Narcotic drugs have always been associated with addiction;
however, narcotic drugs remain the best agents to relieve pain. Pain management
is the reason people are most likely to seek medical attention. Physicians try
to balance their desire to elevate suffering against concerns that the patient
in pain just wants a drug prescription. Physicians remain constrained by problems
of drug dependence and addiction and are reluctant to prescribe narcotics or
prescribe weak, inferior narcotics such as codeine and demerol.
Weintstein et al polled 386 physicians in
Texas and found that a significant number of physicians had prejudice against
the use of opioid analgesics, displayed lack of knowledge about pain and its
treatment, and had negative views about patients with chronic pain. They
suggested that new educational strategies are needed to improve pain treatment
in medical practice.
The narcotics
that are considered to have the greatest addiction potential include codeine 60
mg, oxycodone, methadone, hydromorphone, demerol (meperidine), fentanyl, and
morphine. The World Health Organization (WHO) suggested a progressive treatment
of pain. For mild pain: aspirin, acetaminophen, nonsteroidal anti-inflammatory
drugs and adjuvants. For moderate pain: mild opioids. For severe pain:
traditional opioids. Physician concerns are justified. Narcotic-dependent
people routinely solicit prescriptions from a number of physicians and become
good at feigning painful conditions. Every primary care physician will have
patients who tend to demand prescriptions for pain relievers and other
psychotropic drugs and will become chronic users, unless the physician
steadfastly resists their demands and limits prescriptions to short term
use.
Prescribed narcotics are always available for sale on the
street. Most originate with doctors who are lenient prescribers. Drug
traffickers have lists of lenient Doctors who write narcotic prescriptions on
demand for a fee. Prescribed narcotics
are always available for sale on the street. For example, about two million
Americans have admitted taking OxyContin (oxycodone) illegitimately. The US
Drug Enforcement Administration reported that it is one of the most abused
prescription drugs. Another narcotic, hydrocodone also has a high potential for
abuse. Hydrocodone, as a narcotic cough medicine, is one of the favorite drugs
sought by recreational users when they visit emergency departments. Both drugs
act on the opioid mu receptor which blocks the transmission of pain in the
spinal cord.
In the USA OxyContin is a $1.5 billion per year product. A report
in the New York times from rural Kentucky ( July 2004) provides a perspective
on narcotic drug use: “Ever since prescription painkillers like OxyContin
became the drugs of choice among dealers and addicts in Appalachia, the days of
small-town pharmacists' dispensing medicines from behind an ordinary counter
have become a quaint memory. Now many pharmacies have turned into virtual
fortresses. Some have bars over the windows. The most sought-after drugs are
stored in vaults. The pharmacists often work behind safety glass, and some have
even armed themselves. Surveillance cameras and alarm systems monitor every
spot. Dan Smoot, chief detective for Operation Unite, an anti-drug task force
said that prescription drugs remained the top problem for police agencies in
the mountains. Mr. Smoot recently led the largest drug raid in Kentucky
history, arresting over 200 people on charges of buying or selling prescription
drugs on the black market.”
The muscle relaxer, carisoprodol (Soma) is another favorite
street drug which contains a metabolite of meprobamate, an old tranquilizer.
Taken with alcohol, Soma produces stupor or "Soma coma." Tramadol
(Ultram) is a pain medication that can produce a mild euphoric state.
Dextromethorphan is a cough suppressant found in many cough syrups, which
produces a euphoric state when taken in large quantities and can produce visual
hallucinations. People who take opioid
analgesics for many days will develop physical dependence and will suffer
withdrawal effects if the drug is discontinued suddenly. Symptoms of withdrawal
include drug cravings, muscle cramps, joint pains, anxiety, nausea and
vomiting. Withdrawal is most intense following IV heroin use and is relatively
milder after taking oral medications.
Fentanyl has become the most potent narcotic with the
greatest danger in the form of sudden death. Gatehouse and Nancy reported on
the tragic rise in Fentanyl deaths in Canada. They described:" Over the
past few months, fentanyl has been making headlines across North America, as
police discover more and more of it on the streets, and overdose deaths surge.
Authorities in Alberta linked the drug to 120 fatalities in 2014, and 50 more
in just the first two months of this year. In British Columbia, it killed
almost 80 people in 2014, and was responsible for a quarter of all drug deaths,
up from just five per cent in 2012. In Ontario, where 625 people died of opioid
overdoses in 2013, fentanyl was involved in 133 of those cases and, each year,
it now kills twice as many people as heroin. First developed by pharmaceutical
trailblazer Paul Janssen in 1959, it was originally used as an anaesthetic
under the brand name Sublimaze. The slow-release transdermal patches for
chronic pain relief were introduced in the mid-1990s. Its dangers have also
long been recognized. There have been a number of scholarly studies about all
the doctors and nurses, especially anaesthesiologists, who have become addicted
to it, and notable victims such as Jay Bennett, the late guitarist for Wilco,
who died of an accidental fentanyl overdose in 2009 after being prescribed the
patch for an old hip injury. And the drug’s illicit analogues—there are at
least a dozen variations—have been killing people on the streets since the late
1970s, most infamously under the name “China White.”
The deeper story of
the drug and its abuse is even more worrying. Police and health workers now
face an unprecedented situation, with a burgeoning street trade in both the
legitimate prescription patches and illicitly manufactured fentanyl—often sold
in pill form and made to look like OxyContin, a far less powerful narcotic. The
drug, also available in liquid and powder form, is increasingly being used to
cut cocaine and heroin, dramatically boosting their potency, often with fatal
consequences. Indeed, fentanyl seems to turning up almost everywhere you look.
And it’s killing both inexperienced newbies and hardened addicts. The illicit
fentanyl that’s currently flooding Canadian markets in pill form has more
benign nicknames: greenies, green beans and green monsters (all references to
its emerald hue). But that doesn’t make it any less deadly. Stamped as
OxyContin, the fentanyl has been retailing for as little as $10 a pill—an
indication of how cheap it is to manufacture, and how easy it is to obtain the
raw material.
The big B.C. investigation in March turned up two industrial pill
presses that were used to make the 29,000 tablets. Two of the 14 people
arrested in associated raids in Alberta and Saskatchewan are “full-patch”
members of the Hells Angels. A third man is the president of an affiliated
motorcycle gang, the Fallen Saints.
Then there’s the other problem: the growing
abuse of the legitimate pharmaceutical version of the drug. Prescriptions for
high-dose painkillers have skyrocketed over the last 15 years. A study by a
group of Ontario researchers, published last fall in Canadian Family
Physician, determined that Canadians are
now the world’s biggest per capita consumers of legal opioids, with more than
30 million high-dose tablets and patches distributed every year. Such
widespread availability of opioids inevitably leads to widespread abuse. A
recent meta-analysis by an American Scientist, published in the journal Pain,
found that the average rate of misuse of prescribed painkillers is around 25
per cent and that one in 10 medical
users ends up addicted. In recent years, it was OxyContin that was driving that
trend, because it could easily be crushed and snorted. But, once governments
forced the manufacturer to introduce a tamper-resistant formulation, called
OxyNeo, to the Canadian market in early 2012, the preferred high quickly became
fentanyl.
Dr. Karen Woodall, a toxicologist with the Ontario Centre of Forensic
Sciences in Toronto, regularly testifies as an expert in fentanyl cases. She
first noticed the drug in 2005 in the autopsy files that cross her desk. She
later traced deaths as far back as 2002, mostly via people overdosing after
chewing cut-up bits of patches—a particularly dangerous practice, since there’s
no way to predict the quantity of the drug in each piece. “The big problem with
fentanyl is that a lot of people who aren’t tolerant to the drug are taking it.
And if you’re not tolerant, it’s a lot more likely to cause serious toxicity
and even death,” she says. “It severely depresses breathing and the heart rate.
Combined with alcohol or other drugs that slow the central nervous system, it
becomes even more dangerous. It’s a serious issue, we’re seeing more and more
deaths.”
From The Human Brain by Stephen Gislason MD
From The Human Brain by Stephen Gislason MD
