Deep-rooted causes of opiod addiction


Within the last few years, the full scale of the addition to prescription pain killers has burst into public consciousness and it is being referred to as an epidemic. Anna Lembke, a psychiatrist focused on addiction care and author of the book Drug Dealer, MD, agrees that “the commonly cited causes of the epidemic — doctors hoping to treat previously untreated pain conditions, pain patients demanding better treatments, and big pharma pushing opioids on the market — contributed to the vast overprescription of opioids. That let the pills flow not just to patients’ hands but to their family, their friends, and the black market.”

But in the above interview, Lembke argues that there are even more deep-rooted causes for the problem that get far less attention but need to be addressed.

One of the secrets of medicine — secret even to doctors — is that you can’t just stop opioids or quickly go down and the [patient] will be fine. You can’t do that. They’ll go through terrible, excruciating withdrawal.

I say it’s absolutely true that if you were to get opioids for your pain, it would be like a magical cure for about a month or maybe two.

But after a while, there’s a very high likelihood that they would stop working. And then you would have two problems: You would have your pain, and you would be dependent on this drug and experience painful withdrawal if you try to get off [opioids].

What I think is really important to remind people is that if opioids worked long-term, I would have no problem with patients taking them. The fundamental issue is that they stop working and then you have an additional problem.

She says that while part of the problem is that doctors feel pressured to make patients feel better and do so quickly and opiods can do the trick, another facet is that people are not accepting the limits of their bodies as they get older and think that medication can be used to avoid any lifestyle changes.

So, for example, this is a clinical scenario that happens to me all the time: I have a patient that I’m prescribing an opioid. Then they come in and tell me that they ran out three days early. And I tell them, “You can’t do that. You have to take it as prescribed.” And they tell me, “Well, I was doing yard work, and I had to cut down all these trees, I was chopping wood, and my pain was horrible. So I had to take more.”

And then I have to find a way to say to the patient, that’s not okay. You can’t use the pill to compensate for what your body can’t do anymore.

If you take additional opioids, you can’t hear the signals from your body about what you shouldn’t be doing, and then maybe you’re going to do some long-term damage above what’s already been done.

But even more importantly, you can’t use the pills to extend your limits. You have to accept that there’s some things you just won’t be able to do anymore.

People are very resistant to that idea. I think that speaks to some of the core hope for at least Americans that they should really be able to keep doing what they were doing in their 20s, and that somehow a doctor should be able to fix them and make that happen, instead of accepting that maybe that’s something they just can’t do anymore.

I can imagine that it would be hard for a doctor to deny a patient’s request for relief for genuine pain and essentially tell them to suck it up and learn to live with it. In the current state of medicine in the US where people have been led to think that medication can solve so many problems and doctors are essentially competing with each other, if one refuses a patient’s request to increase the supply, she may lose that patient to another doctor who may not be able to resist the patient’s pleas for immediate pain relief. And if they can’t get a doctor to prescribe for them, as I wrote about the other prescription drug epidemic for Adderall, savvy people still find it quite easy in the US to get prescription drugs that are legal but addictive.

As an older man myself, I know how tempting it is to deny that one’s body is not what it used to be and as one ages to try to hold back the tide, to think that if one could still do the things one could do while younger, then one must still be young. But I am also very averse to taking medications (even over-the-counter ones like aspirin) and so I let pain and tiredness serve as the signals that my body is sending me that I am pushing myself too far and need to slow things down.

Of course, it perhaps helps that I am a lazy person and don’t need an excuse to take things easy.

Comments

  1. Pierce R. Butler says

    Now we hear a lot about opioid addiction.

    We hardly hear anything about methamphetamine problems.

    Has the latter gone away, or is it just that (mostly) middle-class troubles get more attention than (mostly) poor-rural crises?

    And cocaine/crack – did they get left behind, stuck in the 20th century?

  2. agender says

    I am convinced that this is just newspeak for the War On Drugs, which got its beliefs (!!!) debunked thoroughly.
    This example is either unrealistic or a tricky version of suicideforbidding (in theory each and any condition can bring 1 person experiencing it to end their life for being unbearable – although it might be not one that many people choose)
    I did not comment on Adderall, because I do not have any experience with it, but here I am on secure ground: fibromyalgia.
    And my childhood, in the time children did not get painkillers, was HORROR.
    THIS is an example of the things an institution or national state should not have a say. Where´ s the sense of HABEAS CORPUS – in countries that pride themselves to have this legal principle??

  3. smrnda says

    “But even more importantly, you can’t use the pills to extend your limits. You have to accept that there’s some things you just won’t be able to do anymore.”

    Many people don’t have the option. They may do physical work as part of their job and employers aren’t really good at offering accommodations, and it isn’t like it’s going to be easy to get disability for chronic pain. I get a bit pissed at doctors who forget that not everybody out there is an upper middle class office worker who needs to realize that they might have to take it a bit easier playing squash or gardening.

  4. says

    I live with acute and chronic pain daily. It’s not fun. I require pain meds just to make it through the damn day, and be able to work. I’m 59, and in good shape – that doesn’t have jack shit to do with anything. I don’t go nuts and over do, either. That doesn’t stop the degeneration of my spine. It doesn’t stop the near insane levels of nerve pain I get to deal with.

    In my case, pills (and spinal / neck / shoulder injections) do extend my limits. They allow me to put in a semi-normal work day, or to enjoy myself on a day out. Why, exactly, should that be something I should give up because of the stupid fucking “war on drugs” crap? I already have to jump through acres of red tape to get drugs which are barely adequate, hydrocodone, tramadol, and flexeril. Trying to get adequate drugs in this country is a bloody joke, unless you decide to bypass the medicolegal route. I am forced to sign drug agreements, and to take piss tests. If someone decides there isn’t enough medication in my system, I can be turned over to the DEA under suspicion of dealing. That’s standard protocol for all pain patients in the the States.

    It makes me absolutely furious to read a post like this, because it’s damn easy for some people to talk, isn’t it? I’m not quite ready to give up and die just yet, so I do what I have to do in order to deal with pain, and I could really live without the feds and clueless assholes drooling over my head.

  5. Raucous Indignation says

    Caine, Anna Lembke doesn’t know shit about treating chronic severe pain or how opiates work or apparently even how doctors practice. The goal of any effective medical therapy is to allow the patient to lead as normal a life as possible. I have never forced a patient to sign a drug agreement, and very rarely drug test people. Victimizing the patient isn’t part a normal normal therapeutic partnership. Nor is telling a patient to give up on living your life. What an asshole.

  6. says

    I don’t see why it’s not legal for someone to spend their time high as a kite, and then die with a smile on their face if they want to.

    The whole “drugs bad” thing is predicated on weird christian notions that destroying oneself is sinning against god’s gift of life, or some such bullshit. It’s just more of the christian’s inability to tolerate someone going off and doing things their way – the suspicion that someone might be having a good time is utterly unacceptable for christians, but that’s their lifestyle choice. But let’s be honest: christianity fetishizes suffering.

    So because of that, we get ridiculous things like attempting to limit someone’s access to opiates. Why the fuck? Suppose someone was able to spend as much time as they wanted on the couch, with a smile on their face, and then die with a smile on their face? Why is that anyone’s business but theirs? We could actually make access to recreational drugs fairly safe (but why do they have to be safe?) if we wanted to. We could also prevent people from “wasting” their lives watching sportsball or professional wrestling: how is a life spent watching sportsball somehow more worthy than a life spent high as a kite listening to music? Obviously: it’s about political control – if people could spend their time happily chasing the dragon, they wouldn’t spend their time working their asses off to make money so that the upperclass could skim their cut and they could spend their time chasing the dragon.

    American society is deeply sick regarding this issue. Last fall I watched a 45 year-old man die of pancreatic cancer, being reduced to a skeleton of pain because he couldn’t eat (the cancer involved his liver and intestines) they would have intervened surgically to keep his intestinal blockage from killing him, except he went into kidney failure and died in a coma, first. But all along he kept asking “why do I have to go through this? Can’t I just have some pills and get it over with?” No, because taking your own life is a sin, even when it’s not worth anything to you, they have to prop you up so you can “die naturally” (as if “he died of pancreatic cancer” isn’t natural enough, i.e: “he had inoperable cancer so he asked for and chose to drink a glass of phenobarbitol”)

    The whole thing is deeply, disturbingly, sick. It’s based on these sick aesthetics that elevate society’s desire to see people suffer above people’s desire to live as they choose.

  7. says

    PS – the biggest drug dealer in the world is House Windsor. When the opium wars ended, they retained the exclusive right to import/export opium, and now own regulation of transporting opium in most of Europe and the UK, where most commercial opiates are produced. There are huge poppy fields in England.

  8. Brian English says

    but why do they have to be safe?

    Well, I guess the response is if you want to go get high as on your couch, good luck, but if statistics show that a whole lot of people getting high on the couch leads to an expensive increase in emergency or long term care and huge costs, that might be why they have to be safe.
    I agree with you, by the way. We can make Opiods safe, as in not being cut with unknown powders, and can supply needles to whomever wants them. But then we’d be saying it’s OK to go on a permanent bender and a bit like letting women have sex when they want, we can’t have that. So it’s dirty needles, unsafe drugs and disease for the junkies and backyard abortions for the women who don’t do what the patriarchy wants!

    Digressing. In Oz, I have to show id, which is noted when I buy some paracetamol and codeine (9.6mg) tablets at pharmacies. Anyway, this is to protect someone or some such. I think some people hooked on opiods extract the codeine from the pills for a hit, and to stop that kind of thing, pharmacies are required to check id and note who purchased these types of tablets. Similar to what happens with Pseudo-ephedrine and those making meth. The strange thing is I can buy a cold and flu table off the shelf in the same pharmacy, without id, that has paracetamol, codeine (9mg) and some antihistamine. Anyone can get essential the same drug preparation without id. I’m sure our intrepid codeine purifiers can deal with the antihistamine if it needs to be removed. It’s funny, how these loopholes or oversights exist.

  9. springa73 says

    While I agree that the “war on drugs” mentality is bad, I also think that the “drugs are great” point of view flies in the face of reality. The truth is that drug abuse ruins many lives, both the those of the abusers and those of family, dependents, and loved ones. If someone wants to risk ruining their own life through addiction, that is their prerogative, but the damage often can’t easily be confined to one person.

    I am somewhat dependent on prescription medication myself (in my case for a psychiatric condition rather than chronic pain), so I certainly don’t buy into the view that drugs/pharmaceuticals of all kinds are bad, but I also think it’s silly to pretend that they are always good, or that anyone who worries about them must be clueless or sadistic.

  10. John Morales says

    Marcus @6,

    I don’t see why it’s not legal for someone to spend their time high as a kite, and then die with a smile on their face if they want to.

    In principle, me neither.

    But for opioids, the problem is tolerance. Unlike most other painkillers, the dose can be upped more and more to achieve the same analgesic effect without immediate consequences, but eventually the side-effects are extremely serious.

    Here’s an informative article from a medical perspective: Tolerance to Opioid Pain Medications.

    springa73 @9:

    The truth is that drug abuse ruins many lives, both the those of the abusers and those of family, dependents, and loved ones.

    But that’s only a partial truth. It is no less true that many others can and do enjoy drugs recreationally for years, decades and even lifetimes (cf. “functional alcoholics”) without any such ruination.

    (The truth is that calorie abuse ruins many lives, both the those of the abusers and those of family, dependents, and loved ones.)

  11. Raucous Indignation says

    Marcus, you’re cruising past a lengthy discussion of “the slippery slope” and the principle of “double effect.” It’s worth having those discussions, but the ethics of pain relief in the setting of terminal illness is well established in practice. At least, everywhere I’ve practiced.

  12. KG says

    PS – the biggest drug dealer in the world is House Windsor. When the opium wars ended, they retained the exclusive right to import/export opium, and now own regulation of transporting opium in most of Europe and the UK, where most commercial opiates are produced. There are huge poppy fields in England.

    There are poppy fields in England, but otherwise, this appears to be blithering nonsense. “House Windsor” did not exist when the opium wars ended, the largest producers of “poppy for medicinal purposes and poppy-based drugs” are Australia, India and Turkey, and how “House Windsor” could “own regulation of transporting opium in most of Europe and the UK”, I have no idea. (How does anyone “own regulation”?) I think Marcus has been reading too much Lyndon Larouche.

  13. KG says

    On the wider issue, I claim no expertise, but as far as I understand it, medical opinion outside the USA is that the latter heavily underprescribes opiates for pain relief – notably in the ridiculous contention that diamorphine (aka heroin) has no medical use.

  14. says

    KG@#12:
    I think Marcus has been reading too much Lyndon Larouche.

    I admit it’s possible that my source is mistaken; it’s extremely difficult to find out who owns interest in what, at what point. I should have decorated my comment with more caveats.

    As far as the Lyndon Larouche angle: yawn. He’s a crank, therefore someone else is a crank. Can you do better than that?

  15. Raucous Indignation says

    John Morales @10. Your link doesn’t go to a medical society. It goes to a “public policy think tank.” No one should get medical information from a “public policy think tank.” There are actual medical professionals for that. Try the American Academy of Pain Medicine, for starters.

  16. says

    Raucous Indignation @ 5:

    I have never forced a patient to sign a drug agreement, and very rarely drug test people. Victimizing the patient isn’t part a normal normal therapeutic partnership. Nor is telling a patient to give up on living your life. What an asshole.

    Wish you were my doc. What happened here is that when all the codeine-based went schedule II, neurologists referred their pain patients to the pain clinic if they wanted to continue with the meds they were on, as they didn’t want to deal with the new regulations. Used to be, my neurodoc would write me 6 months scrips at a time, but refills aren’t allowed anymore. You have to see your doc every month for a new scrip, unless you go through a pain clinic.

    The pain clinic is strictly under the federal thumb. So, what I have to do is have the pharmacy put in a med request to the pain clinic every 21 days for all my meds, to be picked up 7 days later. I have to see my assigned pain manager every 3 months, or no meds. I have to sign a federal drug agreement whenever one is shoved under my nose; I’ve signed two so far. (They are 4 to 6 pages long and dense). Drug testing is done at the whim of whoever, I’ll be having to take one my next time in. The piss tests mean you cannot manage your own med use. I tend to take less after a series of injections, but if that shows up in a piss test, as I said, I can be turned over to the DEA on suspicion of dealing. The whole thing is wearing me down, and adds to my stress levels. It’s a rank violation of my rights, but it’s this or…

    Even so, I’m considering having them drop the hydrocodone, what I’m given is basically hyped up Ibuprofen and little more, and if I drop it, I get out of federal scrutiny. Honestly, I don’t know what the fuck to do right now.

  17. John Morales says

    Raucous Indignation @15, possibly I should have done differently.

    FWIW, I mostly link to Wikipedia, unless I suspect the article is compromised.

    For you: http://www.painmed.org/search.aspx?f=80&s=opioid%20tolerance

    I guess the point I was trying to make (as per Marcus above) is that I have no problem in principle with either therapeutic or recreational use of opioids, but that tolerance is a problematic thing about their usage.

  18. John Morales says

    Ah! Sorry, I just got it. 😐

    No, I intended to express it was from a medical perspective as it only considers the therapeutic aspect, not that it was from a medical source.

    (I was unclear, good call-out)

  19. KG says

    As far as the Lyndon Larouche angle: yawn. He’s a crank, therefore someone else is a crank. – Marcus Ranum@14

    He’s a crank, one of whose main crankeries was the insistence that the British royals run the global drugs trade, which is why I suggested him – but I admit that even he seems to have become somewhat embarrassed by this nonsense. Which crank did you get your absurd misinformation from? As I asked before, how could anyone “own regulation of transporting opium in most of Europe and the UK”? The claim doesn’t even make sense.

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