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Addiction: Good intentions; unintended consequences

April 2014
by W. Clay Brown, M.D., Medical Director of Adolescent Services, Memorial Hermann Prevention and Recovery Center, and Mike Leath, R.Ph., M.D., Chief Physician, Memorial Hermann Prevention and Recovery Center

In our culture of immediate gratification and quick fixes, the role a medical doctor unwittingly plays in substance abuse or addiction relapse sometimes boils down to simply prescribing a standard medication to resolve a temporary medical issue: Ambien for difficulty sleeping, Soma for a sprained back muscle, or Vicodin for a root canal.

However, a short-term solution may inadvertently lead a patient into a lingering struggle with addiction or a slide back into substance abuse.

Today, there are approximately 750,000 physicians in active patient care in the United States. Unfortunately, a significant number have had less than half a day of training in prescription drug diversion. Thus, many doctors may be unaware of mood/mind-altering properties of certain medications, especially with new medications coming onto the market, or uninformed about the problem of cross-addiction, the swapping one substance for another.

With cross-addiction, an individual may believe the use of addictive substances other than their drug of choice is possible without relapse. In reality, any addictive drug or compound, including alcohol, will “trigger” specific receptor areas in the brain and eventually lead the person with a history of an addiction disorder back to active addiction, either through use of their original drug of choice or something new.

Many sleep aids, analgesics, and other drugs are marketed as “non-narcotic” to both physicians and the general public, but this certainly does not mean they will not trigger addiction. Anything that causes sedation, dizziness, or euphoria has the potential to trigger addiction and may be habit-forming.

Before considering treatment with an addictive substance, prescribing physicians are strongly encouraged to perform thorough patient assessments to identify addictive tendencies or personalities. Next, learn what drugs are safe versus what drugs can trigger addiction.

Fair Warning

Sleeping pills are among the most widely prescribed medications in the U.S. About four percent of Americans use prescription sleep aids, and more commonly by women and older adults.

In a person with a history of addiction, physicians should keep in mind that the pleasure center of the brain is easily simulated. Even when not abused, drugs like Ambien or Lunesta have been found to increase the craving for a patient’s drug of choice because they affect that portion of the brain.

Soma is a muscle relaxant prescribed to relieve pain from muscle injuries and spasms. However, some providers do not know the liver breaks it down into the tranquilizer Meprobamate, a Schedule 4 drug with a high potential for abuse.

Many abusers take Soma in combination with other drugs to enhance their effects. A few years ago, a particular mix that gave users a heroin-like high when taken together became popular on the drug scene in Houston. This mix, dubbed the “Houston Cocktail,” consisted of three drugs: hydrocodone, Xanax, and Soma.

Finally, while new restrictions by the FDA have impacted the abuse of pain pills, physicians should be aware of one possible consequence when a patient is cut off from a legitimate source. Memorial Hermann Prevention and Recovery Center has seen a significant rise in heroin use in suburban areas and among the rural white population. Heroin produces a high similar to prescription opioids, is cheaper, and easier to obtain. According to the U.S. Department of Justice, the amount of pure heroin produced in Mexico has nearly tripled in the last five years, causing heroin availability in the U.S. to skyrocket.

Alternatives

There are many pharmacological options for providers to consider. For anxiety, selective serotonin re-uptake inhibitors, BuSpar, Inderal, or Vistaril can be used to treat anxiety and the body’s response to anxiety. Instead of opiates, patients can be transitioned to non-steroidal, anti-inflammatory drugs after acute pain subsides. Physical therapy, cognitive behavioral therapy, biofeedback, and coping techniques are also useful.

Physicians should be especially careful when treating adolescents with potentially addictive substances. Undergoing dramatic intellectual, social, emotional, and behavior growth and change, teenagers lack coping mechanisms and are much more prone to addiction, manipulative, and difficult to treat.

Successful Recovery

The chances of a person achieving or maintaining long-term sobriety without professional help are not good. According to the National Institute of Drug Abuse even with help, the relapse rate is anywhere between 50 to 90 percent.

At any stage of life, heavy alcohol or drug use alters the brain. When people stop drinking or using drugs, the brain does not return to normal. Medically, unsupervised withdrawal from alcohol or drugs can be extremely dangerous and potentially life threatening.

In regular and heavy drinkers, the body compensates for the depressive effect of alcohol by ramping up production of a number of hormones and brain chemicals, like serotonin, epinephrine, and dopamine. When a person suddenly stops drinking, the body becomes flooded with abnormally high levels of those chemicals. The risks depend on how long a person drank, how much, how old the person is, and any existing medical conditions.

Alcohol withdrawal can produce a range of minor to serious effects, which can occur within a few hours or days after the last drink. Severe complications can include dehydration, vomiting, abnormal heart rhythms, and a condition called delirium tremens, which have about a 15 percent fatality rate. Considered a medical emergency, delirium tremens is characterized by confusion, delirium, and seizures and can occur 24 to 48 hours after the last drink. Unattended, patients can suffer head injuries, lethal dehydration, heart attack or stroke, and can choke on their own vomit.

Primary care physicians faced with an alcoholic patient who wants to quit, might want to think twice about simply prescribing Librium to help with withdrawal symptoms. What happens more times than not, is the patients takes Librium, continues to drink, and winds up in the emergency department.

Patients who have abused Xanax, Soma, Valium, Ativan, and other similar drugs have a high risk of seizure when going through withdrawal. In cases of severe opiate addiction, persons going through withdrawal may experience hallucinations, severe body tremors, and suicidal thoughts.

By far, the biggest risk during the detox period is relapse. People who quit cold turkey usually start off feeling quite strong and determined, but once they get into the throes of withdrawal, they tend to become very different people. Many people reach a point where they will do anything to get more of the drug, even if it involves hurting themselves or others. Then, after just two to three days, their tolerance may already be substantially lower than before and accidental overdose becomes a real issue.

For not only medical and legal reasons, but more importantly, to increase a patient’s chances of recovery, physicians should refer addicts to specialists in that field.

Recovery Options

In addition to managing withdrawal symptoms and stopping drug abuse, the goal of treatment is to return people to productive functioning in the family, workplace, and community. According to research that tracks individuals in treatment over extended periods, most people who get into and remain in a formal treatment program stop using drugs, decrease their criminal activity, and improve their occupational, social, and psychological functioning.

Instead of attempting to manage a situation themselves, providers are encouraged to reach out to addiction specialists who can recognize and treat both the psychological and physical complications of addiction.

Available treatment options depend on several factors, including what type of substance it is and how it affects the patients. Typically, treatment includes a combination of inpatient and outpatient programs, counseling or psychotherapy, self-help groups, and medication.