment. Promising to stay 'clean', without doing something to treat the addiction, will always be an empty promise that ends badly.
I lost my anesthesia career to addiction to fentanyl; I am now a psychiatrist. It has always taken drastic measures to recover from opiate dependence-- such as leaving a high-paying career and going through another three years of residency! Many people make the mistake of thinking that they can beat addiction through 'education'-- again, I was one of those persons. My PhD in neurochemistry, studying receptor systems-- certainly that knowledge would help me!! It didn't... if anything it kept me sick longer, as it gave me one more reason to treat myself instead of asking for help. Even in residential treatment, some people don't 'recover' because they want to hold on to 'who they are' and just get some education... rather than make the changes necessary to find good recovery. Like they say at AA meetings-- 'it works... if you work it.'
The 'rock bottom' is useful to open a person's mind to change. I am a big fan of rock bottom experiences and their effectiveness in motivating change, but studies have shown that a person can recover without having a drastic bottoming process. The biggest problem with waiting for a 'rock bottom' is that many addicts lose everything or die before getting to their own 'bottom'.
We now have Suboxone-- which has introduced a completely different treatment paradigm. Suboxone will induce remission of opiate dependence fairly reliably-- in my experience treating addicts with the medication 'older addicts', say over 35 or so, do much better than 20-y-o addicts-- who tend to get bored on the medication. Suboxone is a Godsend for addicts in that it can take a total mess and make it 'stable' in a few weeks... the problem, though, is that the addict must keep taking the Suboxone to avoid active addiction. It is different from methadone in many ways, and I compare it more to naltrexone than to methadone-- the active drug in Suboxone is a 'partial agonist' (buprenorphine) at the opiate receptor, and it virtually eliminates cravings and at the same time blocks the receptor so that other opiates have no effect on the addict. But again, it is not a 'cure'-- in my opinion a person should stay on it for at least a year, and then go off it only if they are replacing it with active recovery including 12 step meetings. Suboxone does have considerable opiate potency and so it is being used more and more to treat chronic pain as well as addiction (the chronic pain use is 'off-label'). You will find about everything you need to know about Suboxone at http://SuboxoneTalkZone.com
A final comment about the drug testing: Fentanyl will NOT show up in standard drug tests as morphine or as anything else. It is a synthetic opiate; I had to be monitored by the state licensing board after my addiction came to light eight years ago (I was monitored by urine testing for six years). Fentanyl requires special testing that is more expensive and would not likely be done at the local ER. If the testing WAS done for fentanyl, it would not 'cross react' in any way with the test for morphine. I did come up positive once for morphine after eating a Starbucks poppyseed muffin-- I was tested about two hours later and had 700 nanograms per ml of morphine in the sample (a nanogram is one thousanth of a microgram, which is one thousanth of a milligram-- small amounts, so the muffins are not a cure for withdrawal!). Codeine will show up as morphine, of course-- as codeine is metabolized to morphine at the liver. As for what the person was actually taking... it doesn't really matter. Fentanyl is much more potent than morphine, and in my opinion much harder to get away from-- it is very lipid-soluble, and so it crosses into the brain much more quickly than water-soluble morphine. Fentanyl also builds up in fat stores in the body; in low doses it has a short half-life from redistributing throughout the body, but when taken over time, from a patch, it fills the 'fat stores' and leaves the body very slowly, making for a long, miserable withdrawal. My detox required a locked psych ward for a week, followed by over three months in a residential facility. I started sleeping well after about 4 months!
Your sister-in-law needs aggressive treatment of one kind or another. Her husband cannot save her, but he can perhaps use the leverage of leaving with the rest of the family to get her into treatment. Addicts believe that they are completely unique, and that nobody will understand them-- but in reality, addiction is remarkably similar from one person to the next. There IS help for her. But it will take more than a few days-- it will take the rest of her life, living by a new set of priniciples. The good news is that active recovery often provides a life that is better than the addict has ever experienced, even before using. Recovery can help a person learn to open up to others, to establish proper boundaries, to take appropriate risks in life, to experience happiness, rather than 'giddiness'... I am always amazed at how strongly an addict avoids recovery-- something that will improve his/her life so dramatically.
I feel for you, as the situation is truly tragic. You can't carry the load for your sister-in-law, but maybe you can help her see that there is treatment out there, and if she doesn't take it, she will be alone-- if not dead. I wish you well.
|Dr. Rashmi Ojha - Sun Dec 14, 2008 11:05 am|
Dear DC Angel,
Substance abuse is one of the very difficult and painful thing for a family. Your sister in law seems to have developed tolerance with opioids and her recent relapse puts her even at a higher risk. I suggest you to talk to her and ask her to seek help before it is too late. Ask her to schedule an appointment with either a psychiatrist or therapist for better understanding of her situation and adequate referral. It is very important to do so not only for her but for the sake of the little kids and her husband. Having opiods at home puts kids at risk as it can be lethal for kids. There is methadone treatment also available for opioid addiction but she needs to be evaluated first.
|Jeffrey Junig MD PhD - Sun Dec 14, 2008 11:29 am|
Fentanyl will NOT show up in standard tests for opiates. It is a synthetic narcotic and NOT structurally related to morphine. Assays for fentanyl are more expensive and not done routinely as part of drug screens by ERs or employers-- part of the problem in detecting fentanyl is that it is active in microgram doses, as opposed to the thousand-fold higher doses used of morphine; another reason is because fentanyl is metabolized at the liver, rather than excreted at the kidney. As I mentioned in my other post, the nature of the substance in the urine is a moot point. But for the sake of accuracy, codeine and some other opiates will appear as morphine in urine tests; some tests will simply measure 'opiates', but in either case, fentanyl will not show up.
|Tracy Winiarz, EMT-P - Wed Dec 17, 2008 10:22 pm|
Fentanyl is one of the most powerful opioid analgesics with a potency approximately 81 times that of morphine. It is classified as a Schedule II drug in the United States due to its high abuse rate.
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