Excerpt: When Painkillers Become Dangerous

In this book excerpt, Dr. Drew Pinsky calls attention to the risks of addiction to patients using prescription pain killers.

Chapter One: How Addiction Develops

"Get in there and push six milligrams of morphine on that post-op femur. And debride his heel while you're in there." The orthopedic resident glared down at me with disdain. "Get on it." I, a wide-eyed third-year med student, ran into the open ward with six beds arrayed about the periphery of the dormitory. I found Mr. Resnick writhing in pain. He was too distressed to notice my presence. I grabbed his IV tubing, kinked off above the port, and slowly injected the morphine. Within seconds, his breathing became slower and deeper. A calmness swept across his face. As he became more comfortable, I remember my sense of awe and excitement that I had been able to help this man who had been suffering.

This was my first experience as a medical student administering an opiate to a patient. I cannot express to you my satisfaction at having been able to help this man so vividly and quickly. After all, this is what those of us who enter helping professions expect and hope from our careers; and rarely do we get to experience this sense of triumph so thoroughly as with our ability to take away pain.

Every physician learns early that we can reliably and easily relieve pain with opiates. Mr. Resnick had been in a motorcycle accident and suffered multiple injuries. He was an addict, but at that point in my training, I did not understand what that meant. It seemed to me that he was frequently demanding pain medication. But why not? He had just had an operation on his leg. The more he demanded, the more I dutifully came running with the morphine. As time went along, Mr. Resnick told me about his addiction to heroin. I was shocked. He was a college graduate. He maintained a small business. Heroin? How could that be? When it came time for discharge, I made sure that he had an adequate supply of Vicodin. He was extremely preoccupied with being certain of the amount and number of refills. I didn't think much of it at the time, and I agreed with him that he just needed to get out of the neighborhood where he lived and stay away from his heroin-using friends.

It sounds ridiculous in retrospect, but my lack of understanding of the disease of addiction probably did this man considerable harm. Was it wrong to give him opiates for his pain? No. He needed pain medication, and, in fact, because of his addiction and tolerance to opiates, he needed more than the average patient to control his pain. However, I had absolutely no understanding of the addictive disease process and how I might be contributing to it.

Addictive Diseases

I, like every medical student of my time, had essentially no training in addictive diseases. I was focused only on treating Mr. Resnick's orthopedic problems. He needed pain relief, and

it never occurred to me to consider anything beyond that. If he had a drug problem, well certainly he had now learned his lesson, and no doubt, he would avoid all those bad influences that "made" him use drugs.

As a doctor, I felt triumphant in my ability to help this man and rescue him from his suffering. Given what had happened to him as a result of his drug use, I couldn't imagine he would continue using. If he did continue, well, he just needed to take my direction more seriously. If he still continued to use drugs, well, then that was his problem.

Mr. Resnick's case highlights the complications of using medication to alleviate human suffering when the caregiver does not have a sophisticated understanding of addiction. This patient needed pain medication, and he needed specific referrals and treatment for the disease — addiction — that put him at risk for the motorcycle accident in the first place. Mr. Resnick's addiction became even more difficult to treat because of the complexity of trying to manage his pain with the very chemicals to which he was addicted. Later in this chapter, you will see how heroin, morphine, and Vicodin are related substances.

These complex issues are becoming more prevalent every day. The statistics are alarming. The National Institute on Drug Abuse (NIDA) reports that in 1999 an estimated 4 million people (about 2 percent of the American population age twelve and older) were currently (in the previous month) using prescription drugs non-medically. Of these 4 million people, 2.6 million were misusing pain relievers, 1.3 million were misusing sedatives and tranquilizers, and 0.9 million were misusing stimulants. These numbers obviously do not reflect the many thousands of people who may not recognize OxyContin and Other Prescription Pain Medication that they are misusing prescription medication but have become addicted as the result of following a doctor's orders. NIDA further reports from its 2003 Monitoring the Future survey of eighth, tenth, and twelfth graders that 10.5 percent of twelfth graders report using Vicodin for non-medical purposes and 4.5 percent had used OxyContin without a prescription.

We present in these pages a thorough examination of a growing problem for our country: addiction to prescription pain medication. We felt it was important to create a single, complete resource addressing this problem. Our focus will be on a specific drug in this class of medication: OxyContin. Throughout this book, we will look at the nature of addiction, its effect on the family, treatment modalities, and an intervention option.

How Pain Medication Works Prescription pain medications are essentially all related by their common effect on the body's endorphin system. The molecules of the medication mimic the effects of the body's own endorphins, but are much more powerful and last for longer periods of time.

Endorphins are involved in many biological actions, including respiration, nausea, vomiting, pain modulation, and hormonal regulation. There are several types of endorphin receptors, including the delta, mu, and kappa receptors. Each of these three receptors is involved in different physiologic functions. The blocking of pain comes primarily from effects on the mu receptor. The emotional effects of pain medication are quite complex. Pain medications exert their effects on the limbic system, or what is considered the emotion center of the brain, and can in many individuals induce a sense of euphoria.

The Juice of the Poppy

Pain medications share a common historical heritage. Derivatives of the poppy flower, first cultivated around 3,400 B.C., have been used by humans for thousands of years. The term opiate describes naturally occurring and synthetic compounds directly derived from the poppy. The word opioid is used to describe any derivative of the opiate class. Opium contains a complex mix of sugars, proteins, fats, water, latex, gums, ammonia, sulphuric and lactic acids, and numerous alkaloids, most notably morphine, codeine, noscapine, papaverine, and thebaine. Although thebaine has no pain-relieving effect, it is used to synthesize other opioids which have become very popular: hydrocodone (Vicodin), hydromorphone (Dilaudid), and oxycodone (Percocet). OxyContin is a controlled release, high-concentration formulation of oxycodone.

The writings of Theophrastus (third century B.C.) are the first known reference to opium. The word opium derives from the Greek word for "juice of a plant." Opium was actually prepared from the juice of the poppy. The juice is derived from the seedpods of the flower. Ancient Sumerians, Assyrians, Babylonians, and Egyptians learned that smoking the extract causes pleasurable effects. Use of the plant later spread to Arabia, India, and China. In Europe, it was introduced by Paracelsus (1493–1541).

In the eighteenth century, opium smoking was popular in the Far East, and the opium trade was a very important source of income for the colonial rulers from England, Holland, and Spain. Opium contains a considerable number of different substances, and in the nineteenth century, these were isolated. Friedrich Sertürner was the first to extract one of these substances in its pure form. He called this chemical morphine after Morpheus, the Greek god of sleep or dreams.

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