Friday, July 03, 2009

Narcotic Narcissism

What was I just saying about lessons you have to learn over and over?

I'm smacking my head - but gently - this week as I relearn the narcotic lesson. Patients addicted to narcotics will do just about anything to get their drug. It is a powerful poison. Normally nice people will get nasty. Shy people will haul out their inner drama queen and wax poetic. Scrupulous people will lie, cheat and steal. They don't mean any harm by it, honest they don't. They're just trying to get their needs met. And once they get their drugs, they're the picture of contrition.

If it sounds like I'm painting a large group of people with one wide brush stroke, well, I guess it's because I am, in a way. I'd be the first to declare that each of us is an individual, but, that said, I have to assert that narcotic addicts have a lot in common with each other.

Is someone who uses narcotics for legitimate pain an addict? Of course they are. Anyone who takes a narcotic in high enough doses for a long enough time becomes addicted. Physically dependent. Their body needs the drug in order to feel good, and if they don't get it, withdrawal is extremely uncomfortable. Miserable, to the point that they'll do all those things I mentioned above. They'll make raving lunatics or groveling fools out of themselves rather than go without.

As a physician, I struggle with the dueling forces inherent in taking care of a narcotic addict. I don't want anyone to have unnecessary pain. I also don't want to be manipulated. I truly believe the addict has no ill intention toward me when he/she lies or cheats to get drugs that are needed to treat the pain. At the same time, I can't help but feel angry, at the addict for deceiving me, and at myself, for being too gullible, for believing the tales and the tears once again. I also feel an irrational anger at the medical system, at the pharmaceutical companies, at the chemists who don't develop alternative medicines that are as effective and yet less harmful.

My experience with pain patients tells me that not all of us are born addicts. However, some of us are. There's a definite difference in brain chemistry between people that makes some of us far more likely to end up addicted than others. Some of my patients with acute pain, like that from a broken bone, will only take a couple narcotic pills and flush the rest. Others will still be trying for refills long after the bone is healed.

It doesn't seem fair. My lesson patient this week was injured in service to his country. His wounds are as real as his pain, and both are with him for life. Narcotics are the only meds that help. But because we have so few alternatives, he'll be a slave to their destructive seduction the rest of his days.


Anonymous said...

I've been following your blog for some time now and I think you are one of the most level-headed, common sensed, caring people I know. I felt compelled to respond to this post because I happen to be a physician specializing in opiate addiction. I understand your frustration with these patients (I deal with them every day), and I know it is hard sometimes when we feel tricked or lied to. It is hard not to take it personally at times, so maybe looking at it from a different angle may help. I make a distinction between addiction and dependency. When the person is addicted, they totally lose control, they exhibit compulsive use and they continued to use despite adverse consequences. Being simply dependent means that they may need the medication to function (due to severe pain/loss of mobility) and taking the medication makes the patient functional, however if the medication is not available or the dose if not adequate to control the pain, the withdrawal or pain can be so severe they start acting like addicts, desperately trying to get relief, this has been described as "pseudoaddiction", usually the crazy behaviors cease when the person has an adecuate pain control. Unfortunately, it can be hard to distinguish a true addict from a pseudoaddict, and it is possible to have both legitimate pain AND an addiction. A pure, true addict never had pain issues to begin with, and the more they get, the worse they get. They are impaired and their functioning deteriorates. A pain patient will have improved functioning with the right amount of medication, which may be high depending on their tolerance and pain level. Then there are those who are in that middle gray zone, with characteristics of both addiction and pain. So, I usually look at their overall functioning instead of just focusing on withdrawal, with the understanding that there will be those who will exaggerate their symptoms or being in denial about their addiction. Lots of complex issues. So, don't be so hard on yourself, it's hard even for me sometimes, eventually, the truth comes out. They say in recovery that "more shall be revealed", or, like a colleague of mine said somewhere in some bulletin board, "sometimes I get the bear, sometimes the bear gets me". I hope this helps!

Peg Spencer said...

Dear Dr. Anonymous,

Thank you so much for your post! It does help to hear from someone with more experience and perspective. I can see the value of thinking of this in terms of dependency or addiction. I also know that the line is a fuzzy one, and that, as you say, there are many in the gray zone, having characteristics of both.

I'm just so grateful that there are people like you who are willing and able to take care of folks like this! Thanks for your work, and thanks also for your kind words!


Paul Elam said...

As someone who spent a good many years counseling addicts and (trying) to work with physicians who had the responsibility to decided when narcotics were indicated, I have some thoughts on this subject.

And will all respect to the physicians here, it's my opinion that the medical establishment has a long way to go in addressing this problem.

First, it is amazing to me that in the exhaustive training that doctors undergo, that they are so poorly informed, in general, on addictions.

I used to send clients still in residential treatment for addictions with notes to doctors and dentists explaining that they were in treatment and urging them to consider this when writing prescriptions.

Many of those clients returned with the letter, and their prescription for Vicodin or other narcotic. I called many of them and the reaction I got was frequently terse, as though I was questioning their medical judgment.

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