I’ve written about the spectrum of medical and scientific opinion (not, unfortunately, always the same thing) over the use of opioids for treatment of chronic pain.  For those who missed the earlier discussion– one that produced a heated response from readers– I invite you to review those posts.

The essence of the issue is that over many years, there has been significant effort to increase patient access to potent opioids.  This effort has come in part from the pharmaceutical industry, but also from organizations that advocate for patients with a wide range of painful conditions, some with connections to pharma, and some without connections to pharma.

There has even been a push to increase opioid prescribing from Federal agencies.  Back in the 1990′s, when I chaired my local hospital’s Department of Anesthesia, we were warned by agencies hired by the hospital that the Joint Commision on Accreditation was focusing on pain control one particular year, and that some hospitals had been cited for insufficient prescribing of pain medications.

I will get to my promised response to my last post– the one that called out the detractors from Suboxone.  But first I have to share the story I read in the Maine Sunday Herald today about the surge in overdose deaths over the past year or two.  The article mentions the 28,000 overdose deaths across the US in 2007– the last year for which we have such numbers;  numbers that have surely risen since then.  The article also describes, more personally, the current overdose death rate in Washington County, Maine, which has doubled in recent years.

My point in promoting this type of information is to emphasize the magnitude of the problem.  It is one thing to argue about marijuana laws, where the death rate is comparatively tiny.  But people using opioids die at an alarming rate. 

As many readers know, I maintain a forum for people who take buprenorphine for opioid dependence. The initial purpose of the forum  was to serve as a source of accurate information about the new medication. Now, several years later, the forum is also a gathering place for people who share certain interests.

Studies have established a connection between opioid dependence and certain personality traits, including a tendency toward depression. In my conversations with people addicted to opioids, many describe an emptiness experienced throughout their lives. Opioids, prescribed or illicit, initially eased that emptiness, relieving the depression and for some even giving a sense, for the first time, that life was worth living.

I suspect that the emptiness experienced by people with borderline personality disorder is akin to the emptiness that some people find responsive to opioids.  Over the years I’ve had many people write to me, independently, about a ‘hole’ they felt before taking pain pills. I suspect that the current studies of the antidepressant actions of buprenorphine are examining similar effects.

As I’ve mentioned, I receive several e-mails each day asking questions about opioid dependence.  There are a number of confusing opinions, attitudes, and regulations that ultimately get in the way access to treatment.  And with opioid dependence, access to treatment can mean the difference between life and death.

One area of confusion relates to the use of methadone to treat opioid dependence.  Methadone is a potent, low-cost pain medication.  While a month’s prescription for Oxycontin may retail for $400, $500, or much more, a prescription for a similar amount and potency of methadone costs less than twenty dollars.

Besides treating pain, methadone is used to treat addiction to opioids through highly-regulated programs.  Laws allowing for these ‘methadone maintenance clinics’ were enacted in the early 1970’s, to counter the surge in heroin use that began in the late 1960’s .  The clinics were located mainly in inner cities, where most of the intravenous heroin addicts were located at that time.

Over the past ten years several corporations have purchased, consolidated, and refurbished methadone clinics, moving them to suburbs and rural areas to match the dramatic increase in addiction to heroin and other opioids in those areas.

I have several blogs and forums, all part of the mission to educate people about opioid dependence and buprenorphine.  Because of my online presence I am frequently contacted by reporters or journalists, and asked to provide my opinion about some aspect of opioid dependence.  The requests have become more frequent over the past year, suggesting that either my name recognition has increased, or that there is greater awareness—finally—that an epidemic of opioid dependence is killing people in large numbers.

Among those who contact me are people who are ‘anti-Suboxone.’  Some people are very heated in their arguments against the medication.  I run the addiction forum for another large health-related web site, and a couple years ago my presence on that site provoked ‘hate e-mail’ from readers, who accused me of being ‘just another drug pusher’ for my advocacy for buprenorphine!

I would like to lay out a road map for the next few posts.  I would like to write about several issues that relate in some way to the ‘disease theory of addiction.’  I want to explain why addiction is best considered a ‘disease;’ something that most people who work in the addiction field consider to be a fact, not a theory.

From there I would like to point out the differences in how society views addiction, compared to other diseases.  Finally, I want to present what I see as the fundamental flaw in how we treat addiction. To give a preview of that discussion, my concern about the treatment of addiction is that while many people CALL addiction a disease, few medical professionals or societies actually TREAT it that way.

What I write will anger a few readers.  I don’t WANT to make people angry at me; I just don’t see any way to present these ideas without causing anger.  The obvious solution to that dilemma is to simply write about something else.  But that hardly seems like the right thing to do.  Opioid dependence is, after all, the most critical health epidemic in my lifetime— if being critical relates to the years of lives lost to the disease.

My third patient of the day today was Tom, a 22 year old young man who I’ve been seeing for the past four years for treatment of addiction to opioids. We started out the session by talking about how good things have been going in his life since starting buprenorphine, a medication that efficiently eliminates cravings for opioids and that has been available by prescription in the US since 2003.

For several years now, Tom has been working full time. He has regained the trust of family members. He has become more confident in his own goodness, one component of the pathway toward greater self-esteem. The only stumbling block of the past few years was dealing with the attitudes of one family member who would tell him at family gatherings (whether or not she was asked) that because he took buprenorphine, he was not really ‘clean.’

Such an attitude is born of ignorance and can be dealt with over time by letting one’s recovery speak for itself, which is exactly what Tom has done.

Near the end of our appointment Tom shared his sadness over the loss of an old friend from his ‘using days,’ who died last week from an overdose of heroin. “It is sad that he never decided to get better” Tom said. “And I owe it all to you.”

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!’

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.