Are you addicted to pain pills? You certainly have company. 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 the cycle of dependence starts when you appropriately use medication administered by a person who you trust-your physician. Pain pills are often called 'narcotics'--a term that comes from the Greek word 'narcosis', or 'sleep'-because of their sedative effects. Physicians use the word 'narcotic' to refer to different things in different situations. 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 anesthetic that is comprised of drugs that bind to brain 'opiate receptors'. 'Opiate' is another word used by physicians in reference to pain pills. The word comes from 'opium', a substance derived from poppies and used to make heroin and morphine. The 'opiate' reference is also used for synthetic pain medications that have no connection to poppies or opium save their pain-killing effects. Most people have heard of 'endorphins'. Endorphins are produced in the human body, and when released, block pain. Endorphins are often referred to as 'endogenous opiates' because of their role in pain sensation, even though they have no relation to poppies or opium, and are structurally quite dissimilar. These natural pain relievers have other functions in the body, roles not relevant to this discussion. Endorphins are one group out of dozens of 'neurotransmitters', substances involved in the communication between nerve cells. Endorphins and other neurotransmitters act at 'receptors', the receptor being a lock on a nerve cell, and the neurotransmitter being the key that fits in the lock. Amazingly, poppies produce a substance that looks different from the natural key, but that acts like endorphins by fitting the exact same keyhole. That substance-one molecule from the sap of a red flower-has given the human species the ability to ease suffering in 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 extremely potent; an amount the size of one grain of salt, say one tenth of one milligram, placed on the tongue would cause respiratory arrest in a large man within seconds. More commonly opiates are taken by patients in the form of codeine, hydrocodone (Vicodin), oxycodone (Oxycontin), or hydromorphone (Dilaudid). Prescriptions for these substances are handed out to millions of people each day in response to complaints of pain. Opiates relieve pain, and work in different areas of the brain to elevate mood, ease tension, give a subjective sensation of warmth, and cause sedation. They can cause nausea and vomiting, particularly in patients who are nave to them. Finally, they change the response of the brain to low oxygen and high carbon dioxide in the blood, and slow respiration. The most common cause of fatal overdose is respiratory arrest, where the brain stops sending impulses to the diaphragm, and the patient suffocates. This fatal response is most common during sleep, or when opiates are taken in combination with other sedative medications. Opiates are addictive. There is no way to take them without the body adapting and becoming dependent on them. 'Tolerance' to pain medication begins after the first dose, when the 'locks' on nerve cells adjust in response to all of the 'keys' floating around. With time it takes more and more keys to open enough locks to cause the reaction at the nerve cell. Tolerance is one half of the process of addiction, and is the reason for 'withdrawal', the sickness that occurs when tolerance has developed and the drugs, or keys, are taken away. The other half of addiction is so-called 'psychological', which I suppose is accurate to a point. For some reason, once something is assigned to the psychological category, it is treated differently by physicians, patients, and the rest of society. 'Psychological' does not imply that a person has more control than with a 'physical' condition-if anything, things occurring on a psychological level are far more difficult to recognize and treat than are physical conditions. The psychological addiction to opiates also develops very rapidly, and there is little if anything that can be done to prevent it. Psychological addiction is real, and is extremely powerful. The result is a desire to take opiates. The desire may take the form of physical symptoms, such as an increase in pain, and so psychological addiction and physical addictions are intimately connected. To health systems, time is money. Patient complaints are handled as quickly (and sometimes as superficially) as possible. When a person presents in pain, the first determination is whether the pain is a serious threat to health. The second determination is whether enough tests have been done to identify the cause of the pain. If the first answer is no and the second 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 has to be clear before the docs and nurses go home. And so there is the doctor-patients waiting in six rooms, more in the waiting area, and a person in the room complaining of something that isn't going to kill him/her. And in the doc's pocket lies a pad of paper. Amazingly, all that the doctor has to do to clear 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 about addiction. The patient isn't told that within a few days, he will have some difficulty stopping the medicine. He isn't told that after a week when he stops the medicine he will have some diarrhea, he won't be able to sleep, and he will feel depressed. He isn't told that the pain that he has might not go away, and so he may get more potent medicine, and so on, and that it will get harder and harder to stop as the medicine gets stronger. I don't know if the lack of information really matters; most patients would likely take the pain relief medicine now, and worry about the rest later. Besides, the doctor doesn't seem too concerned...and the patient is correct. The doctor isn't concerned, because this was a quick case that got him nearly caught up to schedule. Unfortunately, there are pains that do not go away, even as we patients demand relief. Doctors hate to feel impotent with patients--it is difficult to take a person's money, and then tell him that there is nothing that can be done. And so prescriptions are written, even when the problem may be complicated, and the best advice to the patient would be 'learn to live with it'. This phrase angers patients with pain, but sounds intelligent to patients who have struggled to get off opiates. But usually, the person with pain walks out with a prescription. As tolerance develops, the pain comes back, and the patient goes to the doctor again, this time leaving with stronger medication. Tolerance continues, meds are changed, and tolerance develops again. The doctor gets nervous over the situation, realizing that at some point he will not have anything stronger. Suddenly calls to the doctor are not returned, or are returned by a curt nurse who sounds like the patient's mother. The patient realizes that he is stuck, and becomes depressed. Sound familiar? It is not your fault. I know about this stuff inside and out-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 opiate medications every day as an anesthesiologist. I literally know everything that there is to know about opiates...expect how to stop taking them on my own. I thought I was smart enough to avoid addiction, but I was wrong-laughably wrong-and the outcome nearly killed me. It is not your fault. To get better, you will need to understand the meaning and truth of that statement. That is difficult for some, but possible for everyone. My next installment has better news. You can become free. You don't need to leave your family to go to a far-away rehab center, and you don't need to go through painful detox and withdrawal. Watch for my next installment, or visit me at my address below. There is a new development in treating people dependent on pain pills, a development that will revolutionize the way that doctors treat addiction.
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