Excerpt: When Painkillers Become Dangerous

July 22, 2004 -- 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 thatpost-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 openward with six beds arrayed about the periphery of the dormitory.I found Mr. Resnick writhing in pain. He was toodistressed 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. Acalmness swept across his face. As he became more comfortable,I remember my sense of awe and excitement that I hadbeen able to help this man who had been suffering.

This was my first experience as a medical student administeringan opiate to a patient. I cannot express to you mysatisfaction at having been able to help this man so vividly andquickly. After all, this is what those of us who enter helpingprofessions expect and hope from our careers; and rarely dowe get to experience this sense of triumph so thoroughly aswith our ability to take away pain.

Every physician learns earlythat we can reliably and easily relieve pain with opiates.Mr. Resnick had been in a motorcycle accident and sufferedmultiple injuries. He was an addict, but at that point in mytraining, I did not understand what that meant. It seemed tome that he was frequently demanding pain medication. Butwhy not? He had just had an operation on his leg. The morehe demanded, the more I dutifully came running with themorphine.As time went along, Mr. Resnick told me about his addictionto heroin. I was shocked. He was a college graduate. He maintaineda small business. Heroin? How could that be? When itcame time for discharge, I made sure that he had an adequatesupply of Vicodin. He was extremely preoccupied with beingcertain of the amount and number of refills. I didn't think muchof it at the time, and I agreed with him that he just neededto get out of the neighborhood where he lived and stay awayfrom his heroin-using friends.

It sounds ridiculous in retrospect, but my lack of understandingof the disease of addiction probably did this manconsiderable harm. Was it wrong to give him opiates for hispain? No. He needed pain medication, and, in fact, because ofhis addiction and tolerance to opiates, he needed more thanthe average patient to control his pain. However, I hadabsolutely no understanding of the addictive disease processand how I might be contributing to it.

Addictive Diseases

I, like every medical student of my time, had essentially notraining in addictive diseases. I was focused only on treatingMr. Resnick's orthopedic problems. He needed pain relief, and

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

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

Mr. Resnick's case highlights the complications of usingmedication to alleviate human suffering when the caregiverdoes not have a sophisticated understanding of addiction.This patient needed pain medication, and he needed specificreferrals and treatment for the disease — addiction — that puthim at risk for the motorcycle accident in the first place. Mr.Resnick's addiction became even more difficult to treatbecause of the complexity of trying to manage his pain withthe very chemicals to which he was addicted. Later in thischapter, you will see how heroin, morphine, and Vicodin arerelated substances.

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

We present in these pages a thorough examination of agrowing problem for our country: addiction to prescriptionpain medication. We felt it was important to create a single,complete resource addressing this problem. Our focus will beon 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 interventionoption.

How Pain Medication WorksPrescription pain medications are essentially all related by theircommon effect on the body's endorphin system. The moleculesof the medication mimic the effects of the body's own endorphins,but are much more powerful and last for longer periodsof time.

Endorphins are involved in many biological actions,including respiration, nausea, vomiting, pain modulation, andhormonal regulation. There are several types of endorphinreceptors, including the delta, mu, and kappa receptors. Eachof these three receptors is involved in different physiologicfunctions. The blocking of pain comes primarily from effectson the mu receptor. The emotional effects of pain medicationare quite complex. Pain medications exert their effects on thelimbic system, or what is considered the emotion center of thebrain, 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 3,400B.C., have been used by humans for thousands of years.The term opiate describes naturally occurring and syntheticcompounds directly derived from the poppy. The word opioidis used to describe any derivative of the opiate class. Opium containsa complex mix of sugars, proteins, fats, water, latex, gums,ammonia, sulphuric and lactic acids, and numerous alkaloids,most notably morphine, codeine, noscapine, papaverine, andthebaine. Although thebaine has no pain-relieving effect, itis used to synthesize other opioids which have become verypopular: 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 thefirst known reference to opium. The word opium derives fromthe Greek word for "juice of a plant." Opium was actuallyprepared from the juice of the poppy. The juice is derivedfrom the seedpods of the flower. Ancient Sumerians, Assyrians,Babylonians, and Egyptians learned that smoking the extractcauses pleasurable effects. Use of the plant later spread toArabia, India, and China. In Europe, it was introduced byParacelsus (1493–1541).

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