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Addiction to prescription pain medicine, also known as opiate drugs, has reached epidemic proportions. Everyone from the famous actor to the talented musician to the hotshot CEO to the good suburban kid is the current face of opiate drug addiction. This article will look at the trends and contributing factors that have led to today's epidemic.
Article originally appeared in
Opioids are a class of synthetic or semi-synthetic drugs that are derived from opium. They include prescription pain medicines such as hydrocodone, oxycodone, hydromorphone, codeine, and fentanyl, as well as morphine and heroin. According to a report by the International Narcotics Control Board, consumption and manufacture of every type of opiate drug and synthetic opioid has increased since 1990. The United States is the largest consumer of opiate drugs, and in 2010 it accounted for 99 percent of the total global consumption of hydrocodone, making that medicine the most used narcotic drug in medical practice in terms of defined daily doses. And lest we think Americans are the only ones in pain, "high-income" countries such as Australia, Canada, Japan, New Zealand, and some European countries, along with the United States, account for 93 percent of the world's morphine consumption. Consumption of opioids in low-income countries has remained relatively stable.1
In the United States, the Centers for Disease Control reports that the rate of deaths due to drug overdoses, mainly from prescription drugs, has tripled since 1990. In 2010, two million people reported using prescription painkillers non-medically within the last year, amounting to about 5,500 people per day. The CDC also reports that enough painkillers were prescribed in 2010 to medicate every American adult around the clock for a month.2 The latest studies from JAMA Internal Medicine report that more than 12 million people abuse prescription painkillers annually.
In a Washington Post interview, Keith Humphries, one of the nation's leading addiction researchers, said he estimates that 100 Americans die every day from an opiate drug overdose, and statistics show that it is the leading cause of accidental death in the U.S., second to car accidents.3
Who Is Addicted?
Today's typical addict is very different from the pre-1990s addict. Many addicts today started taking prescription pain medicine for a medical reason. Some of them became hooked, and when pills became too expensive, they turned to heroin. As one New York Times article points out, "the use of medications like Vicodin, OxyContin and oxycodone—all opiates like heroin—has altered the landscape of addiction and relapse, in ways that affect both current users and former ones."4 The pre-1990s addict mainly used heroin, and if none was accessible, he would go through withdrawal symptoms. Today, users can switch back-and-forth between heroin and prescription medicines based on availability.
Another important change since 1990 is the demographic of the typical opiate drug addict. In a headline-making study in JAMA Psychiatry,5 researchers found that 90 percent of the people being treated for addiction to heroin and prescription pain medication are suburban, white, and in their twenties. Almost all of them said that they started with prescription pain medicines like OxyContin or Vicodin, but eventually their drug habit became too expensive, so they turned to heroin to get high and avoid withdrawal symptoms. Ninety-four percent of the people surveyed would prefer pills to heroin because they are "cleaner" and the users know what they are getting.
Humphries points out that prescription drug abuse is different from other types of drug abuse because people are obtaining the drugs legally, in controlled doses, from doctors. The issue is not that they are receiving a black market version with unknown ingredients. Furthermore, people who die from "overdoses" are actually dying from combining multiple drugs, from taking a higher dose after being off a drug for a while, or from long-term "poisoning" from a drug. Impurities and the black market, therefore, cannot be the main reason for overdose death, and because of this, legalizing heroin or making clean needles available will not curb the number of deaths due to overdose.
Let's take a look at the factors that have contributed to the situation we see today.
History Repeats Itself
One of the major reasons for the surge in opiate drug use is availability. There was a marked increase in the number of prescriptions written for pain medicine beginning in 1990. Why that year? As it turns out, something happened in 1990 that is very similar to what happened when heroin was first marketed in 1898.
Morphine was first extracted from opium in 1803 and was found to be ten times more potent than opium itself. Morphine was touted as a miracle drug for its analgesic capacity, but its potential for abuse became quickly apparent.
Heroin, a synthetic derivative of morphine, was synthesized in 1874 and used medically in 1898. It was considered safer than morphine, and some doctors hoped to use it to treat morphine addiction. More importantly, heroin was an excellent cough suppressant. At the time, pneumonia and tuberculosis were the leading causes of death, and without any cures for these diseases, doctors could only prescribe drugs to manage coughing so patients could sleep. Since heroin worked so well, long-term studies pointing to its dangers were ignored, and the drug was quickly approved for market.
As patients developed a tolerance for heroin, doctors began prescribing greater and greater doses. By 1910, heroin addiction had skyrocketed, particularly in the United States, where minimal regulations existed on a state-by-state basis.6
This is strikingly similar to what happened in the 1990s with prescription pain medicines. The Wall Street Journal ran a story in December 2012 on Dr. Russell Portenoy. In the 1980s and 1990s, Portenoy was an outspoken advocate for lifting restrictions on prescription pain medications to make them more widely available to patients dealing with chronic pain. In the 2012 article, he candidly admits his mistakes and explains why he has since changed his position.7
Portenoy was part of a triumvirate of doctors, patients, and pharmaceutical companies who came together, ignoring data and prudence, to promote a way of managing chronic pain. Doctors wanted to improve patient's lives; pharmaceutical companies stood to make large profits from drug sales; and vulnerable patients desired relief from chronic pain and depression.
Dr. Portenoy and his colleague Dr. Steven Passik would travel to various medical meetings proselytizing the benefits of opioids. They presented data suggesting that only one percent of opioid users became addicted.8 Portenoy now admits that his data was based on a very small sample of people who used the drugs for short-term pain, not chronic pain. He now says that, in reality, there is no data for chronic pain, and the one-percent statistic is flat-out wrong.
But at the time, the public was eager to accept his message. Dr. Passik notes that the push to promote opioids "had all the makings of a religious movement." Doctors passionately wanted to improve their patients' lives, and pharmaceutical companies paid them to preach the good news of opioids. As more people latched on to this hope of relief, profits increased. Purdue Pharma released OxyContin (oxycodone, time-released) in 1996; by 2013, $2,462,851 was spent on that drug alone.9
But just as there was no cure for pneumonia and tuberculosis in the 1800s, only management of symptoms, there is typically no cure for chronic pain today. In both cases, the drugs were effective, but their benefits came at a price that was only noticed after their hasty acceptance and widespread use.
Opioids on the Brain
Even though opium and its derivatives have a long history of use, it was not until the 1970s that we began to understand how they worked in the brain. Scientists discovered naturally occurring opioids in our bodies, which they named "endorphins" from "endogenous morphine." They also discovered that the brain has three opioid receptors—mu, delta, and kappa—that receive endorphins, then send a signal along a neurological pathway for the release of dopamine. This highly regulated natural process is how the body responds to pain.
After the brain has made a certain amount of endorphins, a signal will tell the brain to stop the process. There are signals and feedback loops throughout the whole pathway, ensuring that the production of endorphins and dopamine is perfectly balanced.
Opioids act as a stand-in for endorphins, disrupting the body's natural responses to pain. They bypass the regulatory processes that keep the system in check, going straight to the mu receptors. As a result, the receptors fire at a higher rate than normal, resulting in the release of excess dopamine.
Prior to 1990, opiate drugs were used primarily as pain relievers for cancer patients or for patients with severe, acute pain, but by 1990 doctors started prescribing them to address minor pain, like the pain of getting a tooth pulled, and to relieve chronic pain. Addiction after short-term use is generally uncommon, although it does happen in people who already have other addictions. The body will develop a slight tolerance after temporary use, but the changes in the brain are minimal and reversible.
Chronic use, however, changes the brain's physiology dramatically. Continued use of opiate drugs will cause an imbalance of opioids in the body, to which the body will respond by decreasing its production of endorphins. This will result in a need for more drugs to create the same effect. After prolonged use, several of the patient's mu-opioid receptors will completely shut down, and his body will stop producing endorphins completely. These changes will cause him to only feel "normal" when taking opiate drugs, and rather than taking them to feel good, he will have to take them to avoid feeling bad.
Thus, when it comes to relieving chronic pain, long-term use may cause more harm than good. Because the user's body will have fewer opioid receptors and produce fewer endorphins, he may feel pain much more acutely than he did before. This is partly why withdrawal after long-term use is so traumatic.
Additionally, with repeated use, one's brain will begin to follow a set neurological pathway. Rat studies indicate that as a neurological pathway is strengthened through repetition, the brain loses plasticity, and the animal exhibits greater difficulty in making new pathways.10
These internal changes are externally manifested in an addict's behavior; he becomes more and more obsessed with the high, or the resultant production of dopamine. The addict's brain pathway becomes so "well-worn" that eventually he finds it difficult to do anything but satiate the pathway. As Dr. Humphries told the Washington Post,
People who are addicted to drugs for years accumulate a large number of cues that lead them to seek out a high. Eventually, so much of their life becomes associated with getting high that it becomes nearly impossible for them to resist the urge. Going to work makes them think of getting high. Watching television makes them think of getting high. Finishing a meal makes them think of getting high.11
The addict's life truly becomes oriented around his addiction.
The Brain That Is Primed
We can say for certain that opiate drugs change the brain, but it is less clear whether some people have an "addict's brain" while others do not. Some people use opiate drugs for a time, even developing a tolerance, but then are able to stop taking the drugs. Others become hooked after their first experience. Thus, opioids may not be addictive in the same way for everyone. We also know that external factors, such as stress and anxiety, play an important role in drug addiction by elevating drug cravings.12
Some former opioid addicts say that before taking opiates they were already self-medicating with other drugs or with alcohol to deal with a trauma or difficult experience. Their first use of opioids may have been for medical reasons, but it made them feel good, and they developed an obsessive craving for those good feelings again. The Scientist interviewed 19-year-old Alex Peterson, who latched on to opioids after his first experience with fentanyl as an analgesic for a colonoscopy procedure. He had gone through a break-up with his girlfriend and was drinking excessive amounts of alcohol to cope, which led to his need for the medical procedure. Alex reports, "That's when I had my first, like, real rush of painkillers. . . . I just remember coming out of that, it was such a euphoric, numbed-out feeling. It was definitely unlike anything else I'd had."13
From a purely physical perspective, Alex Peterson's brain may have already been primed to become addicted to opioids. But he was also psychologically primed to become attached to whatever would provide him with relief from his emotional suffering. Peterson describes his motivations as something more than the result of having an addict's brain: "With an addict it's a craving, a hunger for something . . . whether it's to get you out of your reality or take you out of your sickness."
Emotional states like depression or anxiety can lead to physical pain. And physical pain, chronic pain in particular, is often coupled with depression. Chronic pain that has a non-physical cause cannot ultimately be solved by a physical means, but many people think that drugs will provide relief. But using drugs to mask the symptoms is not a solution to the problem, and in some cases it does more to put an end to the person than to the problem.
Habits, Rituals & Meaning
Market pressures, neurological states, and psychological trauma are not the only reasons why opiate drug addiction has taken hold of so many people.
Addicts who have gone through Alcoholics Anonymous consistently report that they feel no control over their addiction, even feeling so consumed by it that they will act against their desires. They report "knowing" that they will drink even though they do not want to. There is something beyond voluntary decision-making at work here, but there is still an element of personal responsibility.
In the past, the "choice model," which treats addiction largely as an issue of self-control, was overstated. Today, perhaps as a response to this simplistic view, the "disease model" is prevalent, which treats addiction as a disease and addicts as victims. But neither of these models adequately describes the paradoxical nature of addiction.
Kent Dunnington, in his book Addiction and Virtue: Beyond the Models of Disease and Choice, looks at addiction through the lens of habits and virtues. He draws upon the work of Aristotle and Thomas Aquinas, both of whom explore the reasons why individuals will sometimes seem powerless to act in their best interests even when they knows better.14
Dunnington describes addiction paradoxically, as a habit that is so deeply ingrained that its "object is invested with meaning that extends to every other aspect of an addicted person's life. . . . [It] informs all other habits by determining the end toward which those habits are directed."
The kind of habit that he refers to is different from what we usually mean when we talk about habits today. For instance, when we think of a bad habit, we think of something like biting your nails. What Dunnington means by habit is something that directs your whole being toward a certain end, or telos. In other words, your habits make you into a certain kind of person. As your habits become more ingrained and you start becoming the kind of person they produce, you find that giving in to them becomes increasingly automatic. Trying to change habits at this point becomes exceedingly difficult, and produces an experience similar to the addict's sense of being out of control yet also somehow responsible.
Our habits relieve us from the exhaustion of having to deliberate over every single decision we make in a day. Instead, some decisions are automatic, based on the habits we have cultivated and the kind of person we are. This idea coincides with studies showing that repeated behaviors reinforce neurological pathways.
If we consider addiction a deeply ingrained habit of this kind, then what is the telos toward which opiate drug use leads the user? Dunnington makes the controversial claim that addiction is actually a deeply moral undertaking that provides the addict with certain goods. For instance, it provides order in an otherwise chaotic world.
One of the defining features of modern culture is that it does not have a shared account of what constitutes happiness, or the good life. People can choose autonomously from any number of ideas of fulfillment and any number of moralities, deciding for themselves which ones to follow. But such decisions are essentially arbitrary, for there is no sure way to determine why one might be better than another.
Without a common notion of the good life undergirding it, the gift of autonomy comes with the curse of fragmentation, loneliness, and boredom. When the answer to the question, "What is the purpose of my life?" is "Anything you want it to be," but you have no way of knowing what is truly worth wanting, the result is not optimism, but nihilism. Or as Dunnington says, "The collision of an ethos of self-realization with an account of human action that divorces freedom from teleology is the wreck called modern addiction."
In many ways, addiction is a powerful response to a particularly modern lack. Drug use may begin as a diversion, but it becomes addictive because it provides something more. It is as potent, powerful, and uncontrollable as it is because, unlike other coping mechanisms, it almost works. In a culture of self-realization without a common view of the good life, addiction gives you an identity and a goal, a telos. The identity is that of an addict and the telos is enslavement and death, but in the moment, it feels better than having no identity and no goal.
Several factors have contributed to the widespread use and abuse of prescription pain medicine and heroin. With the pressure on doctors to address pain and the resultant excessive prescriptions for drugs, few regulations are in place for such potent substances. Additionally, there are psychological and cultural factors that make opioids an attractive way of dealing with pain and angst. We cannot begin to address the solution until we come to terms with the complexity of the problem. •
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