Tag Archives: morphine

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).

Coca-Cola

For some readers, this might be the most useful post I’ve ever written. But first; some history. Back in grad school, I was dating a Cliffie. We were out to dinner at a nice (and cheap) restaurant in Cambridge. I’d had the flu and probably should have canceled, but in your early 20s, libido conquers all. So we’re sitting there, and I began to feel really nauseous and said we should pack it in, and I should go home.

She said “Let me try this, my father’s a General Practitioner”. So she ordered a can of coke, opened it and let it sit for a while till it warmed up and the fizz was gone. Then she told me to drink it in slow, small sips. It worked ! The nausea vanished and we continued on.

Fast forward to last night and probable food poisoning (or severe flu). No Coke in the house, but as soon as my wife got to a store opening at 7 this AM, it worked again — no nausea and stomach distress within a few minutes (I’d vomited at least 5 times over the course of the night).

Could this have been a placebo effect, because it had worked in the past and I wanted it to work so desperately? Possibly, but I was generally miserable for a period for a period of 10 hours, and the Coke settled my stomach very quickly. Coke is not an anti-diarrheal, but 10 hours into the illness there was nothing left.

Placebos and Nocebos are very complicated entities and a huge review in Neuron will tell you why. It’s very much worth reading – Neuron vol 84 pp. 623 – 637 ’14 — “Placebo Effects: From the Neurobiological Paradigm to Translational Implications”. The article contains references to studies showing that placebo is as effective as morphine on the third day post-op. In med school I’d heard stories to the effect that in Korea and WWII when they ran out of morphine on the battlefield, saline worked just as well. So probably these aren’t myths. It didn’t happen in Vietnam when I was in the service, as the country is long and thin, and no wounded soldier was more than 20 minutes away by chopper from a fully equipped field hospital (once they got him).

The ingredients in Coke are and were a closely held secret, but most think in the 1880s and 1890s, when it was sold as a medication, that Coke contained cocaine, hence the name. Back then, no one knew the potential of cocaine for addiction. Halstead the great Baltimore surgeon, got into it because cocaine is also a local anesthetic. Freud actually used cocaine to treat morphine addiction. Neither was malevolent, just ignorant.