Dr Gabija Laubner-Sakalauskienė on Opioid Use: When the Dose Makes the Difference Between Medicine and Poison

Dr Gabija Laubner-Sakalauskienė / MF archive

Excessive use of opioid painkillers is a major problem in modern society across the Western world, especially in the United States, Canada and increasingly in the United Kingdom, where these drugs are too easily accessible and are used even when they are not necessary. This phenomenon, referred to as the opioid epidemic, is not yet as acute in Lithuania. However, Dr Gabija Laubner-Sakalauskienė, who, a decade ago, began her research into people who overdose and use prescription opioid preparations without medical need, says that doctors encounter such patients every day. We spoke with the doctor, a clinical toxicologist, and an anesthesiologist-intensive care doctor about her strong determination to help such patients. Here, she shares her thoughts on the current situation in Lithuania. In this interview, she shares her insights into the current situation in Lithuania and reflects on the conclusion she reached in her dissertation, defended at the Faculty of Medicine of Vilnius University (VU MF): that, in fact, there is a solution to this problem.

– The topic of your dissertation focuses on a very important problem – the overuse of opioid analgesics. While observing patients who suffer from chronic pain and who are prescribed opioid painkillers, did you analyse whether their quality of life would improve if they stopped taking these drugs?

– I have been interested in prescription opioids and drug detoxification since 2016, although I have worked in this field for two decades. In 2018, while monitoring patients undergoing detoxification, I observed a clear trend: their quality of life improved once they stopped taking the drugs. I published the retrospectively collected data and began selecting new patients for a subsequent comprehensive study, forming the basis of my dissertation. By the time I was admitted to doctoral studies, I had already accumulated several years of patient research data.

– Were patients willing to participate? After all, it must have been a daunting process to be asked to give up their pain medication.

– The use, recognition, and detoxification of medications are topics often surrounded by misconceptions. Patients frequently struggle to understand why one physician prescribes a medication that another later discontinues. Typically, they are referred to us by doctors who initially treated their condition and prescribed opioid analgesics – such as morphine, tramadol, or fentanyl – for disease-related pain. In many cases, these medications were essential, for instance, in managing cancer-related pain. However, once patients had undergone chemotherapy, surgery, or radiation therapy, and diagnostic results confirmed remission, continuing treatment with simpler, more conventional medications was usually sufficient. Despite this, opioids could not always be discontinued because patients had developed tolerance or dependence, or they continued to experience persistent pain.

We started a collaboration with pain specialists, neurologists, oncologists and GPs. Together, we identified a group of patients who needed detoxification. Our colleagues suggested detoxification treatment for these patients’ addiction. We invited 45 of these to participate in a scientific study. Unfortunately, most often, it is workaholics, those who feel under time pressure, who are unable to detox. They continue to use drugs, even though they are aware that it is interfering with their lives and destroying their families and careers.

– What does it mean when a patient is unable to stop taking drugs?

– When a patient develops dependence on a medication, the brain no longer recognises it as a prescribed pharmaceutical purchased from a pharmacy. Instead, it responds to the substance as to any other psychoactive drug, similar to those obtained illicitly. A specific biochemical mechanism is activated: dopamine is released in the brain, triggering the reward system and motivating repeated use. While the medication provides analgesia, it may also induce euphoria and a sense of calm, reinforcing the desire to continue. After several months of use, tolerance typically develops, requiring progressively higher doses to achieve the same effect. Continued use may lead to addiction, and attempts to discontinue the medication often result in withdrawal symptoms such as insomnia, anxiety, nausea, palpitations, sweating, and, in severe cases, panic attacks or convulsions. These manifestations closely resemble the withdrawal syndrome observed in illicit drug users.

– What does addiction to opioid preparations look like? How do those addicted feel?

– The course of opioid use largely depends on the patient’s diagnosis: Is the underlying illness still active? How do they perceive pain, and what is their level of tolerance? Some patients require morphine injections up to five times per day. In contrast, others need only a single dose, after which they may still experience restlessness, impatience, constipation, insomnia, and impaired ability to work. The duration of opioid action ranges from 6–8 hours and may extend up to 24 hours, depending on the formulation. For some patients, the fear of being without their medication becomes central: before travelling, they ensure they have an adequate supply, and in some cases, they may even return from the airport if a dose has been forgotten. Patients may consume as many as 15 ampoules daily while denying dependence, insisting that their condition is under control.

Addicted patients, however, frequently present with mood swings, episodes of anxiety, gastrointestinal disturbances, drowsiness or intoxication, unsteady gait, and, in severe cases, falls.

It is important to distinguish between two related but distinct conditions. Tolerance occurs when a patient recognises that increasing the dose may cause harm, yet requires escalation to achieve the same analgesic effect. Addiction, in contrast, is characterised by continued use despite the awareness of physical, psychological, and social harm – not only to health, but also to family relationships and professional functioning, which are often clearly recognised by those around the patient.

– Does it happen that it is not the patient, but their relatives who seek help for excessive medication use, because they see that the patient is increasing doses?

– Yes, this is a common occurrence. When patients escalate their doses, the prescribed medication often does not last until the end of the month. Consequently, they may begin to seek alternatives through the internet, local markets, or illicit sources. Relatives frequently observe that the patient’s interests narrow to a single goal: obtaining the painkiller. Work, social engagement, and physical activity become secondary or are abandoned altogether.

Dr Gabija Laubner-Sakalauskienė / MF archive

Family members who accompany patients to consultations are usually the first to raise concerns, while patients themselves are often sceptical or dismissive. To initiate a more open discussion, I typically ask a straightforward yet revealing question: How often do you empty your bowels each week? Opioids – both prescription and non-prescription – commonly cause opioid-induced constipation, and many patients report defecating only once or twice per week. This not only causes discomfort but is also harmful and toxic to the body. When confronted with this reality, patients often begin to acknowledge the negative impact of their condition on their quality of life.

– What is chronic pain, and what makes it special?

– There are two types of pain: acute and chronic. Usually, people clearly understand acute pain: if I cut my finger, it suddenly starts to hurt a lot. Chronic pain, on the other hand, develops when acute pain is left untreated for a long time, or when there is a condition that cannot be quickly cured and causes pain: for example, cancer, chronic neurological diseases of the spine, hernias, as well as joint pain while waiting for joint replacement surgery, and migraine headaches. Chronic pain lasts longer than three months. Unfortunately, one-fifth of the world’s population complains of this kind of pain.

– Do all of them need to take opioid analgesics?

– No, but most take non-steroidal anti-inflammatory drugs, such as ibuprofen, which, unlike opioids, cause psychological rather than biochemical dependence: people believe that taking the medicine will bring relief. Incidentally, many people who take medication for headaches are unaware of the phenomenon of medication-induced headaches. Over time, frequent use of such medication can lead to a habit of having headaches, where the medication is causing recurring symptoms. This can be a very significant part of the migraine problem.

– Is it true that acute pain is stronger than chronic pain?

– Chronic pain can also be very severe. On a ten-point pain scale, 10 is unbearable pain, and zero is no pain. People with arthritis or autoimmune issues may experience very severe pain. However, taking prescription opioids can cause a paradoxical condition called hyperalgesia, or increased pain perception: the person will perceive the pain as much more intense because of the opioids themselves. When a person has been taking opioids for a long time, it is impossible to tell whether they are really in pain or whether their perception of pain has changed. In such cases, there is a fear of discontinuing the medication, as the person claims to be in severe pain, even though the doctor can see no reason for it: the cancer is in recession, the spine has undergone surgery, the joints have been replaced, or the autoimmune condition has been regulated. This suggests that the person needs to undergo detoxification. The perception of pain will return to normal after a while, once opioids are discontinued. Later, even if medication is needed, a minimal dose will suffice.

– How widely are opioid analgesics used for pain relief?

– These drugs are in all hospitals and emergency kits and are used every day. They can be synthetic or natural. Of course, I’m not talking about poppies. I mean morphine, tramadol, fentanyl, pethidine and codeine. Unfortunately, codeine can be found in some over-the-counter medicines, which is a huge problem and dangerous. Despite the low dose contained in a single package, I would strongly recommend banning such preparations. We have encountered patients consuming dozens of packets of codeine-based medicines per day, while simultaneously taking antidotes to counteract the paracetamol contained within them. One might call this, somewhat ironically, “household alchemy”, yet the problem is extremely serious: these individuals know they can legally obtain such substances from pharmacies. In my dissertation research, nearly one-quarter of the patients reported using these types of opioids. It is also regrettable that despite the alcohol restriction legislation for retail shops applicable on 1 September, that is, on the day the new school year starts, it is still possible to buy preparations and tinctures containing alcohol in our pharmacies, which is what a significant number of people do.

– What are the consequences of long-term opioid use, and are there any irreversible health issues caused by these medicines?

– I am pleased to say that there are no irreversible consequences, but long-term opioid use can cause tolerance, dependence, hormonal and immune system disorders, cognitive impairment and altered pain perception. It’s true that the brain has a memory and remembers both the feeling of pain relief and the feeling of calmness for a long time, but this is not a life sentence for a person: it is possible to stop taking medicines. The bigger problem is the symptoms that a person experiences while taking the medication. An overdose can cause breathing and heart problems. People can die from an overdose because their breathing stops. However, if the medication is taken as directed by the doctor, these consequences should not occur.

– Is there a critical overdose limit?

– No, it is very individual for each person. By gradually increasing the dose, tolerance develops, and it is possible to reach a level that would be fatal for another person. We calculated the equivalent doses of pure morphine so that we would know how much morphine there is in tablet form that a person might consume per day. There were cases where a person consumed a dose equivalent to forty morphine tablets! This amount came not only from tablets, but also from injected opioids and fentanyl patches.

– In addition, do most patients take many other medications?

– Most often, yes, and some combinations can be deadly. Opioid drugs not only reduce pain, but also create depression: after taking them, going to work is a real torment, so, to counter it, stimulants are often used. I have patients who take painkillers in the morning, then have a smoke in order to wake up, later take prescription amphetamines, and at night take benzodiazepines for insomnia. And then there’s alcohol and large amounts of coffee – i.e. caffeine. It’s a cocktail of substances.

– The opioid epidemic is already widespread across the Atlantic, but what is the situation in Lithuania?

– In Lithuania and Europe in general, there is certainly no crisis of the same magnitude in opioid use, although the problem is growing in the United Kingdom. In our country, there are significantly more people using benzodiazepines, the most popular of which are Xanax, Lexotanil and Clonazepam. Meanwhile, in the United States, where the opioid crisis is most severe, it has been found that four out of five new heroin users previously used prescription opioids.

– Are prescription opioids the gateway to drug addiction?

– Yes, that is indeed what caused the crisis: at one point, there was very strong pressure from one pharmaceutical company to use prescription opioids, people started using them massively, and when they became addicted, they turned to illegal products.

– However, when we talk about opioid drugs, it is important to understand that they are the most effective painkillers.

– All medicines are good, but it is the dose that distinguishes a remedy from poison. The timing and intervals of medication intake are important. Opioids are excellent painkillers for acute pain. We all encounter opioid drugs at some point in our lives, whether we are undergoing surgery, treating complex diseases, or experiencing acute pain from an injury. Without opioids, we could immediately close all hospitals, as treatment procedures would become unbearable for patients.

Some people read about the side effects of opioids and the possibility of developing an addiction online, become frightened, and refuse to take them even when in pain. However, there is no need to fear these drugs. It is important to know that they can absolutely be discontinued when they are no longer needed.

– Are opioids used for sensitive patient groups such as pregnant women, women in labour, infants, and minors?

– Opioids are avoided during childbirth. Other painkillers, such as lidocaine, are prescribed. However, in cases of extreme pain requiring general anaesthesia, opioids may be administered to pregnant women. Minors who use opioids to the point of needing detoxification are very rare. If a woman used opioids while pregnant, the baby would experience withdrawal symptoms, and neonatologists would ensure these tiny patients are detoxed.

– Is there any pain that even opioid drugs cannot overcome?

– In general, there are no drugs that do not help – it all depends on the dose. Sometimes doctors administer standard doses based on the patient’s description of the pain, but if the dose is not sufficient, a more serious cause is sought – perhaps surgery is needed. A higher dose would anaesthetise the patient, causing them to fall asleep. However, this is only done after ensuring vital functions – such as breathing and heart activity – are stable, typically while the patient is on the operating table or in the intensive care unit.

– What does the detoxification procedure look like? How long does this process take?

– Detoxification is a procedure during which the patient is gradually weaned off opioids while withdrawal symptoms are actively managed. Attempting to discontinue opioid use without medical supervision is extremely difficult: patients typically experience severe distress, including profuse sweating, insomnia, nausea and vomiting, convulsions, panic attacks, and intense pain.

In a clinical setting, treatment is tailored individually to the severity of withdrawal. The process generally lasts 5–9 days. Upon admission to an inpatient unit, opioids are discontinued and replaced with other groups of medications: non-steroidal anti-inflammatory drugs for analgesia, benzodiazepines, and agents such as clonidine to alleviate withdrawal symptoms. Conscious sedation is applied, keeping patients mildly sedated – alert but protected from experiencing the full intensity of withdrawal.

For the first several days, patients remain under sedation; subsequently, the medications used to control withdrawal are tapered, and maintenance therapy is introduced. Following hospital discharge, a rehabilitation phase of up to six months begins. During this period, patients may experience pain recurrence or cravings, making relapse prevention crucial. Interventions focus on re-establishing healthy routines, particularly sleep regulation. Psychotherapy and behavioural therapy are recommended to provide coping skills and ensure continuous monitoring.

Dr Gabija Laubner-Sakalauskienė / MF archive

When psychological and physical rehabilitation are integrated, treatment outcomes are significantly improved. Attention to lifestyle factors is essential: regular mobility, adequate hydration, and dietary adjustments can support recovery. For example, eliminating foods high in sugar is advised, as they are known to exacerbate pain.

– Have there been any cases of relapse among the people you have studied, where you found out after a couple of months that they were using drugs again?

– In general, relapse is considered a normal part of the recovery process in addiction treatment. However, once patients have experienced the benefits of life without opioids, many express a strong desire to return to that state. For patients with ongoing pain, even if opioids are reintroduced, the required dose is usually much lower, which already represents a positive outcome. Occasionally, patients resume medication out of habit or inertia, but often discontinue again, recognising that it was unnecessary and that they can function well without it.

The results of my study demonstrated a mean reduction of 4.5 points on a 10-point pain scale following detoxification, compared to baseline levels. This suggests that opioid receptors had been “reset,” enabling patients to experience normal sensation once more.

We assessed patients’ condition before detoxification, immediately after, and again six months later. The majority did not relapse, and their quality of life showed marked improvement across multiple domains, including self-care, physical fitness, sleep, social interactions, and overall activity levels.

– Is failure to overcome addiction related to loneliness?

– All addictions are closely linked to the presence – or absence – of support. For a patient who is alone, maintaining recovery requires considerable personal strength. In contrast, when family members encourage, remind the patient to stay committed, promote healthy activities such as walking outdoors, and support better lifestyle choices (e.g., starting the day with vegetables rather than sweets), the process becomes significantly easier.

Patients without family support are not left without resources; however, they receive consistent guidance and encouragement from healthcare professionals. In addition, peer support organisations such as Pills Anonymous play an important role. Their group meetings provide patients with the opportunity to share experiences and receive motivation from others facing similar challenges, which has proven to be highly effective.

– What are your future ambitions? Will you choose a new topic to research?

– I would like to research how detoxification influences quality of life in individuals using benzodiazepine tranquillisers – such as alprazolam (Xanax), bromazepam (Lexotanil), promazepam, diazepam, clonazepam, and lorazepam. These medications are widely used and increasingly prevalent among young people, including minors. According to ESPAD (the European School Survey Project on Alcohol and Other Drugs), Lithuania has repeatedly ranked first in reported benzodiazepine use among 15–16-year-old girls. Notably, these drugs are often obtained without direct medical supervision – frequently supplied by a parent, relative, or peers’ parents. Dependence may develop after approximately four weeks of regular use, and the brain can retain a persistent fear of being unable to sleep without the medication, reinforcing continued consumption.