Are you addicted to pain pills? You certainly havecompany. The cycle of use, dependence, and use is playing out, over and over,in every community across the country. Note that I describe the cycle as ‘use,dependence, use’—a description that is accurate, because in most cases thecycle of dependence starts when you appropriately use medication administered bya person who you trust—your physician.
Pain pills are often called ‘narcotics’–a term that comesfrom the Greek word ‘narcosis’, or ‘sleep’—because of their sedative effects. Physicians use the word ‘narcotic’ to refer to different things in differentsituations. For example, when referring to controlled substances, ‘narcotics’may be used to denote drugs regulated by the Drug Enforcement Administration. An anesthesiologist uses ‘narcotic’ to refer to the portion of the anestheticthat is comprised of drugs that bind to brain ‘opiate receptors’. ‘Opiate’ isanother word used by physicians in reference to pain pills. The word comesfrom ‘opium’, a substance derived from poppies and used to make heroin andmorphine. The ‘opiate’ reference is also used for synthetic pain medicationsthat have no connection to poppies or opium save their pain-killing effects.
Most people have heard of ‘endorphins’. Endorphins areproduced in the human body, and when released, block pain. Endorphins areoften referred to as ‘endogenous opiates’ because of their role in painsensation, even though they have no relation to poppies or opium, and arestructurally quite dissimilar. These natural pain relievers have otherfunctions in the body, roles not relevant to this discussion. Endorphins areone group out of dozens of ‘neurotransmitters’, substances involved in thecommunication between nerve cells. Endorphins and other neurotransmitters act at‘receptors’, the receptor being a lock on a nerve cell, and theneurotransmitter being the key that fits in the lock. Amazingly, poppiesproduce a substance that looks different from the natural key, but that actslike endorphins by fitting the exact same keyhole. That substance—one moleculefrom the sap of a red flower—has given the human species the ability to ease sufferingin countless individuals, and has resulted in the deaths of millions of others.
Over the years scientists have developed synthetic ‘opiates’with potencies far beyond anything produced by nature. Anesthesiologists use‘sufentanil’ reduce responses to pain during surgery. Sufentanil is extremelypotent; an amount the size of one grain of salt, say one tenth of onemilligram, placed on the tongue would cause respiratory arrest in a large manwithin seconds. More commonly opiates are taken by patients in the form ofcodeine, hydrocodone (Vicodin), oxycodone (Oxycontin), or hydromorphone(Dilaudid). Prescriptions for these substances are handed out to millions ofpeople each day in response to complaints of pain.
Opiates relieve pain, and work in different areas of thebrain to elevate mood, ease tension, give a subjective sensation of warmth, andcause sedation. They can cause nausea and vomiting, particularly in patientswho are naïve to them. Finally, they change the response of the brain to lowoxygen and high carbon dioxide in the blood, and slow respiration. The mostcommon cause of fatal overdose is respiratory arrest, where the brain stopssending impulses to the diaphragm, and the patient suffocates. This fatalresponse is most common during sleep, or when opiates are taken in combinationwith other sedative medications.
Opiates are addictive. There is no way to take them withoutthe body adapting and becoming dependent on them. ‘Tolerance’ to pain medicationbegins after the first dose, when the ‘locks’ on nerve cells adjust in responseto all of the ‘keys’ floating around. With time it takes more and more keys toopen enough locks to cause the reaction at the nerve cell. Tolerance is onehalf of the process of addiction, and is the reason for ‘withdrawal’, thesickness that occurs when tolerance has developed and the drugs, or keys, aretaken away. The other half of addiction is so-called ‘psychological’, which Isuppose is accurate to a point. For some reason, once something is assigned tothe psychological category, it is treated differently by physicians, patients,and the rest of society. ‘Psychological’ does not imply that a person has morecontrol than with a ‘physical’ condition—if anything, things occurring on apsychological level are far more difficult to recognize and treat than arephysical conditions. The psychological addiction to opiates also develops veryrapidly, and there is little if anything that can be done to prevent it. Psychological addiction is real, and is extremely powerful. The result is adesire to take opiates. The desire may take the form of physical symptoms,such as an increase in pain, and so psychological addiction and physicaladdictions are intimately connected.
To health systems, time is money. Patient complaints arehandled as quickly (and sometimes as superficially) as possible. When a personpresents in pain, the first determination is whether the pain is a seriousthreat to health. The second determination is whether enough tests have beendone to identify the cause of the pain. If the first answer is no and thesecond answer is yes, the goal is to clear out the room for the next patient. There is a clock on the wall and a patient list in the hall, and the list hasto be clear before the docs and nurses go home. And so there is thedoctor—patients waiting in six rooms, more in the waiting area, and a person inthe room complaining of something that isn’t going to kill him/her. And in thedoc’s pocket lies a pad of paper. Amazingly, all that the doctor has to do toclear the room is write on the pad and wish the patient well.
That is how addiction starts. Everyone intends well;everyone is honest; everyone is innocent. The patient is not told much aboutaddiction. The patient isn’t told that within a few days, he will have somedifficulty stopping the medicine. He isn’t told that after a week when he stopsthe medicine he will have some diarrhea, he won’t be able to sleep, and he willfeel depressed. He isn’t told that the pain that he has might not go away, andso he may get more potent medicine, and so on, and that it will get harder andharder to stop as the medicine gets stronger. I don’t know if the lack ofinformation really matters; most patients would likely take the pain reliefmedicine now, and worry about the rest later. Besides, the doctor doesn’t seemtoo concerned…and the patient is correct. The doctor isn’t concerned, because thiswas a quick case that got him nearly caught up to schedule.
Unfortunately, there are pains that do not go away, even aswe patients demand relief. Doctors hate to feel impotent with patients–it is difficultto take a person’s money, and then tell him that there is nothing that can bedone. And so prescriptions are written, even when the problem may becomplicated, and the best advice to the patient would be ‘learn to live withit’. This phrase angers patients with pain, but sounds intelligent to patientswho have struggled to get off opiates. But usually, the person with pain walksout with a prescription. As tolerance develops, the pain comes back, and thepatient goes to the doctor again, this time leaving with stronger medication. Tolerance continues, meds are changed, and tolerance develops again. Thedoctor gets nervous over the situation, realizing that at some point he willnot have anything stronger. Suddenly calls to the doctor are not returned, orare returned by a curt nurse who sounds like the patient’s mother. The patientrealizes that he is stuck, and becomes depressed. Sound familiar?
It is not your fault. I know about this stuff inside andout—I earned my PhD in Neurochemistry at the Center for Brain Research in Rochester New York, studying drugs that cause addiction and tolerance. I administered opiatemedications every day as an anesthesiologist. I literally know everything thatthere is to know about opiates…expect how to stop taking them. I thought I wassmart enough to avoid addiction, but I was wrong—laughably wrong—and theoutcome nearly killed me. It is not your fault. To get better, you will needto understand the meaning and truth of that statement. That is difficult forsome, but possible for everyone.
My next installment has better news. You can become free. Youdon’t need to leave your family to go to a far-away rehab center, and you don’tneed to go through painful detox and withdrawal. Watch for my nextinstallment, or visit me at my address below. There is a new development intreating people dependent on pain pills, a development that will revolutionizethe way that doctors treat addiction.
