What neuropharmacology can’t tell us about opiates and addiction

A friend’s wife had some painful surgery and is trying to get by with as little opiates as possible, being very worried about becoming an addict, something quite reasonable if all she had to go on was the popular press with lurid stories of hapless innocents being turned into addicts by evil physicians overprescribing opiates (it’s the current day Reefer Madness story). Fortunately her surgeon wisely told her that her chances of this happening were quite low, since she’d made it past 50 with no dependency problems whatsoever. Here’s why he’s right and why neuropharmacology can’t tell us everything we want to know about opiates and addiction.

Back in the day, disc surgery required general anesthesia, dissection of the back muscles down to the spine, sometimes chipping away at the bones of the spine to remove a bone spur (osteophyte) and/or removal of the offending herniated intervertebral disc. This meant a hospital stay (unlike my ophthalmologist who had a microdiscectomy as an outpatient a few years ago). This was the era of the discovery of the protein receptor for morphine and other opiates, and we were all hopeful that this would lead to the development of a nonAddicting opiate (narcotic). Spoiler alert — it hasn’t happened and likely won’t.

Often, I was the neurologist who diagnosed the disc and told the surgeon where it was likely to be found (this was in the preCT and later the preMRI era). I’d developed a relationship with most of those I’d referred for surgery (since it was never recommended, without a trial of rest — unless there were compelling reasons not to — trouble controlling bowels and bladder, progressive weakness etc. etc.). I was their doc while they tried to heal on their own.

So post-operatively I’d always stop by to see how the surgery had worked for them. All were on a narcotic (usually Demerol back then) as even if the source of their preoperative pain had been relieved, just getting to the problem had to cause significant pain (see above).

If the original pain was much improved (as it usually was), I’d ask them how they liked the way the demerol made them feel. There were two types of responses.

#1 I hate feeling like this. I don’t care about anything. I’m just floating, and feel rather dopey. I’m used to being in control.

#2 I love it ! ! ! ! I don’t have a care in the world. All my troubles are a million miles away as I just float along.

Love it or hate it, both groups are describing the same feeling. Neuropharmacology can help to tell us why opiates produce this feeling, but it can’t tell us why some like it (about 5%) and the majority (95%) do not. This clearly is the province of psychology and psychiatry. It’s the Cartesian dualism between flesh (opiate receptor) and spirit (whether you like what it does). It also shows the limitation of purely physical reductionism of the way we react to physical events.

The phenomenon of a small percentage of people becoming addicted to a mind altering substance is general and is not confined to one class of drug. We were told never to prescribe chronic benzodiazepines (valium, etc. etc.) to a recovered alcoholic. People who get hooked on one thing are very likely to get hooked on another.

I realize that some of this could be criticized as blaming the victim, but so be it. Medical facts are just that, like what they say or not.

Addendum 11 Sep ’16 — I’m not saying that you won’t become physically dependent on opiates if you get them long enough and at high enough doses. We all would. Even if this happened to you. When you no longer needed them for pain and went through medically supervised withdrawal, you wouldn’t crave them, and do crazy things to get them (e.g. you were physically dependent but never addicted to them — it is important to make the distinction).

Example — when I was in the service ’68 – ’70, we had half a million men in Vietnam. Everyone I’ve talked to who was over there says that heroin use among the troops was 25 – 50% (high grade stuff from Thailand was readily available). As soon as they got back to the states, the vast majority gave them up (and with minimal withdrawal requiring my attention – I think I saw one convulsion due to withdrawal).

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Comments

  • Tom  On September 11, 2016 at 5:58 pm

    Isn’t it also true that a middle class, middle aged surgical patient who becomes addicted (dependent) after a month or so on opioids will have mild withdrawal symptoms? Nothing like Frank Sinatra in Man With the Golden Arm, which is what most of us imagine.

  • luysii  On September 11, 2016 at 6:24 pm

    Tom — excellent point, and I should have covered this in the original post. Have a look at today’s addendum to the post, and thanks.

  • John F  On September 11, 2016 at 9:03 pm

    Have you seen this report on a potentially-non-addictive opiate? http://www.pnas.org/content/early/2016/08/24/1605295113

    • luysii  On September 11, 2016 at 9:42 pm

      What issue? I’ve read most issues completely through 23 August, but then we went on vacation, and I’ve found that playing catchup is very unpleasant and takes a long time. So I plan to resume reading with the issue of 13 Sep. I don’t have it in my notes in what I’ve read so far. Sounds interesting, but with age comes cynicism. I’ve heard this so many times before.

      • John F  On September 12, 2016 at 9:46 am

        From what’s on the page, it appears to have been published on line only ahead of printing. Online pub date 29 Aug 2016.

  • luysii  On September 12, 2016 at 10:28 am

    It certainly looks interesting, and I look forward to reading it when it comes out

    • luysii  On September 14, 2016 at 8:13 pm

      It’s in the 13 Sep ’16 Issue along with an editorial on the paper. pp. 10225 – 10227, and the paper itself — E5511–E5518.

      Time to start reading it.

  • Publius Ovidius Naso  On September 12, 2016 at 11:47 pm

    Sorry for the OT, but an update on your Hillary post would be much appreciated! The absence of objective, informed speculation has only become more glaring…

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