Pain Relief Without Addiction: Walking the Tightrope

[Originally published on hellowellness.in on 29 Oct. 2010]

Roger T., a middle-aged systems analyst, showed up at a LifeRing recovery support group looking for help with addiction to painkillers.  Years earlier he had been a passenger in an auto collision which left him with chronic pain in his lower back and hips.  His doctors had prescribed the standard opiates, and this had provided him with some relief, but over time he needed larger and larger doses.  He said he had been taking 300 Vicodins® per day.  He knew he had to stop the drugs -- but he couldn’t live with the pain.  

Not only patients but also their physicians have to walk a tightrope between pain and addiction.  A hot case in point is the jury trial involving Dr. Sandeep Kapoor, the 42-year old Hollywood internist and physician to celebrity model Anna Nicole Smith.  Smith died of a drug overdose in 2007.  Dr. Kapoor and two other defendants were not charged in her death -- this was ruled accidental -- but were charged with conspiracy to provide her with excessive quantities of pain medications while knowing she was an addict.  

In other words, Dr. Kapoor was charged with crossing the line from medical helper to drug pusher.  It’s an issue that inflames hundred-year old wounds on the U.S. medical community.  With the passage of the Harrison Act in 1914 and regulations and court decisions shortly thereafter, the federal government severely limited physicians’ professional freedom to prescribe analgesic medications.  They could prescribe opiate painkillers only in tapering doses, and their good faith professional medical judgment was ruled irrelevant.  

In the following decades, the US Treasury Department indicted more than 25,000 physicians for prescribing opiates; some 3,000 went to jail, and more than 20,000 were forced to pay fines.  It was a shameful period, and it has left enduring scars on modern medical practice.  The California statute under which Dr. Kapoor was charged is a direct descendant of this period.  These laws have chilled physicians’ treatment of patients with chronic pain problems.  

The Harrison Act rested on paranoia about anarchists, radicals, criminals, and foreigners -- especially Chinese -- who were (wrongly) seen as the typical opiate users of their day.  Scratch any subscriber to what passes as public opinion in the US today and you’ll find, not far beneath the surface, a similar identification of drug users with social undesirables.  

All of that goes on the scrap heap when a celebrity is involved.  As everyone familiar with the criminal justice system in the U.S. must be aware, celebrities are above the law, particularly the law of addictive substances.  Lindsey Lohan, Mel Gibson, Paris Hilton ... all would be locked up for years if their names were Smith, Jones, and Johnson.  And so here.  With Anna Nicole Smith, a genuine neon blazing celebrity at the center of the trial -- even more dazzling a presence in death perhaps than in life -- the judge found ample justification for her possession, post mortem, of more than 1,500 pills.  In a phrase that will reverberate in courtrooms for years, Judge Perry T. Fine admonished the jury, "The number of pills is not a determinative factor in this case. Please keep that in mind.”  

The jury did.  After 13 days of deliberations it returned yesterday a verdict of “not guilty” for Dr. Kapoor.  It found, in other words, that Ms. Smith was not “addicted” and that Dr. Kapoor’s prescription of opiate painkillers was medically justified in view of her many and severe symptoms of pain and anguish.  

Dr. Kapoor still faces a lengthy process of rehabilitating his reputation and defending possible attacks on his medical license.  But he will not go to prison.  

With this courtroom victory, physicians who specialize in the difficult art of pain management -- a small and endangered species -- will breathe a long overdue sigh of relief.  

Most of these physicians are members of the American Society of Addiction Medicine (ASAM), a highly respected and conservative professional body of providers who more or less successfully navigate the tightrope of giving pain relief without enabling addiction, every working day.  

But  there is also a fringe element of medical opportunists who will prescribe whatever the patient asks for, so long as the check is good.  And there are well-intentioned general practitioners with zero schooling in addiction medicine whom the experienced opiate addict plays like a violin.  

There are no easy answers to pain.  I have had conversations in LifeRing meetings with a number of people like Roger T. who suffer from chronic pain, medically managed with conventional opiate-based pharmaceuticals.  They tell me that they have learned to recognize when they are crossing the boundary from pain relief into seeking euphoria.  Unfortunately that insight came only after multiple boundary crossings with harmful consequences.  I have also talked with chronic pain sufferers who have found relief through hypnosis, meditation, special exercises, nutrition, and other alternative approaches.  Pharmaceutical research is also hinting at new types of analgesics that do not involve the classic addictive brain circuits, as the opiates do.  

Obtaining pain relief without falling into addiction is one of the most difficult challenges for professional and patient alike.  One thing seems certain.  There will be more progress if this problem is left in the hands of providers and patients, without massive interference from uninformed legislators and political appointees, frequently with demagogic motives.  To that extent, the jury’s verdict freeing Dr. Kapoor is an important step forward, and Judge Fine deserves recognition for a well-reasoned set of jury instructions.

Well said, in Washington

The Bush years, by wide consensus, were a dismal era for science.  But by a strange paradox, some bright stars emerged in what is normally a dismal field under any administration: addiction science.  

One is the brilliant Nora Volkow, who brings a rare mix of research experience, clear thinking, and leadership ability to the National Institute on Drug Abuse (NIDA).  

Another is Mark Willenbring, Director of the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism (NIAAA).  In a letter to the current New Yorker (the one with the cartoon of Obama as George Washington on the cover), Willenbring precisely skewers a piece that this normally astute mag published in its December 1 issue.  The article, titled "Special Treatment," by Amanda Fortini, featured a Los Angeles area deluxe treatment facility.  

After a string of well-worn 12-step platitudes about addiction and the difficulties of recovery, the owners of the facility claimed that in essence treatment could make no difference, everything depended on the addicted person's motivation.  So why bill the client for clinical services on top of the normal cost of luxury room and board? 

Willenbring's letter goes directly for the jugular.  He writes that the piece:

... shows the irony that paying more does not guarantee access to the most current therapies... The program that Fortini describes appears to base its services on a treatment model that is more than thirty years old .... Although clients may or may not receive some benefit, they are vulnerable to unnecessary relapse risk if more contemporary treatments are not also made available.  For example, research funded by the National Institutes of Health has identified several medications that reduce relapse in early recovery from alcohol dependence.  Newer behavioral approaches, such as cognitive-behavior therapy and motivational interviewing, also increase recovery and provide alternatives to the traditional Twelve Step approach (which in updated form is also effective).  This menu of services makes possible truly individualized treament and  increases client choice and engagement, but only if people have access to it.

The treatment program Fortini described in her article was so clinically clueless and bereft of ideas that the piece might have been a subliminal parody.  It isn't often that I get to cheer somebody in Washington for saying the right stuff.  Could this be the beginning of a change we can believe in?  

Alcoholocaust

If you have illusions about the role of alcohol in creativity, read "Day of the Dead" by D.T. Max on p. 76 of the Dec. 17th issue of the New Yorker. It's a thumbnail bio of Malcom Lowry, author of "Under the Volcano" (1947), hailed as one of the top twelve English novels of all time; he was considered the heir of James Joyce. He died ten years afterward, after passing out from massive quantities of alcohol and barbiturates. He was 47.

The chronicle of his marriage and collaboration with Margerie Bonner is a tortuous, gruesome story of love, hate, help, hurt, rescue and revenge. Bonner, who edited and rewrote Lowry's texts daily, almost certainly contributed the discipline and warmth that raised "Under the Volcano" above the rambling, two-dimensional symbolism that was Lowry's best unassisted effort. He was consumed with rage at everything and everyone; his violent tirades drove all their friends away.

She tried for years to get him to cut down or stop his drinking, but ended up matching him bottle for bottle, and when he finally found a doctor who got him to take a break (using aversion therapy), she refused to stop, and dragged him down again.

Much of the article deals with the theory that she murdered him, for which many women acquaintances and critics applauded her. It's a thin case. British local authorities, who conducted the inquest, pinpointed asphyxiation by aspiration of vomit as the cause of death. That's not murder. But it hardly matters. Lowry was bent on death by alcohol sooner or later. During one of his few lucid moments, he described his own life as an "alcoholocaust."

If a movie is ever made of this marriage, it should be on a double bill with "Pollock," and made required viewing for young artists considering careers in alcoholism and addiction: don't go there.

New drug turns meth to almond extract

A newly discovered drug with the catchy name YX1-40H10 can convert methamphetamine to benzaldehyde, a common food additive with an almond flavor, scientists at the Scripps Research Institute in California claim. If it passes a series of safety and efficacy tests, the new compound could be administered to people who have taken methamphetamine to neutralize the drug in the body. Source.

UK: "Restricted" report urges Rx heroin

The government should consider providing free heroin to hard-core addicts through the National Health Service as a way to reduce crime, says a top-level report by the UK Home Office.

Marked "restricted" because of its controversial recommendations, the document was leaked to The Independent.

There is mounting evidence that trying to restrict the supply of drugs is impossible, says the document. Even if partially successful, supply restriction merely drives up the price of drugs and drives addicts to commit more crimes.

The report comes in a setting where cheap and potent Afghan heroin in unprecedented volume has been flooding into the UK from all ports of entry.

"There is a strong argument that prohibition has caused or created many of the problems associated with the use or misuse of drugs. One option for the future would be to regulate drugs differently, through either over-the-counter sales, licensed sales or doctor's prescription." Source.

For a historical review of similar policy recommendations, see the Transform Drug Policy web site.

Great success in war on drugs: Teens turning to Rx drugs instead

The White House Office of National Drug Control Policy issued a report Feb. 15 citing great successes in the war to reduce teen use of illicit drugs ... but an alarming upswing in teen use of prescription drugs such as Oxycontin to get high. Details.

Congratulations Drug Czar John P. Walters on this great achievement in national drug policy.

People underestimate power of addictive cravings

People systematically underestimate the power of cravings for addictive drugs, says a new study sponsored by the Carnegie-Mellon Institute. The study measured what people addicted to heroin would give for a dose of the medication buprenorphine, a heroin blocker, when their cravings were highest v. when they had just received the drug and their cravings were at their lowest.

People play around with addictive drugs because they don't believe that they will become hooked, says Professor George Loewenstein, lead author of the study. Similarly, people without personal experience of addiction have no clue to the compelling force of the addict's craving, once addiction is established. Source.

New studies boost varenicline for smoking cessation

The smoking cessation drug varenicline, recently introduced in the U.S. under the brand name Chantix (Pfizer), has fared well in early studies reviewed by the Cochrane Library this month. Cochrane's authors write:

Varenicline increased the odds of successful long-term smoking cessation approximately threefold compared with pharmacologically unassisted quit attempts.

In trials reported so far, more participants quit successfully with varenicline than with bupropion. The effectiveness of varenicline as an aid to relapse prevention has not been clearly established. The main adverse effect of varenciline is nausea, but this is mostly at mild to moderate levels and tends to reduce with habituation.

There is a need for independent trials of varenicline versus placebo, to test the early findings. There is also a need for direct comparisons with nicotine replacement therapy, and for further trials with bupropion, to establish the relative efficacy of the treatments.

Source. Wikipedia article.

Heroin abundant, diamorphine scarce

Two leading members of the British Medical Association went public yesterday with the suggestion that Afghan poppy fields be used to make diamorphine, the potent painkiller used in surgery and with the terminally ill. While the streets of Europe and increasingly the U.S. show a plentiful supply of illegal Afghan heroin, over the past year a serious shortage of the legitimate medication has developed.

Dr Jonathan Fielden, a consultant in anaesthesia and intensive care with the BMA, said: "Over the past year the availability of diamorphine has dramatically reduced. It has got to the stage where it is almost impossible in some hospitals to get hold of this drug for use outside very specific circumstances."

Unnamed authorities quoted by The Independent (London) claim that harvesting Afghan opium for legitimate medical uses would be impractical. Source. The most likely reason it would be impractical is that the opium fields are in the hands of the warlords who run the Kabul government under the protection of NATO forces. Heroin is much more lucrative than diamorphine.

Treating substance abuse in schizophrenics

Patients diagnosed with schizophrenia show higher rates of substance abuse than the general population. Because substance abuse, including smoking, may greatly complicate treatment of and recovery from schizophrenia, clinicians are looking for pharmacological tools that are effective with this population. This discussion in Psychiatric Times suggests that newer "atypical" anti-psychotic medications are more effective in combating substance abuse in schizophrenics than older, conventional anti-psychotics. Read details here.

Rehnquist's addiction didn't enlighten his opinions

During the height of former Chief Justice Rehnquist's addiction to sleeping pills -- he was taking three times the prescribed dose each night -- Rehnquist took a hard line toward other addicted persons, denying them basic constitutional protection against unreasonable search and seizure, an analysis on the LawFuel.com website asserts.

In Robbins v. California (453 U.S. 950, decided July 1, 1981, at the height of Rehnquist's addiction), police had opened Robbin's suitcase without probable cause and without his permission. The court majority held that the marijuana found in the suitcase could not be used as evidence. Rehnquist -- at a time when a search of his medicine cabinet could have led to a felony conviction -- dissented and dismissed the majority's holding as "engrafting subtleties on the Fourth Amendment." Details.

Chief justice was addicted and delusional

Former chief justice William Rehnquist was addicted to what the Associated Press described as a "powerful prescription pain-relief medication" for at least ten years and suffered from paranoid delusions, FBI files released today under a Freedom of Information Act request show.

Rehnquist was on a prescription for Placidyl from 1970 to 1981, the files show. Placidyl (ethchlorvynol), known on the street as "jelly bellies," was an addictive drug having slurred speech (a Rehnquist trademark on the bench) among its side effects. Withdrawal from Placidyl can bring psychotic episodes. It was yanked from the U.S. market in 1999.

The FBI file, citing one of his physicians, said Rehnquist experienced withdrawal symptoms that included going to the hospital lobby in his pajamas in a bid to escape. He imagined that there was a Central Intelligence Agency plot against him, and he also seemed to discern changes in the patterns on the hospital curtains. Rehnquist thought he heard voices outside his room discussing various plots against him. Source.

P.S. As pointed out in comment No. 1, below, Placidyl was in fact not prescribed for pain but for insomnia. It is a sedative and a hypnotic. Source.

Afghan heroin hits U.S. Midwest

"For the first time, we have more people addicted to heroin than alcohol in my clinic, and these are suburban kids from St. Louis County. More and more Afghan heroin is coming in," says Percy Menzies, president of Assisted Recovery Centers in St. Louis.

Newly elected Rep. Russ Carnahan, D-Mo., plans to use his recently acquired seat on the House International Relations Committee to propose setting up a legal market for Afghan opium for manufacturing pain relief medications.

"You can't just cut off the poppies because that's the livelihood of the people who live there," Carnahan says. "But providing them with alternative legal markets for pain-relief medication is a way to help cut back on that heroin supply." Details from the San Jose Mercury News.

Let's buy up Afghan heroin, British MP says

London: The UK government should buy up the heroin crop in Afghanistan and use it around the world for pain relief, according to Member of Parliament Andrew Selous.

Speaking in the House of Commons he said to fellow MPs: "Why, given that heroin can have legitimate medical uses, cannot we buy up the Afghan heroin crop and use it around the world for pain relief? That would stop it flooding into this country illegally. We need much serious thought on that issue."

"Given that we know that 90 per cent of the heroin on UK streets comes from Afghanistan and that we have a major military presence there, it is extraordinary that we cannot do more to stop the poppy crop ending up here."

Details from the Dunstable News.

Baby gets cocaine, drugs in breast milk

BATON ROUGE, La. -- A lawyer has been accused of breast-feeding her month-old son while using cocaine and two prescription drugs, which showed up in the baby's system.

Marcie Swaze Koch, 36, was arrested Thursday after her newborn tested positive for cocaine after he was taken to a hospital with reported fever, seizures and difficulty breathing, an arrest warrant said. A pediatric emergency room nurse contacted the sheriff's deputies with the drug test results.

Koch admitted to snorting cocaine last weekend, Monday and Tuesday, the warrant says. She also told investigators that she takes Oxycontin, an opiate used as a painkiller, three times a day, and Xanax, or benzodiazepine, which is a sedative. Along with cocaine, barbiturates, opiates and benzodiazepine were found in the baby's system, the warrant says. Details from KATC.com.

Teen use of illegal drugs declining

The 2006 Monitoring the Future (MTF) survey of eighth, 10th and 12th graders indicates that their past-month use of illicit drugs has dropped 23.2 percent since 2001 (from 19.4 percent in 2001 to 14.9 percent in 2006). By contrast, abuse of prescription opioids remains at unacceptably high levels. The study is funded by the National Institute on Drug Abuse (NIDA), part of the National Institutes of Health (NIH).

The survey showed that past-month marijuana use for all three grades combined declined significantly from 2005 to 2006. Further, since 2001, past-month use of marijuana for all three grades combined decreased by almost 25 percent (from 16.6 percent in 2001 to 12.5 percent in 2006). There was also good news about teen smoking as well as alcohol consumption. Cigarette smoking is at an all-time low for all three grades, and past-month alcohol use continued to trend downward. Details.

Study: Meth not harder to treat than other 'drugs'

The belief that addiction to methamphetamine is harder to treat took a blow from a study of treatment outcomes among more than 12,000 patients in Washington state. All 'hard' drug users (meth, cocaine, opiates) had, on the average, less successful treatment outcomes than users of alcohol and/or marijuana, but there were no statistically significant differences in successful recoveries between methamphetamine users and users of the other 'hard' drugs. Conclude the authors: patients addicted to meth can respond to treatment as positively as those addicted to cocaine and other hard drugs. Thanks, Jason Schwartz, for this item. Original article.

For an anecdotal confirmation of this message, see this story out of Tulsa, OK.

Limbaugh blasts Trump for giving Miss USA a second chance

Radio bloviator Rush Limbaugh blasted media mogul Donald Trump today for giving Miss USA, the underage Tara Conner, a chance to redeem herself following an incident in which she was publicly intoxicated and smooching with another woman.

In Limbaugh's entire commentary on the incident, he somehow never touched on the fact that Limbaugh himself was caught out with an opiate addiction in 2003, and that he is currently serving out the last ten months of a court-supervised treatment regimen in settlement of a charge of doctor-shopping. Source.

When it comes to second chances, Limbaugh wants to hog them all for himself. Oink, oink!

Maine: Rural doctors need to support buprenorphine

A recent act of Congress allows a physician to treat up to 100 patients with buprenorphine, a medication for opiate addiction that avoids many of the disadvantages of methadone. But many general practitioners in rural Maine, where thousands of heroin addicts live, are not stepping up to the plate to administer buprenorphine treatment. This column in the Bangor Daily News asks why. The column might resonate with many other regions that have similar issues.

Afghan heroin tsunami hits Boston area

The impact of the record 2006 opium crop in Afghanistan is beginning to be felt in parts of the U.S., and it's not just in the inner cities. Among other communities reporting lower prices, greater potency and wider availability is this letter from the Boston suburbs by Joanne Peterson, founder of a support group for parents whose children are addicted to opiates. Peterson says:

It used to be that it started with OxyContin. Now it starts with 70-80% pure heroin, which can be snorted and is so easy to obtain that it is being experimented by kids that you would be shocked to see using this stuff.

In the past 8 weeks there have been 9 deaths so far of young souls from the suburbs ...

We are in a panic because more and more young people who were brought up well, taught right from wrong, went to church, CCD, participated in sports, dance classes, graduated high school, etc., are dying a sad and slow death. Some have had to be plucked from college to go to detox (if a bed can be found) and many have died. Their parents and siblings are absolutely desperate to try and save them but the treatment access is close to impossible to deal with. Insurance refuses to pay for enough treatment. And private treatment is so expensive your normal, every-day, middle-class family has to second mortgage their home or sell off assets to afford it.

The south shore is taking a big hit right now, the death toll is climbing and we are begging the public to get involved and help us get this drug out of Massachusetts, We need to demand it at this point. Like we all say, heroin is not grown in the USA. Where is it coming from? Who is responsible for allowing it in?

Read the complete letter here. Ms. Peterson's group, Learn to Cope, is also on the web, here. More on this story from the South Boston Enterprise, here.