Good Drug, Bad Drug

22aJanuary 2003, Denver, Colorado: A woman gets into her car in the middle of the night, wearing only a thin nightshirt despite the 20-degree weather. She proceeds to wreck the car, leave the vehicle, expose herself, and urinate in the middle of an intersection. When arresting officers arrive, she is belligerent and confrontational. The next day, she has no recollection of the event.

October 2005, Rock Hill, South Carolina: A man takes the wheel late at night and smashes into a parked van. He then leaves the scene of the accident and rams his vehicle into a tree. The next morning, he wakes up in jail, with no recollection of the night before.

If these two defendants had been found to be intoxicated by alcohol or under the influence of an illegal drug such as methamphetamine, they would have faced stiff fines, at the very least, and possibly extensive jail time. However, the charges against both defendants were reduced because they had been under the influence of the prescription sleep aid Ambien.

Ambien and other sleep aids are just one class of prescription drugs currently dominating the U.S. market. Forty-two million sleeping pill prescriptions were filled in 2005, according to the research company IMS Health—a 60-percent increase since 2000. Ambien sales alone totaled $2.2 billion in 2005. The spike in sales of this and other psychoactive drugs has increased concern about the potentially serious side effects of prescription sleeping pills, pain relievers, stimulants, diet aids, and mood-altering medications.

Pill Culture and the Quick Fix

“Sleep problems are symptoms of many disorders; some have a physiological or neurological basis, and others are due to stress or lifestyle changes,” says UAB psychologist Jesse Milby, Ph.D. “Before medication is prescribed, each patient should be fully assessed to see if there might be other treatable causes of the insomnia, rather than just addressing the insomnia.”

Milby participated in a controlled study that compared the effects of sleep medications to the effects of “sleep hygiene” strategies: eliminating naps; using the bed as a place for sleep and sexual activity only—no reading, watching TV, eating, preparing taxes, and so on—going to bed and rising at the same time each day; deep muscle relaxation; and other techniques.

Study participants who learned the behavioral strategies experienced an eventual reduction in their insomnia, while those who took the active drugs experienced immediate improvement in their symptoms. “People don’t know about sleep hygiene approaches, so when they suffer from insomnia, the temptation is to look for the quick solution that puts them to sleep,” says Milby.

Some Prescription Drugs of Abuse

  • Benzodiazepines: These drugs are sedatives, or central nervous-system depressants. They slow brain activity and create a calming effect—therefore they’re often prescribed for anxiety, panic attacks, and sleep disorders.
    Examples: Valium, Xanax, Klonopin, Ativan
  • Opioid Analgesics (painkillers): Opioid analgesics suppress perception of pain and calm emotional response to pain by reducing both the number of pain signals sent by the nervous system to the brain and the brain’s reaction to them.
    Examples: OxyContin, Tylenol with Codeine, Dilaudid, Lortab
  • Selective serotonin reuptake inhibitors (SSRIs): SSRIs affect the brain’s use of a chemical messenger (neurotransmitter) called serotonin. SSRIs are prescribed for depression, anxiety, and chronic pain.
    Examples: Prozac, Paxil, Celexa, Zoloft
  • Stimulants: Stimulants treat attention deficit hyperactivity disorder (ADHD) symptoms such as short attention span, impulsive behavior, and hyperactivity.
    Examples: Ritalin, Adderall, Dexedrene
    Source: WebMD site

Americans have come to expect immediacy when seeking relief from insomnia and a whole array of other maladies. After all, says Milby, if a pill can dissolve a bothersome symptom in a matter of hours, why go through weeks and possibly months of expensive and often burdensome therapy or behavioral modification?

“It’s a temptation for everyone. The behavioral interventions involve work; they involve dealing with things that are psychologically uncomfortable in order to get at the root of conflicts or problems,” Milby acknowledges. “It’s easier to just take medication two or three times a day than to go through all of that.”

“The perception is that everyone should be happy all the time,” says UAB internist and palliative-medicine specialist Rodney Tucker, M.D., “and if a person doesn’t effectively deal with every stressor in his or her life, then that person must be depressed and must need a pill.” While many people who are struggling with clinical depression or anxiety can truly benefit from prescription medicines, Milby believes that the best road may be a combination of pharmacological and non-pharmacological therapy.

“Evidence suggests that time-intensive methods of therapy can be very effective,” he says, “and we’re trying to determine whether pharmaceutical interventions on top of those will produce additional benefits.”

Informed and Eager

Information about prescription medicines—and what they can do to improve one’s life—is more available to the general public now than ever before. Pfizer, manufacturer of the popular drugs Xanax and Zoloft, was the fourth leading spender of advertising dollars in 2003, laying down more than $2 billion to market their products.

Because of such media saturation, consumers are increasingly aware of psychological conditions and possible treatments—and this heightened awareness creates both benefits and dangers, according to Milby. “Public information that identifies symptoms of depression might help some people realize that they have the disorder and seek treatment. If ads can lead depressed people into treatment, then that is beneficial for society,” he says.

But sometimes consumers use this information to act as their own, or their friends’, amateur pharmacists. “People have been doing that for centuries,” Milby notes. “Someone comes over to help chop wood, hurts his back, and his friend knows of an herb that has helped his own pain in the past, so he uses it to try to ease his friend’s pain. It’s a natural human reaction, though it is foolish and can harm both friends.”

Slick advertising by pharmaceutical companies may also lead some people to believe that they’re suffering from illnesses that they really don’t have. And some ads may convince people that by simply popping a pill twice a day they can easily cure a complex disorder.

But dealing with a demanding patient armed with a little online research and the latest advertising pitch is less problematic than what many doctors face when dealing with pain management and painkillers: the addicted and intentionally deceitful patient. The National Survey on Drug Use and Health, published in May 2004, estimates that the number of Americans age 12 or older who have abused or been dependent on pain relievers has eclipsed the users of all other categories of drugs other than marijuana. The report reveals that 1.51 million Americans either abused or were dependent on painkillers, compared to 1.49 million for cocaine, 430,000 for hallucinogens, and 210,000 for heroin.

The misuse or abuse of painkillers can lead patients to addiction, often causing them to lose their jobs, friends and families, and financial stability. And an overdose of painkillers can easily be fatal—even on the first use.

I Wanna Be Sedated

Jill Billions, M.D., is an addiction recovery specialist in the Center for Psychiatric Medicine at UAB. She points out that certain people are simply predisposed to opiate addiction, while others are not. “People get prescriptions for legitimate reasons,” says Billions, “and they stumble upon the fact that they respond to their medicine in ways they weren’t expecting. Most anyone who’s had his or her wisdom teeth out has gotten a prescription for Lortab or a similar opiate. Some will feel nauseous, some will feel pain relief, and some will feel really good—to the point that they continue taking the medication after the pain is gone. For those people, painkiller addiction is just waiting to happen.

“Not a lot of people pick up a substance and become addicted the first time they take it,” she continues. “Usually it’s a cascade of events. The person may pick up and put down the substance many times, over a period of years, without a problem. Yet at some point it is as if a switch is flipped in the brain—a permanent ‘go’ signal. The dopamine reward system is biophysically and chemically altered. The person craves the drug because of this and loses all control over its use. People will lose their jobs, families, and even their lives in pursuit of the drug—that is the disease of addiction.”

Often, it is after this point that Nabil Ali, M.D., director of the Kirklin Clinic’s Pain Treatment Center, sees such a patient. “Doctors sometimes prescribe very powerful pain relievers for patients with chronic pain without looking at alternatives; then, when their patients become addicted, they send them to pain-management clinics,” says Ali. “Treating chronic pain is multifaceted and different from treating acute pain, because the pain that the patient is experiencing is not a symptom—it is the disease.”

To Spot an Addict

Alan Fredricks (not his real name) is 32 years old, an MBA graduate, and a successful member of a large consulting firm. He’s also a recovering opiate addict.

Fredricks engaged in recreational drug use throughout high school and college, experimenting with drugs such as marijuana, cocaine, hallucinogens, and ecstasy. He also took the occasional Lortab or Lorcet handed out at a party, but he never felt an overwhelming craving for any of the drugs. At one point, he recounts, he even boasted that he felt he could never become addicted to anything. When a waterskiing accident caused him to slip two disks in his back, he was prescribed Percodan, an opiate, for the pain. “I remember thinking that it was great, but I never got hooked on it,” says Fredricks. “I liked it, but never enough to make any effort to get more of it.”

After his recovery, when he experienced a flare-up of disk pain, a friend recommended a doctor who prescribed 20-mg pills of OxyContin, a time-released but powerful painkiller that some compare to heroin. When taken as prescribed, the time-release of the active ingredient prevents the user from getting high, but when chewed, snorted, or injected, the drug releases all of its potency in one giant rush, which often leads to addiction and potentially fatal overdoses. “The first time, I took it as prescribed and swallowed it, and about 45 minutes later I felt great,” he says. “Not only was my pain gone, but all of a sudden my worst enemy wasn’t so bad, my problems weren’t a big deal, and my best friends were the best friends.”

Fredricks’s recreational experience with other drugs, as well as his seeming imperviousness to addiction, made him curious and bold. After his prescription ran out he ran into a friend with 80-mg OxyContin tablets, and he was given half a pill; this time he chewed the pill rather than swallowing it. “Twenty minutes later I had the most euphoric, incredible experience—just pure bliss,” he says. “It was true euphoria in every sense of the word. A lot of dope addicts refer to it as a romantic drug, because it makes everything so pretty and beautiful.” Before long, he was scouring the yellow pages for doctors he could deceive in order to get the pills. “I was very knowledgeable of the symptoms of a flared-up herniated disk because I had had one, so I was very believable and articulate. Some doctors would even tell me stories about people faking symptoms for pills, telling me they could always spot them, while they were writing me prescriptions.” Soon he was consuming a month’s worth of prescriptions in a week and going to the street for the rest.

Meanwhile, Fredricks’s back pain continued. At one point he was admitted to a hospital and given an intravenous dose of Dilaudid, which gave him the idea of shooting up. “The first time I shot 20 mgs all at once,” he says, “and it was like a whole new drug at that point. I hadn’t been that high in a year. I would find myself waking up at 5 a.m. because I was so excited about getting my fix that day.” Fredricks’s addiction to OxyContin ballooned to a $400-a-day habit that emptied his bank account and cut him off from his friends and family. His performance at work began to suffer, and he finally began to realize that he was in over his head.

Fredricks believes that the way the drug affects the brain kept him from realizing that he had a serious problem for a long time. “OxyContin removes introspection in the sense that there is no worry,” he says. “That mental process is completely eradicated. There is no concern.” Fredricks first attempted to quit the drug cold turkey after Thanksgiving 2004. On the third day the withdrawal symptoms became so severe that he called his dealer to see if he had any Lortab to help him come down a little easier. All he had was OxyContin. Fredricks turned him down but called back 20 minutes later.

Shortly thereafter Fredricks realized that he could not get off the drug under his own power, and he enrolled in a treatment program with an outpatient option so that he could continue to work. The clinic used controlled methadone doses to ease the pain of the withdrawals, and Fredricks says that the psychological support of counselors and other addicts who had the same experience was key to his recovery. Today he is still with his consulting firm; he says his work has never been better, and his personal relationships have been restored. But he lives every day painfully aware of his vulnerability. “I left the clinic on July 28, 2005. If I did not go to see my counselor every morning, I would relapse. I still think about how incredible I would feel if I took one. I wonder if it’s going to be like this forever...I still crave it.”

Ailing or Addict? Doctor or Dealer?

Dealing with pain management has become a catch-22 for doctors, making them walk a tightrope between under-treating their patients’ symptoms and potentially leading their patients down the road to addiction.

Diagnosing levels of physical pain is problematic, because pain is a subjective experience and cannot be measured by X rays or lab studies. The doctor must depend on the honesty of the patient and his or her own observations of the patient’s behavior, even though a patient seriously addicted to painkillers will say or do anything to get them.

“Pain is a clinical, subjective syndrome,” says Tucker. “We don’t have a meter, or blood work, or an X ray, that we can look at and assess pain.” Doctors use a pain scale that is mainly determined by simple observations of the patient and the patient’s description of his or her pain symptoms, with a 10 being the worst and 0 being the least.

“If a patient is sitting in front of me and is smiling and saying that they have 20 over 10 pain, and they’re not sweating or shifting in their chair or grimacing, it’s hard for me to say that the observational finding and the subjective match,” says Tucker. “That’s when there’s a disconnect, and that’s when we have to really be diligent with the physical exams and patient histories.”

Unfortunately this option is rarely available to most doctors working in hospitals, due to pressure to see as many patients as possible during their rounds. “It’s the business of running hospitals that’s pushing doctors to see more patients, to see them faster, to make more money,” says Billions. “In medical school, I wasn’t taught anything about addiction or prescription drug abuse, but it’s a huge problem. You’ve got all these doctors out there writing prescriptions, and for some patients it’s like giving them a loaded gun.”

Preventing an Epidemic

Rodney Tucker, M.D., who sees mostly patients with advanced illness—many of whom are elderly—says older patients actually tend to de-emphasize their pain symptoms when talking to their doctors. As a result, they sometimes get prescriptions that are ill-suited to their pain symptoms and then end up taking too much of these drugs in an effort to relieve their pain.

In order to maintain control over patients’ intake of medicines, Tucker and other palliative-care physicians require some of their patients to adhere to “pain contracts” in order to continue receiving their medicines regularly. “If patients break the terms of their contracts, they may only be able to get prescriptions for one week at a time, so that we can limit the amount of medicine they can take,” he says.

Tucker acknowledges that geriatricians and palliative-care specialists typically have the luxury of spending more time with their patients than other physicians. “Taking clinical histories and giving good physical exams are definitely time-consuming, and going through the aspects of a contract with a patient is even more time-consuming.”

Billions insists that all doctors simply must find the time. “Otherwise we’re letting all of these people choose unhealthy ways to heal their pain. Doctors have to take time to talk to their patients.”

The Alabama Department of Health is developing the Pharmacy Network, which will one day connect all pharmacies in Alabama through a database that will allow doctors and pharmacists to closely monitor patients’ prescription purchases. This network could cut down on “doctor shopping”—the habit of many prescription drug abusers who go from one doctor or pharmacy to another in order to get more prescription drugs. Unfortunately the network will do nothing to curb the flow of prescription drugs from online pharmacies and from the street.

If prescription medicines aren’t more tightly regulated soon, Tucker worries that their abuse may prompt Congressional action that could tie his hands in delivering such drugs to people who really need them. “I think the regulatory bodies are going to try to start practicing medicine,” he says. “That approach could prevent patients who need the medications from getting them. Eventually that would affect everyone’s quality of life.”

The good news is that the public is becoming more aware of prescription drug abuse and its effect on our culture and the medical profession. If more information is paired with patient education, Tucker says, perhaps Americans will better understand not only the benefits of prescription drugs, but also the perils.