A Prescription for Trouble: Levorphanol Addiction

A Prescription for Trouble: Levorphanol Addiction

About 10 years ago, pain specialists were engaged in a controversy about the use of narcotic painkillers such as levorphanol that are typically prescribed only to the terminally ill. These drugs in the morphine family are similar chemically to heroin and just as addictive, but the new thinking was why should people with arthritis, back pain and other chronic pain have to limit their lives when these remedies are available? As Seattle pain specialist Dr. Jane Ballantyne told the New York Times: “We were on a mission to help people in pain.”
As the rules for pain treatment loosened up, drug companies became more aggressive in marketing narcotic painkillers. They conducted many of their own clinical trials, and some threw out results that were not in their favor. Drug companies such as Purdue Pharma hired fleets of sales staff and upped their bonuses to promote the drugs among doctors and reprinted articles based on dubious science that indicated their products were not as addictive as most medical professionals believed. Its marketing was misleading enough that Purdue pleaded guilty in 2007 to a federal criminal count of misbranding the drug “with intent to defraud and mislead the public,” paid $635 million in penalties, and today remains on the corporate equivalent of probation.

Within a decade, the medical community could see the results of the new surge in painkiller prescriptions. Studies of people under workers’ compensation programs were indicating that the more they used a narcotic painkiller, the more likely they were to have their dosage and the length of your recovery time increased. Parts of the United States where the drugs were most heavily promoted were seeing increases in addiction. The annual Monitoring the Future study of young people was showing increases in teenagers experimenting with narcotic painkillers, and celebrities such as Matthew Perry, Rush Limbaugh and Cindy McCain were entering treatment for addiction to them.

By 2012, painkillers were causing more overdose deaths than cocaine and heroin combined, a 400% increase since 1999. As reported in the Washington Post, one review out of the Yale School of Medicine found that diagnoses of addiction were “common” in patients given opioids for back pain. The federal Centers for Disease Control and Prevention has urged doctors to use opioids more judiciously; in 2008, the most recent year with available data, 14,800 people died in episodes involving prescription painkillers.

The latest disturbing trend is that people addicted to narcotic painkillers such as levorphanol are now turning to heroin because it is cheaper.

As Ballantyne said recently, “The long-term outcomes for many of our patients is appalling, and these painkillers are ending up destroying their lives.”

What is levorphanol?

Levorphanol is a manmade narcotic painkiller first synthesized in Germany in 1948. It comes as a white crystalline powder soluble in water and its chemical formula is C17H23NO•C4H6O6•2H2O.

Like all painkillers, Levorphanol is compared to morphine, the original narcotic made from a natural substance found in poppy plants.  Aspirin is 1/360th times as strong as morphine, oxycodone is seven times stronger, fentanyl is 100 times stronger, and levorphanol (taken at therapeutic levels) is eight to 12 times stronger than morphine. Levorphanol is considered as addictive as morphine. As an opioid painkiller, levorphanol works in the brain and spinal cord to disrupt signals between nerve cells and thus ease pain.

Levorphanol is similar to methadone in that it stays in the body for a long time. Unlike heroin, it does not produce a strong euphoria. Methadone and levorphanol do not provide the “highs” and “crashes” of heroin.

In legal terms, levorphanol is a Schedule II Controlled Substance, which means it ranks with oxycodone, methamphetamine and morphine in terms of its potential for severe psychological or physical dependence. These drugs can be used for medical purposes, but only under the strictest controls. Anyone caught possessing, selling or dealing in levorphanol can face the harshest penalties under the federal drug laws.

What are the medical uses of levorphanol?

Levorphanol is prescribed for moderate to severe pain. It is so addictive that one cannot get a refill — a new doctor’s prescription is required. It is frequently administered by injection in doctors’ offices or hospitals.

Roxane Laboratories manufactures levorphanol under the name Levo-Dromoran. It comes as small, white 2 mg tablets or in little vials of liquid, also 2 mg in strength. The typical dose for adults is 2 mg every six to eight hours, and not more than six to 12mg per day. The effects of the medicine peak within 30 minutes of an injection, and within an hour of taking a tablet.

A 2003 study by the University of California in San Francisco attempted to examine whether levorphanol should be used for neuropathic (nerve damage) pain. Most patients needed a high dose of levorphanol to achieve pain relief and one in four dropped out of the study because of its side effects, including anger, confusion and irritability. Dr. Michael Rowbotham, lead researcher, wrote in an article in the New England Journal of Medicine that “levorphanol does not help everyone.”

Does Levorphanol show up in urine tests?

Levorphanol will show up in routine urine and blood tests. It has a long half-life in the body, from 11 to 16 hours. Levorphanol could show up in tests for up to 80 hours or three days after it’s taken. Levorphanol can also produce a false positive for dextromethorphan, a frequently abused drug found in cough medicines. Dextromethorphan is a codeine analog of levorphanol.

What are the side effects of levorphanol?

Levorphanol, like any opiate painkiller, can produce addiction, which in turn can cause long-term damage to the body. When used recreationally, narcotics can create stupors that last for hours and decrease sex drive. As one person put it, “Your ability to get things done and your sex life goes away.

Constipation can be such a difficult problem for opioid users that they often limit themselves to sweets, starches, and other easily digested foods. Relistor is a relatively new drug prescribed to opioid patients for constipation.

A study of 1,400 people taking levorphanol found that the most common side effects were nausea, vomiting, mood changes, runny nose, flushing, constipation, problems with urination, dry mouth, depression, sleep apnea and abnormal vision. Agitation, confusion, changes in consciousness, dizziness, fainting, insomnia, hallucinations, slow breathing, slow heartbeat, hostility, lethargy, lightheadedness, stupor, sweating, wheezing, chest pain, unusual dreams, delusions, sadness, irritability, discouragement, itching, and nervousness have also been reported.

Doctors typically tell patients to stop taking levorphanol it if they experience dangerous side effects such as seizures, very slow breathing and severe confusion.

What are the dangers of levorphanol?

Because of its addictive nature, levorphanol carries a warning label that tells patients not to share it. Its manufacturer also warns that certain vulnerable patients are in danger of severe respiratory depression, sleep apnea or hypotension when using levorphanol.

The drug causes drowsiness, thereby increasing one’s chances of falling and or being involved in accidents when driving a car or operating other machinery.

If levorphanol is used in amounts not medically recommended or combined with alcohol or certain drugs, there is a risk of death by overdose.

Levorphanol can be problematic to prescribe because the drug has such a long half-life. It can accumulate to toxic levels if the dose is increased too much or without waiting for a steady state to occur, usually within two or three days.

People who are allergic to narcotics can enter a life-threatening syndrome called anaphylaxis the first time they take levorphanol. They may develop swelling in the mouth, face, and lips, have difficulty breathing, faint and develop an irregular heartbeat or seizures. Other symptoms include rash, hives, and itching. A person in anaphylactic shock needs emergency treatment by medical professionals.

What drugs interact with levorphanol?

Levorphanol has serious and life-threatening reactions with hundreds of drugs. Any drug that depresses the central nervous system can react with levorphanol to slow down the body to dangerous levels. The person may start breathing very slowly and then simply stop breathing. Some of these drugs are alcohol, other narcotic painkillers or illegal narcotics such as heroin, tranquilizers, sleeping pills, anesthetics for surgery (even dental surgery), chloral hydrate, antihistamines, sedatives, barbiturates, medicine for colds and flu, and anti-seizure medication. If you take levorphanol, you should avoid fentanyl, carisoprodol, alprazolam, diazepam, meperidine, hydrocodone, oxycodone, opium, morphine, perampanel, risperidone, tobacco, tricyclic antidepressants, and phenothiazines, monoamine oxidase (MAO) inhibitors and gamma hydroxybutyrate (GHB).

Naltrexone will cause levorphanol to stop working.

Who should not take levorphanol?

Because levorphanol can depress breathing, it is not usually prescribed to people with breathing disorders such as asthma, chronic obstructive pulmonary disorder or sleep apnea. It is not prescribed to patients who have Addison’s disease, a history of alcoholism or substance abuse, enlarged prostates, hypothyroidism, mental illness, brain tumors, pressure in the head, gallbladder disease, heart disease, low blood pressure, history of heart attacks, kidney, stomach or liver diseases.

Because the elderly are in danger of falling, experiencing confusion, and may have impaired liver or kidney functions, levorphanol is not ordinarily prescribed to them. The studies that exist on the effect of levorphanol on children and unborn children are inadequate so it is not usually prescribed to pediatric patients or pregnant women.

What is levorphanol withdrawal?

Symptoms can be similar to an extremely difficult case of flu, and may include diarrhea, anxiety, runny nose, sneezing, goose bumps, tremors, insomnia, nausea, vomiting, muscle pains, rigid muscles, rapid heartbeat, shivering, cold sweats and hallucinations. How long the syndrome lasts and how severe it is will depend on individual factors, such as the amount taken, whether more than one drug was abused, the length of time the person was abusing drugs, age, weight and general health. Withdrawal from levorphanol can be extremely difficult and many people give up in the middle of the syndrome, which can last several days or more.

The best and safest thing to do is to check into a medical facility that specializes in drug addiction and undergo withdrawal under supervised conditions. Medical professionals can administer certain drugs to ease the symptoms.

What is a levorphanol overdose?

Levorphanol overdoses can be fatal. Studies have shown that they are more likely to occur if a person takes more than the recommended dose, if the drug is accidentally ingested by a child, or if the person taking the drug had certain illnesses or is a particularly small adult.

Symptoms of a mild overdose can be euphoria, vomiting, drowsiness, nausea, slow heartbeat, low blood pressure and pinpoint pupils. Symptoms of a severe overdose can be respiratory depression, apnea, coma, irregular heartbeat, and hypoxia (a condition in which the body has inadequate oxygen).

In an emergency room, doctors will open the person’s airwaves, administer intravenous oxygen and fluids, and monitor the patient’s vital signs. The usual antidote for opioid poisoning is naltrexone, which is sometimes given intravenously. Naltrexone can wear off before levorphanol; consequently, patients can be sent home too early and relapse. Pumping the patient’s stomach can result in a prolonged absorption of levorphanol, and acute lung injuries can develop after a levorphanol overdose.

What is levorphanol addiction and abuse?

Levorphanol is not as popular among people addicted to prescription painkillers as oxycodone or hydrocodone. Levorphanol does not provide the intense euphoria that these other drugs do, and it is 10 times more expensive than methadone and twice as expensive as morphine. A bottle of 250 levorphanol pills can retail for $450. The drug is not prescribed as often as hydrocodone or oxycodone, and therefore not as readily available. Levorphanol tablets cannot be crushed and therefore cannot be snorted or injected.

Nevertheless, some people abuse levorphanol for non-medical reasons, particularly when other drugs are unavailable, and others actually prefer it over other opioids.

When levorphanol is prescribed for pain, patients do not usually become addicted because their doctors are monitoring them. Many who are taking strong opioids like levorphanol have terminal illnesses and therefore are not at risk for long-term addiction.

How can I tell if I am addicted to Levorphanol?

If you can answer yes to any of the following questions, consider talking to your family physician, an addiction specialist at a drug rehabilitation center or a mental health professional at your local clinic about your levorphanol problems.

  • Are you using levorphanol or other opioids without a prescription?
  • Are you obtaining drugs by stealing them from medicine cabinets, using forged prescriptions, buying from street dealers or otherwise through illegal means?
  • Do you worry you will get caught?
  • Do your family and friends criticize you for using drugs?
  • Do you think that your use of drugs is limiting your life and potential?
  • Do you feel guilty, ashamed or embarrassed about your use of narcotic painkillers like levorphanol?
  • Is it impossible for you to go a day or more without using narcotics?
  • Have you driven a car when you were using drugs?
  • Do you experience withdrawal symptoms when you stop using levorphanol or other painkillers?
  • Is your drug use interfering with your performance at work or school?
  • Have you tried to stop using drugs on your own but failed?
  • Do you worry about your abuse of narcotics?
  • Is your use of drugs causing you such physical problems as constipation and headaches?

What treatments are available for levorphanol addiction?

Addicts need to take levorphanol just to feel normal. Doing drugs becomes a lifestyle.

Unfortunately, there is no magic drug or physical therapy to treat addiction. State-of-the-art treatment involves a change in lifestyle and finding new interests and pursuits that replace the addiction. This usually involves giving up drug-using friends, avoiding places where drugs are available, becoming involved in your career or hobbies, taking care of yourself physically and developing healthy relationships. State-of-the-art treatment is to enter a drug rehabilitation center to first detox, and then learn how to develop this new lifestyle.

People who enter treatment centers sometimes wonder why they have to attend art, music and drama classes or learn yoga or sit with a therapist to discuss their situations on a one-on-one basis. These techniques, however, have been proven medically effective in double-blind studies as ways to treat addictions to narcotics. Yoga, for example, relaxes the body without drugs. Talking with a trained mental health professional can help you learn where you want to go in life and what jobs, relationships, and pursuits you want to keep and which ones you want to eliminate. Your therapist can help you make new choices for yourself and steer your life in a new direction. Art and music can get you in touch with your emotions and help you better understand yourself. A good residential treatment center can be an amazing, life-changing experience if you are willing to try.

Once you return home, you typically will remain in an aftercare program that involves attending support meetings and continuing in psychotherapy with a local counselor.

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