Painkillers

1,000 New Jersey Residents are in Substance Abuse Treatment, Every Day

In New Jersey on any given day, nearly 1,000 people are in a clinic or hospital receiving substance abuse treatment. Most have entered a detox program (Sunrise Detox in Stirling services over 100 individuals every month) for what is typically a week to ten days of medically-supervised treatment. The initial detox is needed to stabilize them medically, so they can prepare for rehab or another treatment plan. The rest are in hospitals, also receiving detox before further treatment.

People are often surprised by the high numbers. Nearly 1,000 moms, dads, workers, professionals… one thousand New Jersey residents every day, getting treatment for a drug or alcohol addiction. Nearly half (42%) are in for heroin and prescription pain killers (heroin is an opiate, and many painkillers are synthetic opiates known as opioids, also highly addicting). Over 30% of the rest are in for alcohol abuse (dependency).

These data are from 2010. The trend lines for both alcohol and opiate abuse have increased dramatically since then, so today's numbers are likely to be even higher.

Prescription Drug Reduction Creates Unintended Consequences, But No Surprises

With crackdowns increasing on improperly-prescribed and illegal prescription drugs, more pill users are turning to heroin, according to studies in Maryland. Prescription drug overdoses are down by 15%, but heroin ODs are up 41%. The total number of combined overdoses is up about 6%. That’s probably because naïve users have greater difficulty managing heroin dosage than they do with the controlled strength of pills.

This shouldn’t have surprised anyone. Reducing the availability of prescription drugs will probably reduce the number of new addicts to a limited degree, but folks who are already addicted aren’t going to be kept from copping. Most prescription drug users, pushed by the fear or actuality of acute withdrawal, will have no trouble finding street drugs, and when the availability of pills drops on the street, the move to heroin is simple and obvious.

That might sound like I’m against nailing the pill mills. Not at all. Those sorry excuses for physicians are a blight on society, and need to be dealt with. Ditto the folks who sell drugs on the street. But anyone who thought addicts would come flocking to get help when their supplies got scarce really doesn’t get the facts of addiction.

Bottom line: addicts will find drugs. If treatment was supported nearly as well as the so-called “War On Drugs;” if addicts could more easily access detox and primary treatment; if the focus of society was less on punitive measures and more on curative ones, then our drug problems could be dealt with far more effectively.

We’re finally getting the idea across that addiction is a disease, and that addicts need to be dealt with as patients, not as offenders, but until society gets behind treatment instead of spending huge sums supporting the drug suppression/law enforcement industries, we don’t have much chance to make real inroads into the overall problem.

I’m a former law enforcement officer and a recovering addict. I’ve seen it from both sides, and I’m telling you that we are putting our priorities in the wrong place. Deal with the criminals on one end, but reduce the number of customers on the other. Put people first, and we have a shot at making real progress.

Safety Margins

I came closer to using drugs last night than I have in over 20 years. My experience — totally unexpected — draws a line under the reasons that we have to keep our heads in the right place, have supports available, and the several other things involved in maintaining our sobriety.

Briefly, some unfinished dental work developed an infection, and over a period of four or five hours went from mild discomfort that was easily controlled by Tylenol to pain that I’d put at about an 8 on a scale of one to ten. When I realized it was increasing I had my dentist call in a prescription for antibiotics, but unfortunately they don’t work all that fast. I’m OK now, but for several hours I went through intermittent periods of pain that could have had me gobbling anything in sight that I knew would make it stop.

But I didn’t, for several reason that I don’t take complete credit for. I decided when I got sober that I would avoid narcotic painkillers whenever possible. I don’t keep them around “just in case,” and I make sure that my physicians know that I don’t want them. But mostly I made sure that the people close to me know how dangerous they are to me, and that they are to be extremely critical of any requests I make.

Now don’t get me wrong; there’s nothing wrong with painkillers when they’re actually needed. Thing is, people in pain aren’t necessarily in a position to decide when they’re actually needed. As a former martial artist I know that I have a high pain threshold, but that’s temporary pain, not pain that threatens to go on for who knows how long, and maybe get worse. While I might be able to tolerate more pain than some people, the fact is that I reached a level last night that I perceived as all I could tolerate. Only the barriers that I put up for myself long ago came between me and taking a potentially addictive drug.

Would I have been throwing away 22 years of sobriety? Of course not — on the face of it. But who knows what temptations to keep enjoying those feelings might have surfaced? What rogue brain chemistry might have been triggered that started up my cravings again? Is my “won’t power” good enough to put the stuff down when I no longer need it? Could it trigger my addiction to alcohol, or benzos?

I don’t know, you see. And I don’t want to find out. If the time comes when I need major pain relief, I trust my medical surrogate(s) to make the right choices at that time. But I’m an addict. My disease is arrested, not cured. I don’t trust me to make those choices, not even after all this time. I need to be certain that I don’t fool myself, and I need to make sure that the people around me aren’t fooled — by me. And last night proved to me what a very good idea that is. It was a shock to learn just how little time it takes to strip away all those layers of recovery.

I would probably have been OK. But what if?

New powerful painkiller has abuse experts worried

Far be it from me to comment in public about the ethics and morals of people I haven't even met, so the less said the better.

justice.gov

NEW YORK (AP) — Drug companies are working to develop a pure, more powerful version of the nation's second most-abused medicine, which has addiction experts worried that it could spur a new wave of abuse.

The new pills contain the highly addictive painkiller hydrocodone, packing up to 10 times the amount of the drug as existing medications such as Vicodin. Four companies have begun patient testing, and one of them — Zogenix of San Diego — plans to apply early next year to begin marketing its product, Zohydro.

If approved, it would mark the first time patients could legally buy pure hydrocodone.

MORE…

I’ve heard that opiate overdoses often occur when users relapse. Is this true? What’s the deal?

It is true, but in order to give you a good overview, let's talk about overdoses (ODs) in general.

Most overdoses are caused by people mixing drugs such as heroin, alcohol, methadone and benzodiazepines (Valium, Xanax, Ativan and similar “tranquilizers”). These drugs are all central nervous system (CNS) depressants. When used together, there can be a synergistic effect, where the presence of both drugs creates more CNS depression than either could alone — sort of a 1+1=3 effect.

In an OD, they cause unconsciousness, slow the heartbeat and depress breathing. In lethal doses (LD), the user dies from suffocation when breathing ceases entirely. However, a lethal dose of a drug or drugs is not necessary in order for you to die. If you are lying on your back and unable to swallow because of CNS depression, a small quantity of liquid, such as vomit, can cause suffocation. This has killed many people who would probably have survived the OD otherwise.

There is also the matter of misjudging the amount of drugs in your system. Most drugs taken by mouth reach their highest levels in the body quite some time after they begin to have a noticeable effect — as long as 30 minutes to as much as 4 hours. You can easily become dissatisfied with the effects and continue to swallow more, then down the line the blood levels continue to rise and give you more than you bargained for. It is not uncommon for this to happen when mixing oral and injected drugs. The pills aren't getting the job done, so you crush and inject and — whammo!

Finally, we get to the issue you asked about. Opiate tolerance drops rapidly when you're not using. People who have abstained from drugs during detox and treatment, or while in jail or prison, end up with a very low tolerance in comparison to what they had when they stopped using.

If a person who has been abstinent for several weeks relapses, they will require much smaller doses in order to get high. This kills thousands of addicts every year, because the lethal dose (LD) drops as well. If they go back to using anything close to what they used previously, an OD is not only possible, but likely. People most at risk are those getting out of detox and treatment, or out of prison.

The best defense, of course, is to hit meetings, use your supports and stay clean. But if you think you need another run, be really careful or it may be your last.

Is Medical Detox Really Necessary?

I received an email from a hard-nosed recovering addict/alcoholic who stated, in essence, that inpatient detox isn’t necessary, that he did it on his own, and that all anyone needs is a (little of this, little of that) to get through it just fine, and he knows a bunch of folks who did it that way, and…blah, blah, blah.

I replied, politely, that everyone is different, and that just because it worked for some does not mean that it will work for everyone, and that detox is too important to take a chance on getting it wrong (or killing someone).  I refrained from asking how many of his acquaintances had a successful detox, culminating in long-term happy sobriety with no relapse.

In my years around the 12-step rooms I’ve heard similar comments every now and then.  Some guy (it’s nearly always a guy) makes some remark to the effect that if it was good enough for him and Christopher Columbus, it ought to be good enough for all these young whippersnappers.  Somehow I don’t see how surviving the threat of seizures, heart attack, stroke, DTs, profound depression and a variety of other jackpots (depending on the drug or mixture of drugs) proves anything, except that you were one of the lucky ones, but maybe that’s just me.

Just about any drug that will alter your mood noticeably can be addictive, including weed.  Getting off any of them can create enough withdrawal symptoms that it can be really difficult to make it through a self-detox, although not all are physically dangerous.  (Of course you could argue that things like possible psychotic episodes and profound depression are physically dangerous, but we'll let that go for another time.)

The bottom line, though, is this: Under the supervision of medical personnel who are trained to administer the proper medication and equipped to handle any problems, detox can be surprisingly comfortable.  Lacking that, there can be some nasty surprises.  Not everyone has complications, which explains the position of the scoffers, but enough folks do that it’s not worth taking a chance if you don't have to.

Why Do Addicts Keep Using Despite The Consequences? — Part 2

Previously we mentioned that the pleasure center is a portion of the brain over which we have no conscious control, and that it can be stimulated by a variety of chemicals — some of them produced inside our bodies and some that we introduce from outside.  We said that the pleasure center rewards us for activities that it interprets as contributing in some way to our survival, whether they be social interactions, exercising, or more prosaic things such as eating.  We also stated that these pleasurable feelings, when pursued too far or for too long can create problems.  Now we need to examine how that happens.

While the actual mechanism of addiction is terrifically complicated, the underlying principles are reasonably simple.

  1. When we use drugs or are involved in pleasurable activities, they stimulate (or cause the stimulation of) receptor sites in the pleasure center and other areas of the brain. This causes us to feel good.
  2. With constant stimulation, the brain begins to adjust to the higher levels of brain chemicals by making physical changes that involve, among others, the growth of additional receptor sites to accommodate the excess neurotransmitters.  This leads to tolerance: needing more stimulation in order to achieve the same effects.  Tolerance is one of the first signs of developing addiction.
  3. As tolerance develops, we reach a point where our brain needs the presence of the stimulation in order for us to feel normal.  If we cease whatever is causing the stimulation, whether it be alcohol, other drugs or stimulating activity, for very long we begin to feel uncomfortable because all those extra receptors are telling us they need to be filled up.
  4. Eventually, we reach a point where any pleasure is short-lived, and we simply need the stimulation to keep going.  When we don’t have it, we experience withdrawal, feelings that, as a general rule, are the opposite of whatever good feelings the stimulation caused.  If we were using cocaine or other central nervous system stimulants, we feel depressed; if using downers, agitated; if we are a thrill junkie, bored and/or depressed, etc.  Because of the changes in other parts of the body there are often other symptoms.  For example, opiate withdrawal is like the worst case of flu you can imagine, doubled, combined with overpowering anxiety, nervousness and generally feeling terrible both physically and emotionally.
  5. At the point of marked, prolonged withdrawal in the absence of the drug or activity, we are definitely addicted.

But why can’t we quit?  We know using is causing us life problems, and we know withdrawal doesn’t last forever.  There are even medications to help.  What’s with the constant failures to stop using?

Remember that we said the pleasure center is a part of the brain over which we have no conscious control.  This part of the brain, because it is survival-oriented, interprets failure to meet its needs as survival issues.  We have created an artificial situation in which the brain needs extra stimulation to feel normal.  Therefore, when it does not get the extra stimulation, it sends messages to our subconscious that our very survival is threatened.  Addicts continue to use because their subconscious, over which they have no control, tells them that if they don't they're liable to die.

Those messages alone are enough to make it extremely difficult to stop using.  When reinforced with physical withdrawal, they are sometimes impossible to overcome with conscious effort because — again — we have no control over the feelings or the symptoms except for the use of more drugs.

Of course there is more to it.  The stresses created in our lives by addiction-related problems (and perhaps problems that preceded the addiction) make it even more difficult for us to allow ourselves to return to reality.  We must first detox from the drug, and then we need a lot of support and help while normalizing our social, emotional and health issues during the first months and years of sobriety.  We also need help getting through the “post acute withdrawal syndrome” (PAWS) that occurs while the brain and rest of the body are rebuilding and getting back to something like normal.  This can take a long time, and the issues associated with PAWS are a frequent (if not the most frequent) cause of relapse.

That, however, is a subject for another article of its own.  For now, understanding that addicts are subject to powerful emotional and physical experiences over which there can be no direct control will clarify a lot about addiction and the problems of getting clean.