The Shrink As Sherlock — Detecting Opioid Addiction

She was exactly my age, with a birthday only two days before mine. Same year.  I know that there are more people born under the sign of Aquarius than any other astrological sign, so I am no longer surprised at the number of people who have birthdays in February. (Especially since, if you count back nine months, you end up with June, which is when everyone’s thoughts turn to love and their thyroids and probably other glands are hyper-secreting.) But  this was one of those people who makes me think I look awfully good my age.  Probably a function of middle class privilege and doing more intellectual than physical work.

This woman had a son who cared about her.  The fact that she came to the clinic with him made her fairly special among those I was serving at the time.  He had been worried when she seemed too sleepy and too angry and not herself.

Like most patients, she really did not want to tell me much about the other doctors she saw or what medications they gave her.  I told her that I could check for interactions, and that her failure to tell me would increase her risk of having problems.  I know that a lot of people get “pain killers” and don’t think that they count for “real medicine.”

Well, this woman with the wig a little lopsided on what seemed to have been a shaved head, with skin like leather, was probably, I thought, getting some Vicodin for the bad back she often complained about.  After all, I remember rolling my eyes heavenward and covering them with my hands when Dennis Miller the comedian announced on television that there were only two kinds of doctors.  There were the ones who would give you Vicodin over the telephone and the ones that would not.  The audience who applauded were obviously the patients of the doctors who would.  I obviously would not.

I was surprised when he told me what she had not.  She was on Methadone; a fairly high dose.  I was giving her things for “anxiety,” some antidepressants. She had been getting them from the clinic for a fairly long time.  She had been getting a high dose of methadone for a long time, too. I had her cleared by a local emergency room, which took the better part of a day, to make sure we were dealing with a “drug” thing, and not with any underlying medical problems.  We weren’t.  She was a tough cookie.  I talked to her Methadone doctor.  We would work together and bring her down easy.  Her son would monitor her medications.  She had been lots of years on lots of heroin.  Her son told me how hard it had been to get her into methadone, something he did not realize she had never shared.  I gave him all the support I could, thanking him for what he had done.  I really think she is going to do fine now.

The prevalence and severity of heroin addiction in this nation right now depends on who you talk to. Some say the problem is over estimated. There are two reasons for which these arguments do not impress me. First, I don’t think statistic collection and research methods do a good job of knowing who or what is abusing drugs.  The dual diagnosis program in the clinic where I am spending my time right now told me they have not seen a heroin abuser for a really long time.  This is amazing since I see several each week.  Obviously whatever people have this problem and go to treatment do not talk.  It may be shame; it may be more. Second, most of the abuse of the drugs in the opioid family, of which heroin is but one member, seems to be prescription drug abuse.  The study above mentions this. Some people say that opioid addiction, even with prescriptions, is not that much of a problem.

I see it everywhere.  I cannot believe it is not a problem.  I just believe that Dennis Miller was right.  There are doctors who prescribe Vicodin over the phone and those who do not.  As one who does not, I feel pretty lonely sometimes when I talk to general or family physicians. Opioids are a reasonable and effective treatment for pain.  There has recently been a major and appropriate national initiative for doctors to treat pain. It is possible, after all, to use these drugs to help people have productive lives where otherwise they may not be able to.  But somebody here has gotten major league carried away. First, the facts.  The government has produced some responsible, even conservative guidelines for the treatment of addiction.  Addiction happens, and the treatments work. But whether we are talking about prescription or street opiates, we are talking about a serious risk here. I can’t link you to this one; it is on doctors only sites.  But I can tell you that as a citizen, at least in California, you can walk into any medical library and find the January 19 issue of the Annals of Internal Medicine, and find an article telling about a study by the Group Health Research Institute and the University of Washington telling you that people receiving higher doses of prescription opioids are about 9 times as likely to get an overdose than people receiving lower doses. Right now opioids, this heroin-like class of drugs, seem to be being prescribed, chronically, to about 3% of the adult population. The study looked at pharmacy records for some health maintenance organization.  Now we are NOT talking about cancer patients here.  We are talking about people with “benign” pain; stuff like back pain, and neck pain, and menstrual cramps. The editorial accompanying the study, by Dr. McClellan of the White House Office of National Drug Control Policy calls for more responsible prescription of these drugs by physicians. Dr. McClellan is a PhD, so he doesn’t write prescriptions, and I have no idea how he could get doctors to be more “responsible.” To his credit, he picked up on something really crucial. The overdoses were more frequent in patients who had been diagnosed as depressed, or had substance abuse problems (presumably other ones, hardly a surprise) or who were getting some kind of sedative or sleeping pill at the same time. All of these were known to be risk factors for overdose.

Of course, I am worried about the patient I described above.  The one with my age and the leathery skin, and the depression she had and I was trying to treat.

Opiates work specifically on pain.  They work specifically on the opiate “receptor.”  Receptor theory has been around for a long time. It explains some things but not others.  There are supposed to be no interactions between opiates and other drugs, because they work on different receptors.  I am supposed to know and believe this as a psychopharmacologist.  But I also know about risk factors for overdose.  And I also know I do not like to put too many drugs together that will weaken or confuse a patient, or make him or her sleepy.

I know something else,too. The risk of addiction is always there with this class of drugs.  Chronic pain is tough to treat. There are other regimens of pharmacology that work for specific types of pain. There is psychotherapy of varying sorts.  I am partial to Emotional Freedom Technique, and use it frequently for pain patients and it does not have this
kind of dangers.

I talk to doctors and plead with them; I get patients detoxified when I can, and treat them the best I can.

I think that both patients and physicians are looking for–and accepting–quick and easy solutions.  Doctors are overworked with too many patients. Patients are overworked and want fast help.  A thoroughly informed consent is hard to come by.  It is very easy to get patients “hooked;” the hard thing is not to.