Extended-Release Opioid Agonists Like Exalgo Can Also Be Misused
Abuse of around-the-clock hydromorphone extended-release.
While not as popular as a drug of abuse as oxycodone, Exalgo abuse is still a concern. The drug contained in the Exalgo delivery system, hydromorphone, is the same drug that is branded as Dilaudid. Doctors who believe that they can avoid issues of abuse and diversion of their prescribed medications should be aware that all opioids, including extended-release hydromorphone, can be abused. In fact, misuse of Exalgo and similar opioid pain medications may be more common than we previously thought.
Abuse by swallowing a pill.
As noted in the CDC 2016 report on opioid prescribing, much of the abuse of opioids occurs by users simply swallowing a tablet. They are not crushing, snorting or injecting. So, all of the efforts of pharmaceutical companies to put abuse deterrents in their opioid drugs are useless against this form of abuse. How is swallowing a tablet with a glass of water abuse? If the patient takes more opiate pills than directed, it is abuse. Or, if they take opiates not prescribed to them. Additionally, if the opiate is being taken to get high rather than for the reason it was prescribed, the patient is abusing it. So, it is possible for a person to swallow Exalgo with a sip of water and still be abusing it.
FDA-approved extended release opioids can cause opioid-induced respiratory depression.
When we think of respiratory depression, we may imagine a person who has shot up too much heroin or fentanyl on the streets. Or, we may imagine someone who has crushed up a bunch of pain pills to inject into a vein. However, it is possible for respiratory depression to occur with extended-release opioid agonists, such as Exalgo, MS Contin, Oxycontin, Oxymorphone ER or even Zohydro ER. If these time release drugs are taken in excess or if there is co-administration with other sedating drugs, the risk of respiratory depression increases. Therefore, while we are concerned about abuse of these drugs, we also must consider the possibility that patients who take these drugs as directed may possibly experience respiratory depression as well.
Shorter-acting opioid pain medications may be safer than extended-release opioid agonists, such as Exalgo.
The CDC 2016 report on opioids discusses the dangers of extended-release opioids compared to immediate-release opioids. This contrasts with the beliefs of pain management experts and pharmacists for many years. The thinking was that long-acting opioids have a longer, more steady release, so overdose is less likely. Also, many of the extended-release tablets have some sort of abuse deterrent incorporated into the drug release system. However, the fact is that long-acting opioids, such as Exalgo and others, can be much more dangerous. One of the main reasons for this is that these extended-release tablets are available in much higher dosages than their short-acting counterparts. For example, Oxycontin is available as an 80mg tablet, compared to Percocet 10mg, a commonly available short-acting equivalent.
Sedating effects of opioid pain medications are also dangerous.
While we are often mostly concerned with the dangers of opioid-induced respiratory depression, we should not discount the dangers of the sedating effects of opioid agonist drugs. If a patient takes Exalgo and drives a car, there is possibly an increased risk of accidents due to the sedating effects. This is especially true within the first week or so of taking the medication or after an increased dosage. Once the drug reaches a steady-state in the patient’s system, safety from sedating effects is somewhat improved. Concomitant use of this opioid with sedating medications, such as muscle relaxers, anxiety meds or even certain over-the-counter drugs can cause profound sedation due to CNS depression. For information on drug-drug interactions, you can consult with your pharmacist.
Other adverse reactions caused by Exalgo.
If a patient or a drug abuser suddenly stop taking hydromorphone, they are at risk for suffering from a withdrawal syndrome. This is not unique to Exalgo. Withdrawal can happen with any drug that acts on the mu-opioid receptor. While not life-threatening, opioid withdrawal syndrome is very unpleasant. There are also other possible adverse reactions, such as constipation and allergic-type skin reactions.
Treating Exalgo addiction.
First, we should acknowledge that a patient can be physically-dependent and opioid-tolerant on prescribed Exalgo and not be addicted. If a patient is prescribed this once-daily opioid pain medication long-term, they will likely get physically sick with a withdrawal syndrome if it is discontinued abruptly. Physical dependence by itself is not the same as addiction. However, if a patient is addicted, they should consider medication-assisted treatment as a solution to transition from being addicted to this opioid pain medication to being clean and in recovery. Medication-assisted treatment (MAT) involves the use of buprenorphine, or the non-opioid drug naltrexone. Methadone is another option that may be best in some cases.
Is MAT a long-term solution to Exalgo addiction?
After many years of experience in treating opioid use disorder, we have learned that the condition is a long-term chronic condition that is best treated with ongoing medical management. For example, patients who take Suboxone long-term have a high rate of success in avoiding relapse. They also have a high quality of life, especially compared to their life during active addiction. If you are addicted to the extended-release opioid pain medication, Exalgo, there is hope to recover and get back to your normal life again. The first step to getting better is seeing a doctor who is experienced in providing MAT for opioid addiction.
Frequently Asked Questions about Exalgo Addiction
What makes Exalgo different from Dilaudid?
Both are opioid pain medications that contain the drug hydromorphone. The difference is that Exalgo is long-acting and Dilaudid is short-acting. Exalgo makes use of a specially designed tablet that has the opioid inside of a rigid shell with a single laser-drilled hole. There is a substance within the shell that expands when wet. This pushes the medication out through the hole at a steady rate. This advanced delivery system is licensed by the manufacturer from another company.
Why was it necessary for Exalgo to be invented when there are already other extended-release opioid pain medications?
Exalgo is an extended-release version of hydromorphone, the same ingredient in Dilaudid. In the treatment of chronic pain, it is typical for a patient to get a prescription for an extended-release and an immediate-release opioid. The immediate-release preparation is used for breakthrough pain. It is recommended, when possible, to use a pair of medications that contain the same active ingredient. Until the release of Exalgo, there was no extended-release version of hydromorphone to pair with dilaudid. This is one possible explanation for why Exalgo was FDA-approved.
What is more likely to be abused, Oxycontin or Exalgo?
Oxycontin has a long history on the market and it has a high level of street recognition. This means that drug users know what it is and how to abuse it. Because of this, they will more readily buy it from a drug dealer. As a result, around 2010, Purdue, the manufacturer of Oxycontin, implemented a new abuse deterrent feature that involved an internal polymer gel matrix that made certain types of abuse of the drug more difficult. Exalgo, on the other hand, has no specific abuse deterrent system. Still, it is relatively difficult to abuse because the tablets are difficult to break. Additionally, Exalgo has the benefit of “security through obscurity”. It is a far less popular opioid pain medication, so it likely has a lower street value and the abuse rates of Exalgo compared to Oxycontin are significantly lower.
Would there be any difference in starting Suboxone after quitting Dilaudid versus Exalgo?
The only difference would be the time necessary to wait after taking the last dose of opioid. Because Exalgo is an extended-release medication, it takes longer to leave the patient’s system than Dilaudid. Hence, the patient would have to wait a bit longer before they are ready to start Suboxone. Otherwise, the treatment protocol would be essentially the same.