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June 2 - June 7, 2021
The risk of overdose and death is a result of opioids’ depressive effect on the respiratory system—in short, taking high doses of opioids slows one’s breathing and reduces the amount of oxygen that gets into the bloodstream (and so, ultimately, to the brain).
Opioids not only depress breathing, they also depress digestion, which is the cause of another well-known cost of opioid therapy—constipation.
This mechanism of tolerance, combined with the side effects and dangers of opioids, is precisely why the medical literature now tells us something that initially came as a surprise to many in the healthcare community: opioids simply aren’t very good medications for many kinds of pain. Traumatic and postsurgical pain? Yes. Powerful opioids are important and effective. But as the patient builds tolerance to the analgesic effects of the opioid, she will need more and more of the drug, and the respiratory depression will become more dangerous (increasing one’s risk of overdose) while the digestive
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In addition, the general sedative effects can be dangerous as well.
“Opioid-induced hyperalgesia,” as it’s known, leads opioid therapy patients to become more sensitive to pain as a result of their therapy.
There is virtually no good scientific data supporting chronic opioid therapy beyond two or three months, and a wealth of high-quality evidence warranting extreme caution. Opioids are dangerous, and for long-term use, they don’t work very well. Combine this with the observation that they have costly side effects, and the medical community has exceedingly good reason to be careful with these drugs.
Most opioids have a short half-life, and so the effects of withdrawal can be felt surprisingly quickly after missing a dose.
Suboxone is a combination of the opioid buprenorphine and the overdose-reversal drug naloxone, and it has been gaining popularity in the treatment of opioid use disorder.
Millions of people, from all over, are seriously or gravely injured and are inducted into the healthcare system in a way similar to me. They are given lots of opioid medications and will predictably be on them for weeks or months. And, like me, many of them will plan to be off the medication at some point. The mechanisms of tolerance, dependence, and withdrawal, though, make this exit from opioid therapy more challenging than simply stopping the medication when it’s no longer needed: stopping the medication hurts, because the body has become accustomed to it.
Recall that the body’s opioid receptors—which typically respond to the body’s own opioids, such as endorphins—are responsible for both blocking pain and causing euphoria. When an artificial source of opioids is introduced, these receptors have both an immediate and a longer-term response. First, in the short term, they go wild, capable of both providing significant pain relief and releasing a euphoric rush the likes of which most people would never experience naturally; that is, you get truly “high”—a feeling that many describe as being wrapped in a warm, comforting blanket, with pain,
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In the longer term, though, the brain tries to adapt to this new environment of opioid plenty so as to achieve normalcy.
The more times that a flood of opioids is introduced, the harder the brain works to adapt to this new situation, reacting less strongly in the presence of the opioid. The result is the phenomena of tolerance, which means that more of the drug is required to achieve the same pain-relieving or euphoric effects, and dependence, which means that removing the source of opioids induces withdrawal symptoms. Withdrawal is, to put it simply, the opposite of the drug’s effects: symptoms typically include dysphoria, hyperalgesia (increased sensitivity to pain), restlessness and insomnia, as well as
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Addiction, then, is not merely a habit; it’s a harmful habit that can seem to change the very identity of the person suffering from it.
Addiction, then, is basically an affliction during which people make bad decisions that hurt themselves and other people.
After all, watching an addiction bloom is basically the process of watching someone repudiate an entire set of good, understandable values and replace them with a singular, destructive drive: pursuit of the desired thing.
addiction should now be thought of as a chronic, relapsing brain disease, characterized by craving and compulsion—experienced as an inability to refrain from pursuit of the object of addiction, despite harmful consequences. Addiction on this model is often described by use of the “3 Cs”: craving, compulsion, and lack of control.
Sure, by telling someone that they “have addiction,” which is essentially like “having schizophrenia,” we help destigmatize their condition. It’s not their fault that they suffer from addiction, we can say, and so their inability to stop drug use isn’t their fault. But doing this also undermines the possibility of taking responsibility for their own recovery—it undermines their agency altogether. The casualty of the disease model, according to this line of criticism, is our ability to recognize those with addiction as full persons, able to exercise judgment.
Many of the critics who have this sort of problem with the brain disease model think it should be replaced with something more like a “learning” or “developmental” model of addiction.
The addicted brain isn’t broken—it’s merely learned a devastating habit too well, or developed in a way that makes what we think of as normal functioning much harder.
The appropriate response to addiction, on the learning model, is more learning. Addiction is the result of a brain learning bad habits, so the way to fix addiction is for the brain to learn better habits.
Central to our understanding of addiction, then, is the thorny, very difficult set of issues surrounding when beings like us are able to make free decisions.
Everyone agrees now that the addicted brain is different, and that this helps us to explain the harms of addiction; but whether we call that change a disease that must be medically managed or a problematic development that we should address through further, corrective development helps us to understand how much responsibility to assign to those suffering from addiction.
Someone with an addiction, it turns out, is perfectly able to make at least some choices freely, at least some of the time. Having an addiction is not the same thing as being a robot or a zombie.
This does not mean, however, that the choices of someone with an addiction necessarily reflect their values. The language of “compulsion” and “inability to control” are intended to make clear that addiction seems to undermine our ability to refrain from drug use, even when it’s obvious that this use is harmful.
Addiction comes with incredibly strong desires that pull people toward some behavior, but we most often recognize that the person wrestling with this affliction doesn’t actually value the object of addiction more than anything else.
And the science confirms this: the addicted brain has developed circuitry that makes those lower-order desires—which we do not, on reflection, endorse—pull us with incredible strength toward action. The addicted brain, in other words, has an incredibly hard time doing what the rest of us do fairly effortlessly, which is aligning our desires with what we genuinely value.
Focusing on the difficulty of acting in line with one’s values, rather than on the impossibility of doing so, does what I think we must do: it explains simultaneously why empathy is the appropriate response to addiction and why we should also bolster and recognize the exercise of agency when it’s possible.
What’s most important is to recognize that addiction is a behavioral affliction that sufferers experience as a threat to their very ability to act freely on their central desires and values.
The problem, however, is that the same stigma attached to suffering from addiction is attached to treating addiction, and so treatment for substance use disorder is consistently devalued, understaffed, and massively underfunded.
The goal of this treatment is to engage the brain’s opioid receptors so as to prevent withdrawal, but to do so in a way that lessens the euphoric highs that drive addictive behavior. When it’s successful, it allows patients to stabilize their behavior, giving up the single-minded pursuit of drugs and resuming a normal life.
Mismanagement of opioid therapy doesn’t only risk harm in the form of withdrawal. Importantly, it can also contribute to addiction.
A common way of understanding it is that addiction “hijacks” the brain’s normal process of pursuing good things (reward) and avoiding bad things (punishment) and begins to create pathological circuits that turn one’s focus, attention, desire, and energy to the object of addiction, while at the same time undermining one’s ability to resist.
The process of developing an addiction is simply the process of pursuing rewards and avoiding punishments, with some rewards and punishments making it more likely than others that the brain changes become pathological.
Addiction is caused by the properties of some chemicals, which get their hooks into one’s brain.
The human brain is much better at forming a pathological connection when it can focus on a single reward intensely. Distraction by other, competing rewards challenges the development of addictive pathways.
Opioids relieve pain (reward) and they cause euphoria (reward), but they also relieve the suffering that taking them away causes (reward). The
Most people who are prescribed opioids for any length of time will develop some amount of dependence, and very few of them will develop an addiction. But dependence is related to addiction because it adds another layer of reward and punishment to an already potent substance.
Recognizing that doctors have a duty to protect patients from the harms of medication that they prescribe will not, then, take a revolution in medical ethics. It’s a totally sensible idea that almost everyone, on reflection, will accept. What it will take, though, is a recognition that this well-established principle applies in the case of pain medicine.
If we, as a society, want doctors to do better at taking care of their opioid therapy patients, we probably shouldn’t have them work within a system that makes doing it so intensely difficult.
The key, then, is to go slow enough to avoid the worst punishment of withdrawal, without increasing the reward from taking that medication in a way that could help push the patient’s brain toward addictive patterns.
Tapering is likely to be uncomfortable even in the best cases, miserable in the worst, and many patients will find it difficult. Going slow will help a lot of patients, but others will need medication in order to make it through the tapering.
These patients start to blur the line between treatment for withdrawal and treatment for opioid use disorder. (Such patients are sometimes said to suffer from “complex persistent dependence”: they do not exhibit the behavioral signs of addiction, but they are far too dependent on the medication to wean directly and can suffer from extended withdrawal effects.)
The cruel joke of withdrawal (clearly evident in my own experience) is that it gets worse as you get closer to the end, because you eventually get to the point where the dosing of the pills means that you can’t taper as slowly; and eventually, you have to drop from some medication to no medication.
but a very different concern in what are often called “legacy patients,” or those patients who have been prescribed high doses of opioids for years or even decades.
Doctors, many of whom don’t really know how to manage tapers to begin with, are being pressured to taper patients who are (justifiably) terrified of tapering.
One class of concern is simply that forced tapers cause avoidable suffering, and so they are wrong. The suffering at issue is the suffering of withdrawal, and it’s avoidable because continuing the medication would prevent it.
The pain we are expecting legacy patients to go through if we decrease chronic opioid therapy should not be overlooked.
Another outcome that everyone recognizes as possible is that cutting off patients with serious dependence on opioids risks driving them to the black market.
An additional danger here is that illicit prescription opioids are expensive, while heroin is cheap. But of course, heroin is much more dangerous, as it is increasingly laced with the superpotent drugs fentanyl and its analogues.
An unintended consequence of forcing legacy patients off opioids, then, may be an increase in the number of heroin users. As we try desperately to invest in policies that reduce the number of overdose deaths, adopting prescribing policies that push some percentage of prescription opioid users to heroin seems like a terribly self-undermining move.
