Dr. Jekyll and Mr. Hyde

Quick, what is the most commonly prescribed drug in the United States? Hint: you will never see it advertised on TV.

It's an opioid analgesic, or more precisely a formulation of hydrocodone and acetaminophen (tylenol). The most common brand name is Vicodin. Bridget Kuehn, in JAMA (Jan. 17) informs us that Americans got 100 million prescriptions for this drug in 2005, and that we consume 99% of the global supply of hydrocodone. Prescriptions of opidoids in general have been increasing dramatically in recent years. Hydrocodone is the most popular because it's relatively short acting and therefore physicians are allowed to give patients refillable prescriptions, which is not allowed with most drugs in the class.

Opioids, of course, are drugs whose mechanism of action is similar to that of morphine, the active chemical in opium. These drugs, starting with morphine itself, are a great boon to humanity. There is still nothing as effective at relieving pain. Without these drugs, many people's lives would be unbearable, much surgery would be nearly impossible, dying would be agonizing for many if not most of us.

Most people, I'm quite sure, have an exaggerated idea of the long-term harms of regular opioid use. People who take these drugs for relief of moderate pain can readily get to a stable dosage at which they get effective analgesia without any disabling euphoria or sedation. About the worst side effect is constipation. Opioids don't rot your brain.

But, they do cause physical addiction and, in some people, intractable psychological dependency. So why do long-term junkies look so bad, have so many severe health problems, destroy their careers and families (if they ever had any), commit crimes, and die young? It's not because they are using heroin and other opioids. It's because they are using them illegally, which means they are hard to get, expensive, and often not there when the junkie needs them. Junkies are continually going through incipient withdrawal; spending most of their time and energy and all of their money seeking the drugs they need; lying, cheating and stealing to get drugs; injecting themselves using unclean needles, containing unknown amounts of heroin along with who knows what else; and neglecting nutrition, hygeine, shelter, health care and everything else in their obsessive pursuit of relief from their uncontrollable cravings.

One answer, which actually works very well, is just to give them the shit. In the U.S., we generally supply it in the form of the long-acting opioid methadone. People on methadone generally go to a specialized clinic where they swallow the juice in the morning, and then get on with their lives, without evident impairment. But we tend to have a moral revulsion against drug dependency, so in many states, people are forcibly weaned from methadone after a period; or they aren't allowed a high enough dose in the first place. Then they relapse and they're back in the life, or in the slammer.

Nowadays, there is strong evidence that abuse of prescription opioids is replacing heroin abuse in North America. Kuehn cites research by Leonard Paulozzi at CDC finding that overdose deaths from prescription opioids now exceed deaths from heroin. The regular national surveys on illicit drug use, although they are of questionable reliability, also indicate that abuse of prescription drugs is more widespread than abuse of illegal drugs such as heroin and cocaine.

I had a friend and colleague who was an HIV positive recovering heroin addict. He was given an opioid prescription for a back injury, wound up relapsing, became erratic in his adherence to his HIV medications, and died. Why did his addiction relapse cause him to stop taking his meds? Again, not because taking narcotics directly stopped him from taking his antiretrovirals, but for the reasons given above: the total disruption of his life and motivational system caused by the relentless pursuit of illegal chemicals. But what might have happened if he hadn't gotten treatment for his back pain? Chronic pain can lead to depression, other somatic symptoms, disability, physical and mental decline, and suicide.

I once interviewed a man with HIV whose doctor had made a deal with him. She'd give him a prescription for morphine if he would take his antiretrovirals. He didn't actually need the morphine for pain, but he needed it to stay away from the dealers, and to stay straight enough to take his protease inhibitor. Technically, I guess, she committed a crime. But she was trying to save his life.

So, what do I have against Rush Limbaugh for being a Vicodin addict? Only that he's a hypocrite.

By the way, I once spent a few days heavily doped up with morphine after surgery. I absolutely hated it. It made me stupid and groggy, and then it made me start to itch and sweat. I asked them to take me off it before they were ready to. Some people aren't so lucky. It makes them euphoric, and they just want more. That's just a curse you are born with.

Is there a political point to all this? Yes, there are a few. But there's some background, now we can get to those later.