From time to time during her late teens and early twenties, a young woman—we’ll call her Bethany—felt depressed, although she wouldn't go for therapy despite her family’s urging. “What’s it going to do for me?” she told her parents, reasoning that nothing could help her poor body-image seeing that Bethany was pudgy and even the most rigorous dieting and exercise regimens never worked for very long. When a dietician referred Bethany to an endocrinologist who said nothing could be done because her metabolism and thyroid were functioning fine, Bethany became even more discouraged. Bethany’s friends and family assured her she was pretty, likeable, and had an endearing personality, so she pooped along, bucking herself up as best she could. But later, when she was twenty, Bethany was dumped by a boy she had flipped for, who dropped her for someone slimmer and shapelier. On the inside, Bethany was devastated, but she hid her feelings. "Why are you so worked up about someone you barely knew?" her friends and family scoffed at her, not realizing the pain Bethany was trying to cope with.
Bethany came from a stable, two-income family; her father had a good job in a local factory; her mother was a receptionist at a nearby dentist’s. Bethany’s older brother worked construction; her younger sister lived at home and attended community college. No one in the family abused substances—although a distant relative did several stints in rehab for “a drug problem” and later died of a heroin overdose—“Darby the druggy,” he was referred to contemptuously. There was no domestic violence in Bethany’s upbringing; no childhood sexual abuse. Everyone was loved and valued. Everyone got along. Everyone was otherwise healthy. Sounds like a normal home, right? So far this could be anyone.
So . . . Bethany became a cosmetician, working in a salon where she was well-liked and developed a loyal clientele. Secretly she wanted a husband and family but dated only sporadically, never letting herself get too attached out of fear of being hurt like when she was younger.
And then it happened. The twenty-four year old Bethany developed a toothache and wound up having a root canal. The next day she was in agony because of a dry socket and the endodontist prescribed thirty 5-325 mg Percocet pills with two refills; the directions read, “Take one or two tablets every six hours as needed for pain.”
“I’ll remember what came next for the rest of my life,” Bethany explained.“Looking back, it was worst thing that ever happened to me.The first Percocet put me on cloud ten and a half. I never knew I could feel so good, so relaxed and at ease with myself. I even felt better about my body. For the first time in my life, I didn’t care what anyone thought about me. I felt like I could conquer the world.”
However, one Percocet every six hours soon turned into one every four hours and then two at a time instead of one and before she knew it Bethany was on the last refill. The pills were generic and covered by insurance so she paid cash at the local pharmacy; although she was living at home her parents had no idea what was happening. “I knew I was doing something I shouldn’t be,” Bethany said in retrospect, “but by then I was starting to feel terrible if I didn’t take the pills and I needed them because they made me feel normal.”
Those Percocets started a nightmare that didn’t end for four horrendous years: begging doctors for pain pills; poaching for pills from friends; scavenging through acquaintances' medicine chests; cash-advancing her credit cards to the max to buy pills off the street. Whenever Bethany tried to detoxify herself she felt so sick she could barely drag herself through the day. On and on it went: months of intermittent sobriety followed by relapses that had her feeling so terrible she wanted to die. Bethany’s parents were frantic. What was happening to their daughter, who had withdrawn from her friends and, except for work and to scrounge for pills, had all but barricaded herself in her room? Bethany was mortified to come clean about her drug habit because she knew how the family felt about Darby the druggie who had thrown his life away. Finally, finally, Bethany broke down and told her parents. “It was either that or kill herself,” she said, but knowing she would be remembered like Darby the druggie is what finally made her come clean.
Thankfully, this story did not end tragically, although it has taken a long, long time and is far from over. Bethany’s parents supported her going into rehab where she was tapered completely off all Percocet and entered an intensive outpatient program, where the withdrawal symptoms of and craving for opiates never fully went away. The outpatient program and its associated twelve-step meetings insisted that Bethany not take any habit-forming medications, which started three hellish years of sobriety-relapse cycles. The longest Bethany could stay drug-free on her own was four months and even when she attended meetings twice a day, the craving for opiates never subsided. She was consumed with pills, where she could get them and how much she craved them. She even dreamt about them. And, of course, every time Bethany relapsed, she felt worse. Then came another twenty-eight day rehab followed by six months in a therapeutic community where Bethany and her cohorts found ways to smuggle Oxycontin and Dilaudid into the compound. Eventually she was expelled from the community and wound up suicidal again, pounding on her parents’ door begging for help.
Finally, finally after four years of torture, buprenorphine maintenance treatment was begun. That, in combination with psychotherapy and medication for the chronic depression that had plagued her for for so long, has given Bethany back her life. She’s back at work. She and her friends have reconnected. No, she doesn’t live on cloud ten and a half; nor does she want to. She goes to 12 step meetings and therapy and blesses every day that she is alive. “You just don’t talk about buprenorphine in meetings,” Bethany confides. “No one does; it’s taboo. But I know I would be dead if it weren’t for buprenorphine. Dead. I know it.”
Nowadays, I see Bethany for buprenorphine maintenance and relapse-prevention therapy. She also sees a psychiatrist who manages her depression; and a therapist to deal with body image and coping, although the fear of being rejected persists until this day. Bethany works on it in therapy; often the work is painful and sometimes she feel heartache, but as long as she takes her medicine she recoils at the thought of using opiates, which she is certain would happen were she to stop her buprenorphine.
So this is what it takes to save the life of a young woman like Bethany. Think for a second of all the people young and old who don’t or can’t get this kind of treatment: thousands upon thousands of men and women with chronic depression or anxiety disorders who drift into drugs as a desperate way to self-medicate unbearable angst.
Even as the American Society of Addiction Medicine and the rest of organized medicine cracks down on prescription medication misuse and over-prescription, it is incumbent on everyone to recognize how quickly opiate use disorders can develop in vulnerable individuals like Bethany. For her and many others with a malignant genetic predisposition to opiate addiction—let’s be clear: not everyone, of course, exposed to opiates will go on to develop the full-blown addiction syndrome—the terrifying and sobering fact is that the addiction cycle can start in only a matter of days. Brain changes can set in that fast.
From a public health perspective the risk of developing opiate use disorders may not be the same as contracting a sexually transmitted disease from one instance of unprotected sex, but for the most vulnerable individuals—and we don’t yet have a genetic test to identify who they are—ingesting repeated doses of opiate medications is playing Russian roulette with a loaded container of pills.
Yes, it is good that there is life-saving treatment like Bethany’s; but that is still akin to saying it is good that there are respirators to see polio victims through the worst of their disease. Even at that, polio is caused by a virus, against which we have developed a vaccine. There’s no vaccine to prevent opiate use disorders. And even when and if the incredibly-complicated neurobiology of opiate receptors are fully elucidated, there is no guarantee that that understanding will abort the opiate addiction cycle once it has taken on a life of its own.
We in medicine understand that there are extremely vocal opponents of the disease model of drug addiction; they see doctors who prescribe medications like buprenorphine as a component of opiate treatment programs as drug dealers. They see drug addiction as a choice, not a disease. Although I disagree fundamentally with their position that prolonged and recurrent opiate addiction is a choice and not an illness, I urge them to use their voices to educate people about the dangers of acquiring opiate use disorder and the need for primary prevention.
So here are the takeaways:
First, chronic opiates do have a role in palliation and end of life care, but no one should be given a refillable prescription for opiate pills for more than a few days of post-operative pain. Once the pills are no longer needed, they should be discarded immediately lest they wind up in medicine chests like the ones Bethany raided.
Second: Bethany did not choose to feel chronically depressed; nor did she choose to feel euphoric when she took her first Percocet. She did not know the danger signs of developing opiate use disorder. Everyone should be educated about the danger; it should be taught in hygiene class. I agree that a person can choose not to take pain pills, but that is fundamentally different from choosing one's chromosomes.
Third, be extremely wary of those who become euphoric after taking opiate pills. Clinical experience shows that they are the most vulnerable to becoming addicted. Rapid tolerance to the analgesic effect of opiate medication develops, and there is scant evidence that prolonged, high dose opiate therapy for post-operative or post-injury pain is better than non-addictive medications or behavioral protocols for pain management.
And finally, doctors and patients alike must understand that despite periodic claims for a magic cure, clinical experience shows that there is no single pill or treatment that completely reverses the addiction cycle afflicting the most vulnerable individuals. Buprenorphine treatment gives people back their lives and stabilizes their opiate receptor function without causing addiction, but buprenorphine is still a compound that binds tightly to opiate receptors and can precipitate the full-blown opiate withdrawal syndrome once it is discontinued in vulnerable individuals. It is a mistake to think that buprenorphine can be taken temporarily after which a gentle taper will proceed smoothly.
Until a completely non-habit forming opiate analgesic is developed—and there are many, myself included, who doubt that will ever happen—the only way to prevent opiate use disorders is to keep these medicines out of people’s brains.