Addictive Drugs and Questions They Raise

I heard it long ago, when I was early in my training, at some big international psychopharmacology meeting so I reproduce it here. “What people really want is an on-off switch.” Most people seem to get through life pushing the envelope only minimally.  A few cups of coffee in the morning helps promote “alertness.” A drink or two with the guys after work helps to “wind down” on the way home. Neither of these decisions is harmless. Although there are indeed some beneficial compounds in some forms of alcohol, I have come to believe that civilization has taken a poor turn in validating its use for a very long time.

Louis Pasteur’s statements about wine being the healthiest beverage known to him were made while he was salaried by — the French wine industry! I was actually taught French in medical school that a certain amount of cirrhosis was normal, and to be expected, especially in men. Nobody has a good answer as to why.  And this was before the era of the liver transplant. Don’t even get me started on caffeine.

I have had patients get manic on a few cups of coffee — at an average of 100 mg. of caffeine in each cup.  (Of course, sizes of cups and strength of coffee are incredibly variable.) I have had patients get grossly psychotic (seeing and hearing things that are not there) with one or two of those caffeine tablets that truck drivers take to stay awake,(generally 200 mg. of caffeine each). I have diagnosed “caffeinism” in patients who present with symptoms of panic disorder, whose symptoms seemed to have been caused by drinking a few pots of coffee a day. I have gently and lovingly tapered them off their caffeine slowly enough to avoid the dreaded withdrawal headache, generally best treated by slightly and temporarily increasing caffeine consumption.

We are admittedly a fairly long way from the ancient myth that somewhere in the Arabian peninsula, goats frequented primordially on coffee beans still on the vine and got extra-frisky.

The people who abuse drugs are, at least in the beginning of their substance abuse careers, no different from us. They are us. The one way they seem to me to differ from us is at the very beginning of their substance abuse career, when they are quite young. The ones who visit with me almost always started at an age less than one-third of my present age. (It is public knowledge I am 63. My internet-savvy patients generally check me out with the California Board of Medicine.)  It is still hard for me to imagine someone trying a prescription painkiller or anti-anxiety drug, or even heroin, just to see what it feels like.

Maybe at least part of that feeling is because I have spent so many years now studying drugs and their chemistry that I have a great respect, even a fear of them.

There is a feeling, a statement, I have never quite been able to identify definitively as either truth or mythology. I have heard that there are great legions of people who, generally recreationally, “try” abusable drugs, and walk away, never to get addicted. I never have, and never would, meet such people. They would never see a psychiatrist, because they would have no psychiatric complaints. They certainly would never see someone who works with addicts, as they would never be addicted. Their lives would be very happy, and they would simply continue along with their happy lives.

I have heard of mythology related to people doing this. Mostly they are stories about people using cocaine for weight loss, and stopping it when they reach target weight. They always expect at least a little rebound weight gain, although few seem to prepare ahead for this. My star-following friends (curiously enough, including nurses who work at a facility that treats addicts) have told me that this method is commonly used among Hollywood stars. I would not know if they are addicts or not.

Curiously, British research has demonstrated that cocaine acts not only as an appetite suppressant, which has been previously known, but to reduce leptin in the body, a hormone associated with fat absorption. The bigger question is whether it really is true that while some people who try potentially addictive substances become addicted, others who try them simply do not.


Why some people who use drugs get addicted and some do not.  Can you get addicted to drugs after using one time? Is opiate withdrawal psychologically or environmentally induced? And an introduction to “Dual Diagnosis” — the field psychiatric illness with concurrent addictions.

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