Guinevere Gets Sober

Recovery news, reviews and stories, by Jennifer Matesa.

Tag: chronic pain (page 2 of 2)

The stigma of addiction (part n): Doctors and addiction

In Addiction and Art (a book I swear to G-d I’m going to review very very soon) the authors, professors of psychiatry and behavioral biology at the Johns Hopkins University School of Medicine, write that compared to other medical illnesses, addiction receives little attention from the medical and public health communities. The reasons: the perception that it’s primarily a law enforcement problem, not a public health problem; skepticism about treatment; and “poorly funded research, weak leadership, stigma, and stereotypes.”

The authors go on to add, “Many of these obstacles to appropriate action, however, are caused more by indifference and prejudice.”

We can see this in the kind of outburst registered last week on the comments section of the New York Times story about a piece of Washington state legislation that would require physicians to refer pain patients on increasing doses of opioids to specialists if their symptoms were not improving.

Note well, reader: not cut off the patients, but refer them for further consultation if symptoms were not improving.

Listen to the uneducated voices that went ballistic:

I would much rather have some people become addicted to pain medicine than to do anything which restricts people with legitimate pain from obtaining pain medicine. … There is not one bit of evidence to suggest that if pain medicines were not available for misuse that people inclined toward addictions would not just find another drug. That is the history of drug use.

Here we have a guy who would prefer to sentence some people to a deadly disease, rather than consider implementing reasonable regulations that might allow clinicians to distinguish who might not be benefiting from these powerful drugs.

Another:

Patients who use narcotic drugs for real pain relief need them and do not become addicts.

Well, yes, honey, I’m here to tell you that some do! Get yer head out of the sand.

Moreover, patients who use opioids for real pain relief may still be addicts. They might have ruptured discs or spinal stenosis or no cartilage left in their knees. These conditions, which may require pain treatment, don’t exempt them from having addiction as a disease.

There were a very few sane voices:

As 21-year-old who has arthritis (19 years)and fibromyalgia (6 years) and experiences widespread pain every day, I don’t really have a problem with these regulations. If a medication is not working, its use should be reevaluated, especially if the medication could cause further health problems. I’ve been on a variety of different NSAIDs (different than a pain killer, I know) over the years. Whenever the medication stops working or isn’t doing enough for me, I change meds. If a powerful painkiller isn’t making any difference, why would someone keep taking it?

And another:

During my residency I only prescribed OxyContin to terminal cancer patients. … It was abundantly clear that most primary care physicians have very little to no training in managing and prescribing chronic opiates. Many of these patients encountered were physically and or psychologically dependent. Some were addicts.

Even when physicians have training in managing and prescribing opioids for chronic non-malignant (that is, non-cancer) pain, they often do not have the first clue how to recognize addiction inside their offices. And if they can recognize addiction, usually the stigma and stereotypes take over: they see their patients as having become morally corrupt rather than as having an(other) illness.

Pain physicians are trained to get patients ONTO drugs, not OFF drugs. So, largely in fear of DEA reprisals, they kick addicts roughly out of their practices, they refer them to psychiatric hospitals, and the patient is faced not only with negotiating a disruption in continuity of care for their pain problem but also with setting up treatment for their addiction—about which they may be in severe denial—and having to do it in opiate withdrawal, while also having to work, and/or take care of kids, aging parents, etc.

Total nightmare scenario. One that every chronic pain patient who-deep-down-suspects-she’s-an-addict wants to avoid, so this is why she usually stays in denial. She does not know how to get out. She doesn’t need to be kicked out of the practice, she needs help.

I wish this kind of legislation had been around five or six years ago. All I had to do to convince my doctor I was doing well was to go in and say I was doing well. I was taking pain medication for two real, diagnosed, legitimate neurological problems (which I still have), but it had also dimly entered my awareness that it was helping me cope with psychological problems as well. (Of course, the two can’t really be separated. The wellbeing of the body is the wellbeing of the mind.) If my physician, who is diligent, had been required to submit me to a protocol of questions and demonstrations at each visit to determine my actual functionality, it might have been determined, over time, that the opioids weren’t actually helping me improve. But again, I was afraid of being kicked out, cut off, sent to the psychiatric hospital, forced to take care of my child in the interim while enduring opioid withdrawal, etc. It was a conversation I was afraid to have with my physician, because to broach it would be to puncture that can of worms and let escape The Stigma.

In my opinion, and this is just off the top of my head here, I’d really like feedback on this: every pain clinic should have a staff of certified addiction specialists who consider addiction to be a disease and not a moral failing. They would be there to protect the patient population from the risk and to help those who have the disease and who also have chronic pain (because, as above, pain patients can also be addicts).

If you’re going to call pain a disease and you’re going to be in the business of handing out opioids, you need to get real about the disease of addiction. And not in a punitive way.

Getting ready for work: Chewing Vicodin

I didn’t plan on writing about Michael Jackson again, but the news today (via the Associated Press, see story) is pretty shocking:  Jackson paid a physician to administer the anesthetic propofol intravenously every night for two years so he could get a full night’s sleep.

On the one hand, it’s appalling; on the other, predictable. I did the same sort of thing myself. And I’m hardly unique: I’m a 44-year-old white middle-class American addict.

What’s predictable is the fact that Jackson was so desperate for sleep.  If he was taking as many drugs every day as they say he was (two heavy-duty opioids, a benzodiazepine, a muscle relaxant, and more), he was definitely screwing up his body’s ability to regulate its sleep-wake cycles, also called “circadian rhythms.”

When I made it into detox last year, I was taking 100mcg/hr fentanyl—usually more, because I sometimes took more than prescribed. That’s roughly equivalent to 400mg morphine. (To give you some perspective, after routine surgery, patients are usually given 5mg Percocet, which is about equal in strength to morphine.  I was taking about 80 times that, every day.)

Fentanyl is the strongest opioid available by prescription. It’s commonly used for cancer patients. I was prescribed it for migraine and fibromyalgia.

Any opioid addict will tell you that addiction wrecks your sleep.

Morphine was named after Morpheus, the god of sleep, and heroin addicts have made the image of the “nod” a cliché.  But there’s another side to opioids that many non-addicts don’t realize: a spike in blood-levels can give you extra energy.

I started taking Lorcet 10mg for headaches about eight or nine years ago. (Lorcet is the same as Vicodin: it contains hydrocodone and Tylenol.) I was given 30 per month—an amount that seemed enormous then. So I took about one per day. As soon as I discovered I could get refills a bit earlier than exactly 30 days, I started taking maybe one-and-a-half per day. Here’s why: on Lorcet, I could Get Everything Done.

I could get up at 6 with my son, get breakfast, do the dishes, get him dressed, get myself dressed, get his lunch packed and get him out the door to daycare, and I was showered and in my chair ready to work by 9.

I could work at a computer for hours and never move. I could get an amazing amount of work done in the half-day I had to do it. I could get my son, put him down for a nap, get more work done, get him up, clean the house, get dinner, and after dinner, weed the garden or do other chores.

For someone like me, that level of control was central to my ability to feel like I could survive in this world.

About 18 months or two years into my run with Lorcet, I was taking two tablets per day (and facing the consequences: I’d face several days per month when I was out of medication). Because, as with any drug that results in dependence, after 18 months at the same dose, the effects of one tablet weren’t as powerful. So I increased the dose—not under supervision. Just on my own. Because, of course, I knew best.

So I could “function.”

Many addicts take drugs so they can function.  For us, it was a solution.  For many years, I reasoned—rationalized—that I wasn’t an addict because I had a common image of addiction: Real Junkies lay around on the couch, eating Doritos and watching soap operas.

I was Working.  I was Productive. Just like Michael Jackson. Right?

The press often mentions that Jackson was taking all these drugs to “prepare” himself for the 50 London shows he’d signed for.  As if it is a truth universally acknowledged that a celebrity musician—or anyone—needs drugs as part of his “preparation” for his work. Even the press continues to enable him in his death.

My habit of “preparing” for my work each day was to chew a pill or two before I even got out of bed.  I chewed them to maximize their effects: most addicts discover that taking drugs in some manner “not as prescribed” is the best way to manipulate their effects. The practice led me into a deep well, out of which I’ve climbed step by step in the past nine months. I’m seeing the light, and for that I’m grateful.

What’s shocking is that there is a health professional on the face of this earth who would be so greedy for money and so interested in exploiting his association with a celebrity that he or she would agree to carry out something so harmful one time, much less over the course of two years.  Not only did the practice apparently finally kill Jackson, but also the drug itself had to be stolen: propofol, an anesthetic designed for hospital use, is not available by prescription.

Where is the word “addiction”?

For this first post I was planning on introducing myself but instead I’m sitting here reading the New York Times and being gobsmacked all over again about the fact that folks STILL don’t get addiction.

The New York Times’s “Well” column today tells us we really, really shouldn’t be afraid of the Tylenol in Vicodin and Percocet. All we have to do is take it as prescribed.

BTW today’s column is a followup to a July 1 piece about a federal advisory panel’s recommendation to the Food and Drug Administration to ban Vicodin and Percocet, “two of the most popular prescription painkillers in the world,” because of the toxic effect on the liver of massive doses of Tylenol.

I was floored when I read this. Banning Vicodin for the Tylenol would be like banning hot dogs for the preservatives. There would be a strong outcry, especially from the owners of, say, baseball teams?

One wonders how much influence a possible complaint from McNeil, Tylenol’s wealthy manufacturer, could wield over the editorial content of the NYT’s website. Because a statement on www.tylenol.com, issued last week by the senior medical director, Edwin K. Kuffner, M.D., offers pretty much the same viewpoint as today’s “Well” column: Don’t worry about Tylenol.

But a word of caution: if you are someone who has ever used Vicodin or Percocet “not as prescribed”—notice how little this physician’s statement either understands (or admits) why enough folks are taking too much to worry the federal government.

Where is the word “addiction” in all these statements?  Absent, as usual.

The word “addict,” in the public imagination, conjures a low-life waste-case heroin junkie cooking and shooting under a bridge. A sad-sack patient in an early-morning queue at the methadone clinic that nobody wanted in their neighborhood. Even yuppie partiers snorting coke off a toilet lid in a dirty downtown club might not be “real addicts”—they’re just “having fun.”

An addict surely can’t be an ordinary person with a very common illness that has psychological, neurological and behavioral components, who buys her drugs at—a drugstore.

It is very difficult to get good statistics on how many people use drugs because of the stigma still surrounding drug addiction. The Monitoring the Future survey, which the federal government claims is one of the most reliable, polls school kids ages 12 and up. The 2007 results on Vicodin: 2.7% of 8th graders, 7.2% of 10th graders, and 9.6% of 12th graders had used Vicodin for “nonmedical purposes” at least once in the previous year. Which, if anything, points to how accessible the drugs are. All that stuff’s just out there, waiting to be picked up.

And our society has become so used to taking a pill for every condition.

Why we take too much Vicodin or Percocet: our head hurts; the site of our injury/surgery/chronic condition hurts; it helps us deal with stress; it calms us and stimulates us; it helps us sleep; it helps us wake up; it helps us get through boring parts of the day; it helps us not explode in impatience when our spouse or kids irritate us—

I invite you to add your own below.

If you want to stop taking these drugs but can’t imagine how, I post on a forum with tons of experience. One of the best and most popular spots is the board about Detoxing from Pain Meds.

If you’re already free of opioids or other substances, please tell us how you did it.

And tomorrow I’ll tell you who I am, what I do, and why I’m here…

—G

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