The Peril and Folly Of Opiate Abuse

Transcription

1 The Peril and Folly Of Opiate Abuse By John R. Ewing, MD Illustrations by Rhea Ewing A Spirit Lake Wellness, Inc. Publication Mystic Sheep Studios Press 1

2 copyright 2011 John R. Ewing, MD All rights reserved A Spirit Lake Wellness, Inc. Publication Mystic Sheep Studios Press, Baraboo, Wisconsin ISBN

3 Wakefulness In the morning, we start to wake up. The light inside comes on. It might be somewhat dim as we are still sleepy. As we wake up, the light inside becomes brighter. Some days are gray and gloomy. Sometimes it s like climbing a mountain to get going. 3

4 Sometimes we really light up with joy. We can describe these peak experiences with a graph. This inner light comes from the brainstem which acts like a flashlight. This lights up the part of the mind we are paying attention to. 4

5 The brain is like a hollow ball on a stick. The brain is wrinkled up so our heads don t have to be so big. When the brainstem lights up the cortex we wake up. When the light is dim we sleep. 5

6 When we are happy, an extra light gets turned on. We glow with happiness. The reward activation system turns up the brightness. The reward activation system is like an extra flashlight that turns on our happiness. This gives us a peak experience and makes us feel good. We feel high and glow instead of feeling low and dull. 6

7 The reward activation system sends increased dopamine into the frontal lobes and serotonin into the rest of the brain s cortex. This combination of chemicals makes us feel good. With dopamine, the reward activation system can inhibit activity in our frontal lobes. This dampens our critical reasoning and judgment and opens us to new experiences. With the frontal lobe suppressed, our judgement is impaired and we feel uninhibited. We might even dance around and get silly. or even do risky crazy things like - 7

8 People do a lot of different things in pursuit of pleasure and to turn on their reward activation system. They climb mountains, they ski, they shop, they eat pie. Some people drink coffee and tea or eat chocolate. Others might smoke, drink or do drugs. 8

9 The common link between drugs of abuse is that they turn on the reward activation system producing euphoria. Substance abuse is the use of a euphorigenic substance to a planned degree of disinhibition or intoxication. The problem is that we can t maintain that state and we feel bad afterwards. People that are already happy are more likely to just get side effects and usually don t get addicted. Depressed or anxious people may be more susceptible to getting a high. They may have an aha moment where they become imprinted with the ideal of using a drug to be happy. But the high always goes away, leaving us empty. 9

10 Our bodies like to be in balance. Not too hot, or too cold, but just right. If it gets too hot, we sweat. Too cold, we shiver. This also applies to taking drugs. Our bodies compensate for conditions to stay just right. 10

11 We can use animals to measure the dopamine release from euphorigenic drugs. The dopamine surge corresponds to the high provided by the drug. We can actually measure the high and watch as it goes away. Dopamine peaks are dampened in just a few days by a compensation process. 11

12 Adding the drug effect to the compensation effect allows us to graph out the course of a high. There is a peak, a plateau phase, then a crash. Initial State ---- = drug and compensation = state that is experienced In a few days, the compensation effect strengthens and the high weakens. Addicted State 12 Addicted state of dependence

13 As the body adapts to a chemically induced high, it begins to take more of the drug to have the same effect. The low that follows gets worse. Initial State Addicted State Reward deficiency If we take the same dose, the effect is less and less until we don t get that high any more. No matter the dose, the high always goes away. Despite taking more and more of the drug, people finally just don t get high anymore. They discover that instead of getting high, they are just trying to maintain being normal. 13

14 The Big Lie Assuming that the drug effect is gone when the high goes away is the Big Lie. The truth is that a drug induced high is followed by a low. With repeated use, the high weakens and the low gets stronger. We adapt to reward activating drugs by developing a state of reward deficiency. In time people may think they are maintaining their high... but in reality they are escaping from the after effect of reward deficiency. They end up using more and more just to feel normal. 14

15 Cocaine provides the classic pattern of reward activation followed by reward deficiency. The brief high of cocaine is followed by a depressed state of reward deficiency that can last 3-7 days after a single episode of use. Many budget conscious experienced users quickly conclude that cocaine is an expensive way to get depressed and paranoid. They soon realized that the brief high is not worth the depression that follows. Many drugs such as caffeine do not have as intense an effect. The high and the low is not as severe. Many people develop unhealthy relationships with euphorigenic substances. Practice causes the bad feeling of reward deficiency to last longer and to become more severe. 15

16 Let s delve a little deeper into how the body copes with stress. Humans have a daily or circadian rhythm. We wake up, become active, get food, socialize, and then sleep. When we rest, we go into a repair mode. There are several natural substances our bodies produce that help us cope with the need for increased activity and stress. These increase in the morning. Adrenaline and nor-epinephrine : are natural substances that activate the brain and body. Adrenaline is associated with fear and anger. Nor-epinephrine causes us to be awake and alert. Cortisol : Helps dampen inflammation. It tells the body, Keep going, we ll fix it later. Endorphins: Help to dampen our experience of pain and adrenaline. Endorphins can be calming by dampening the effect of adrenaline. This makes us less vulnerable to anxiety, anger, and irritability. Opiates work by imitating our endorphins. 16

17 There are 3 centers in the brainstem that adapt to opiates. 1. The effect of adrenaline is dampened and we adapt by producing more adrenaline. 2. We become more sensitive to pain. 3. Reward deficiency becomes more severe. Opiates dampen the response to adrenaline. This can result in sleepiness. (morphine is named after Morpheus, the god of sleep and dreams.) If there is enough opiate the sleep may be deep enough that the person stops breathing and dies. (This is how people overdose.) The body adapts to opiates by increasing adrenaline levels. This helps prevent respiratory depression and decreases the sleepiness produced by opiates as the person becomes more tolerant of a higher dose. When the opiate is stopped, the high level of adrenaline is unmasked. The excess adrenaline is what causes most opiate withdrawal symptoms such as cold sweats, goose bumps, yawning, and muscle twitches. 17

18 In opiate withdrawal, the relative excess of adrenaline is unmasked by the removal of opiates. Adrenaline excess = anxiety, fear, dread, and irritability or anger. (Nor-epinephrine, also called nor-adrenaline, is what increases our alertness.) Symptoms include : dilated pupils nausea vomiting diarrhea runny nose watery eyes cold chills goose bumps increased blood pressure increased heart rate. The frontal lobe is inhibited by adrenaline as well as dopamine. States of fear and anger or silliness can both cause us to lose control. In opiate withdrawal, people can easily lose control of their anxiety and irritability. Withdrawal symptoms are most severe for 7-10 days with most opiates and 3-4 weeks with methadone (severe) and buprenorphine (which is milder). Opiate withdrawal often increases a tendency towards panic attacks. This is how panic attacks or adrenaline surges work: Our respiratory center detects increased CO2 which leads to yawns and sighs. If this is ineffective, an additional surge of adrenaline is released. This causes increased heart rate, feeling short of breath, and feelings of doom. Panic attacks are often worsened by hyperventilation. 18

19 Pain Sensitivity Opiates cause our analgesic zone to move upward. High opiate levels cause pain sensitivity to increase. In opiate withdrawal, everything hurts. There is increased pain sensitivity. This declines gradually over a 1-3 month period and the pain threshold comes back to normal. In opiate withdrawal, even normal, uninjured parts of the body can hurt. 19

20 Reward Deficiency Although initially opiates may trigger the reward activation system and produce a high, this effect fades. The Reward Deficiency State gradually improves after opiate withdrawal. 20

21 We can now summarize the peril and folly of seeking peak experiences with opiates. The frontal lobe is what enables us to make plans. Our plans are overwhelmed when frontal lobe activity is inhibited by either dopamine or adrenaline. The high makes people vulnerable to losing control and doing more of the drug, despite the risk of overdose. Despite knowing the drug is causing their bad feelings of withdrawal, adrenaline (which causes irritability and anxiety), pain and fatigue make people vulnerable to losing control. They go out to get more of the drug to fix their situation. This hijack of the self causes the loss of control we call addiction. a = without diction = word as in dictionary The addict can t stick to their plans. Their word is no good. They lie first to themselves and then to others. dictum = command. The addict has no command or control over their use of the drug. The drug takes control and all of their problems become interpreted as the result of too little or too much drug. 21

22 There are several types of users. 1. Weekend Warriors - give all their extra money to the dealer. They use every pay day and work all week in the dreary gloom of reward deficiency. They are less likely to figure out that they would be happier without opiates. 2. The Star Chasers - think there is some secret here. They save up for larger and larger amounts to try to get that ultimate high. They are most likely to overdose. 22

23 2a. Cocktail Artists - are likely to mix other drugs with opiates for a more intense or unique effect. They use opiates with carisoprodol, alprazolam, or diazepam. This pattern also increases risk of overdose. Alcohol at the driving limit of 0.08 and above increases the likelihood of a fatal heroin overdose by 22 times. 3. Regular Users - are most likely to become physically dependent and have severe withdrawal symptoms. They are likely to develop all three types of compensation to opiate use - increased adrenaline with increased irritability and anxiety, increased pain sensitivity, and severe reward deficiency. Regular users require ever higher doses of stronger opiates to trigger the reward activation system. But no matter how high the dose, it rapidly becomes more difficult to get high. The high always goes away. The high goes away and the advanced user gradually settles down to just trying to maintain being normal and avoid being sick. The usual course for users that survive into their 40 s and 50 s is to gradually wean off of opiates. Because many addicts use alcohol to dampen withdrawal symptoms, many users settle into a life of serious alcoholism. 23

24 Most opiate users eventually come to realize that they have a problem. At first, it may seem the only problem is to get enough drug. Then, they begin to alternate between episodes of fatigue, irritability and depression from a withdrawal state. They have episodes of nodding out and being unable to function from taking too much. Life gets harder and darker. All of this started out as an attempt be happy and cope with stress. The high always goes away. In Conclusion The crash lasts longer and gets deeper. The pursuit of pleasure and peak experiences with opiates results in: Irritability and anxiety with withdrawal symptoms, Increased pain, fatigue and a lack of joy. 24

25 With repetition, substance abuse evolves into addiction. Who you spend time with is a major part of how things turn out. With prolonged abstinence comfort, calmness, and joy return. People can learn to cope with life more effectively. They can transform anxiety into security, anger into determination, shame into a sense of purpose, and emptiness into joy. People can learn to trigger their reward activation system at will and become joyfully euphoric just like children do. Please don t let opiates take that away from you. 25

26 Appendix Medical Therapy for Opiate Addiction 1. Supervised withdrawal and abstinence. 2. Methadone 3. Buprenorphine Buprenorphine activates opiate receptors only part way and stays there a long time. Short acting opiates with a rapid onset can make addiction worse. The drug is always wearing off and users learn they have to keep using to avoid getting sick. Adrenaline reinforces learning to avoid withdrawal at all costs. It takes a lot of work to keep enough opiate in the system at the right time and at the right level to be able to keep functioning. Long acting opiates such as methadone make it easier to avoid a state of withdrawal. Unfortunately, methadone can be abused and result in overdose, especially when combined with other drugs. Buprenorphine is a long acting opiate that has a ceiling effect. The ceiling effect makes it unlikely that an experienced opiate user will overdose. Using any more than mg daily has no psychological benefit and only results in running out of the medication. Overdose can occur if buprenorphine is combined with alcohol, sleeping pills, or tranquilizers. Because buprenorphine is so powerful, it pushes other opiates off the receptor. This can cause withdrawal symptoms if other opiates are in your system when you start buprenorphine. This is particularly true of methadone. 26

27 Unlike conventional opiates, where activating too many receptors causes overdose, virtually all of the receptors can be covered by buprenorphine. Like a full glass of water, more buprenorphine just runs out and is wasted. Suboxone* is a formulation of buprenorphine plus naloxone. If injected, naloxone blocks opiate receptors and produces severe withdrawal symptoms. Suboxone dampens the roller coaster on and off cycle of opiate addiction and blocks the craving from opiate withdrawal and can be used to stabilize an addict until they learn more effective ways of being happy. More than half of long term outcome is determined by a person s social circle. Spending time around people who engage in substance abuse makes relapse more likely. With education, effective counseling and practice, people can learn to avoid being depressed, anxious, and irritable. Once they are fully stable, people can be tapered slowly off buprenorphine. Large decreases in dose are uncomfortable compared to small steps. Waiting days between small dose reductions makes tapering off easier to tolerate. Suboxone is trademarked by Reckitt Benckiser Group, plc. 27

28 28

29 Order Form Spirit Lake Wellness, Inc You may order more copies of this booklet using this form or by going to Visit our website to see other titles in this series. Name : Address : City : State : Zip code : Title : Peril and Folly of Opiate Abuse Quantity : x $3.00 ea. = $ Shipping and handling + $ Total enclosed : $ Call for quantity discounts for orders of 100 or more. Send this form with check or money order to : Spirit Lake Wellness, Inc. PO Box 32 Baraboo, WI

30 $3.00 USD Produced in part with a grant from the Spirit Lake Wellness Publication Mystic Sheep Studios Press ISBN