Archives for October, 2010
Like many people with opioid dependence, I did not progress to a severity of illness where I decided that I needed addiction treatment. It would have been less burdensome for my family, of course, had I come to such a realization. But I needed stronger ‘encouragement,’ in the form of life falling apart and having nowhere to turn, except treatment. The nature of opioid dependence leads the addict to cling to the illusion of power, believing that if he tries one more time--- just a little bit harder, or perhaps using some special technique—he will find the will power to taper off drugs on his own, and then avoid them forever. Of course any person addicted to pain pills desperate enough to walk into a psychiatrist’s office has tried to stopping dozens of times, if not more. That doesn’t prevent cold feet at the prospect of surrendering to the treatment of some doctor, and patients often scramble to reverse the actions set in motion by spouses, parents, and other family members. ‘I really think I can do it this time,’ they say. I’ll cut back by a tiny amount every few days, and THIS time I’ll REALLY stick to the schedule!’
I've described the gray area between appropriate treatment of chronic pain using opioid medications, versus deliberate or accidental over-prescribing of narcotics for patients who don't need them. In many cases, the decision whether the prescribing is justified depends on who is making the determination. There are clearly physicians who act too aggressively at increasing dosages of narcotics, and there are clearly patients who are too careless in their use of addictive medications. At the same time, there are a number of patients who suffer from severe pain, who are unable to find a physician who will prescribe opioid pain medication-- medication that if managed properly could relieve that pain. And then there are cases that remind me of the famous quote from Justice Potter Stewart, in a 1968 Supreme Court case involving pornography: "I know it when I see it." Such was the thought that came to me as I read the news story about a physician and his wife, whose prescribing of opioid pain medications has been linked to at least 68 deaths:
Addiction has historically been viewed not as an illness, but instead as either the personal choice to engage in bad behavior or a lack of self-control over intoxicants. But a growing body of research has demonstrated that genetic and neurochemical factors play large roles in substance dependence. Increased understanding of the science of addiction has led to a new way to thinking and speaking about substance dependence, for example the phrase ‘disease theory of addiction’ replaced by ‘the disease of addiction.’ Of course there will always be members of society who see addiction as a lack of will power, and I sometimes wonder whether the definition of addiction as a disease by the medical profession is more a matter of lip service than of actual belief. But at least according to ‘medical political correctness,’ addiction has gained standing as an illness that warrants research dollars, rather than a character flaw that warrants public scorn.
Over the past fifty years, a period of time that sometimes seems like only a blink of the eye, a number of different substances have held the position of society’s most-favored drug of choice. Some substances have been more popular in one group of people or another, but there have been broad trends toward the use of certain classes of substances that to some extent have defined, and have been defined by, the decade of their popularity.
In a response to an earlier post, a woman wrote that her son, an opioid addict, developed a new addiction to alprazolam—a medication prescribed by his physician to treat opioid withdrawal while starting buprenorphine. I’ll soon write about the use of buprenorphine for opioid dependence, but for now I will note that the opioid withdrawal that occurs when starting buprenorphine is short-lived, and does not generally warrant treatment with an addictive substance like alprazolam. I did not, of course, witness her son’s anxiety, and I know nothing about the details of the case. But her remarks reflect a common phenomenon that deserves examination.
I’ve shared a small amount of information about my own addiction to opioids. My addiction started in the early 1990s after I took codeine for a lingering cough from a respiratory infection. As an aside, codeine is converted to morphine by the liver, a metabolic process that varies in efficiency from one individual to another. Some people obtain little pain relief from codeine because of the lack of conversion to morphine. Unfortunately, some doctors interpret a patient saying ‘codeine doesn’t seem to work to me’ as evidence that the patient is an addict seeking strong narcotics. I’m sure that in some cases, a request for non-codeine narcotics is a sign of drug-seeking. But some people have a legitimate beef with taking codeine—a medication that in their cases has minimal pain-relieving activity. I knew fairly soon during my use of cough medicine that I had become addicted, but I tried my best to push thoughts of addiction from my mind and instead get on with life. The realization of the depth of my problem became harder and harder to avoid as my tolerance increased. It is one thing to self-medicate a cough with a half-teaspoon of cough syrup; but something else to gulp down cough medicine from the bottle!
In earlier posts, I provided background for a problem that has captured headlines in recent years, namely the problem of addiction to opioid pain medication. My reason for providing background was to make clear that addiction to opioids is not a problem confined to high school kids or back-alley junkies, but rather cuts across all age groups and socio-economic divisions. Moreover, the problem of prescription drug addiction blurs the dividing line between illicit use of substances and the appropriate use of medication; appropriate use that can become problematic over time. And while there are people, policies, or companies that can be blamed for some of the increase in opioid dependence, a number of cases arise from reasonable efforts by doctors or patients to relieve pain and suffering.