The forces of nature appear intent on reversing mankind’s progress toward better health. An example is the ever-increasing resistance of bacteria to antibiotics. A timeline of the existence of humans and bacteria shows that bacteria have been around for a very long time— much longer than mammals, and much, much longer than humans. In fact by the dawn mankind, bacteria had been thriving, relatively uninhibited, for over 2 billion years.
Modern humans have been around for 40,000-200,000 years or so, depending on the definition of ‘modern.’ Bacteria have had the upper hand during all of mans’ existence, save for the past 100 years after penicillin and other antibiotics were discovered. Only the most self-centered of species would look at a timeline and conclude that humans have won the battle with bacterial diseases. There are always reasons for optimism, but a fair assessment of our current struggle with antibiotic resistance suggests that someday, people will look back on the current sliver of time, when humans can treat most bacterial infections, as a golden era of medicine that wasn’t appreciated as such at the time.
Viruses adapt to mankind’s health efforts too, with new variants arising from the sludge at the bottom of the food chain to infect birds, swine, or other creatures before moving on to human hosts. The CDC and other scientists work to predict the vulnerabilities of the next super-virus, hoping to reduce the severity of the next pandemic. As with bacteria, we are enjoying an era without smallpox, polio, or other dreaded viral diseases that used to kill otherwise-healthy people. We take the victor’s position for granted to the point that our children don’t know why chlorine was first added to swimming pools. Gone with the last generation are the fears associated with iron lungs, orange window-signs, and leg braces.
Even the Human Immunodeficiency Virus, an agent of certain death in the 1980’s was transformed into a chronic, treatable illness. I was new to medicine when ‘universal precautions’ were first instituted (can our children even imagine having their teeth examined by someone not wearing latex gloves?!) Researchers don’t celebrate, though, since medication-resistant strains of HIV were expected …
Several of my patients have warned me about the world ending in a few days, on December 21, 2012. There are variations on the theme, but the basic idea is that the Mayans, who were accomplished mathematicians and astronomers, used an advanced calendar to measure planetary cycles… and that calendar ends at the end of this week. Some patients tell me that the end of the Mayan calendar coincides with predictions by the French seer Nostradamus, although the definitive authority on everything, Wikipedia, holds that Nostradamus did not make such a prediction.
I’ve browsed internet sites about this topic in order to prepare this post and found that there are about as many different versions as there are web sites about the prediction. I suspect that some versions have more adherents than others, and I have no idea which web sites are the most authoritative. I’ve read, though, that the world will end as described in the Book of Revelation in the Bible, or that instead, humanity will be erased, leaving the Earth unscathed. I’ve read that the Earth and Sun will line up in a way that eclipses the energy flowing from the center of the Milky Way Galaxy, causing humanity to die off and be replaced by aliens from outer space.
Like any good prediction, this one has plenty of wiggle-room. Comparisons between our modern calendar and the Mayan calendar require assumptions about how the Mayans determined months and years, so December 21st is only one best guess for the end of times. Some interpretations place the date a year or so ago, and others place the date a year or so in the future. In other words, things are not quite as tidy as they were at the millennium, when people only had to figure out which time zone marked where midnight would spell disaster.
Talk about the end of the world carries a certain levity, but like anything conjured by humans has a dark side. In 1997, 39 members of the religious group Heaven’s Gate committed suicide in order …
The FDA recently released a Drug Safety Announcement regarding the use of codeine in young children after tonsillectomy/adenoidectomy surgery for obstructive sleep apnea. I was somewhat surprised to see a safety announcement on a medication that has been in use for decades, but the release underscores our improved knowledge of drug metabolism, and the broadening demographics of the United States.
Codeine has little activity at opioid receptors. The analgesic effects of codeine are actually caused by morphine, after the conversion of codeine to morphine at the liver. The conversion is catalyzed by an enzyme called CYP2D6, part of the cytochrome system of enzymes that are involved in the breakdown of a number of compounds.
I have written about the addictiveness of narcotic pain medications. People addicted to opioids often go to significant lengths to obtain prescriptions for narcotic pain relievers from healthcare practitioners. Emergency room physicians and nurses become aware of the efforts of ‘narcotic-seekers’, which range from faking pain symptoms or dental injuries to self-catheterization and instilling blood into the bladder to fake kidney stones. Distinguishing those with real pain from those who are addicted and not experiencing pain is a serious situation, but doctors roll their eyes at some of the more-typical presentations. One such situation is the patient who reports an ‘allergy’ to all of the weaker narcotics, and claims that ‘the only drug that works is (insert Dilaudid, morphine, oxycodone, or another potent opioid here).
Codeine is one drug that is commonly rejected as ‘ineffective’ as part of a request for something stronger. When I was a medical student, we assumed that requests for something other than codeine were disingenuous. But at some point, maybe 15 years ago, I remember reading an article that described the conversion of codeine to morphine by the liver. The article reported that the enzyme that performs the conversion exists in varying forms across the population, with some ethnic groups having more active forms of the enzyme than others. Some people have very low levels of CYP2D6, and therefore get very little analgesia from codeine. In …
I received the following email last week. I considered trimming it down, but the story is well-written and describes a history that is similar to that of many of my patients. As usual, I will write a follow-up post in a week or so.
Dear Dr. J,
I have read many of your posts over the past few years. Like many, I started out disagreeing with your comments and insight, while blaming my inability to manage my addiction on the Suboxone treatment. My active addiction to opiate pain medications was brief, about 4 months of hydrocodone/oxycodone use in the end of 2007. In early, 2008), I reached out to my primary care physician who directed me to an inpatient stabilization followed by Suboxone maintenance/addiction therapy.
When I entered treatment I maintained the belief that I was not an addict, and my doctor initially supported this attitude. He described my situation as physical dependence stemming from treatment of pain. I was a recent college graduate, I had a wonderful upbringing, a bright future…I believed that “people like me don’t become drug addicts.” So of course I wanted to minimize the seriousness of my illness.
I convinced myself that this physical dependence “happened to me,” and I was doing what needed to be done to resolve the issue. So I saw my doctor monthly and went to weekly addiction therapy sessions. I did not use “street drugs,” or any other RX meds, so my UAs were always clear, and eventually I was seeing the doctor for a refill every few months.
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.