May 8, 2016
In one of the weekly reviews of the news to which I subscribe, I ran across three news items between which I saw some tie-ins. Others, I thought, might have seen the three items as unconnected.
The three items were the following:
1) The British Royal College of Physicians, like our AMA, recommends the use of e-cigarettes as a “harm reduction” strategy.
2) The Wall Street Journal for 4/28/16, (p. A-3), in an article by Arian Campo-Flores, reported that there is an increased demand for qualified addiction counselors because of a [Ed: doctor-driven] boom in prescription opiate addiction, coupled with an Obamacare requirement that addiction disorders be covered by private insurers and Medicaid. Campo-Flores says there is, however, a scarcity of addiction counselors due to a history of low pay and rapid burn-out in the field.
3) Suicides hit a 30-year high in the U.S., according to a recent release from the National Center for Health Statistics.
My first reaction when seeing these three items is that in my experience it seems they may be causally interrelated.
Sometime around the early 1990’s, there emerged a new specialty in medicine, designed to deal with “chronic pain”. At the same time a division was developing among addictionologists. Most doctors sought to help addicts to abstain from their drugs, by a combination of long-term cognitive therapies, like the 12-step programs, and the brief initial use of medications designed to ease the impact of withdrawal symptoms over a short period of detoxification. A growing number of others, who seemed to have given up on actually treating addiction, were satisfied to deal with addiction by prescribing similar addicting substances that were less risky than the original drugs of choice. The best examples of this “harm-reduction” approach were the methadone clinics that provided a free oral drug (developed by the Germans during WW II when they were cut off from access to regions of the world growing poppies, the source of opium and morphine). The theory was, while methadone was just as addicting as heroin, it was longer acting, and, could be administered orally, once a day, in a clinic. Since several intravenous fixes of heroin a day were no longer required to feed the addiction, at least the risks of needle-sharing; HIV, hepatitis C, etc., could be avoided. Because the drug was provided free, the need for criminal activity to pay for drugs was also reduced.
The “risk-reduction” approach grew popular with public entities like city and county governments, partly, it seemed to me, because, requiring only minimally trained personnel, it was cheaper and easier to administer than to offer treatment with a goal of eliminating the addiction itself.
This shift in public health policy coincided roughly with the Chinese experiment of providing basic, low-level healthcare to its underserved population by sending “barefoot doctors”, with two years of medical training, out into the countryside. Here in the U.S. the experiment took the form of allowing supervised practice by former military paramedics, and by nurses with an additional two years of training as nurse-practitioners. I don’t mean to question the wisdom of the U.S. programs. As a matter of fact I was asked to be the first private practice physician in Northern California to act as a preceptor for a member of UC Davis’ first graduating class of nurse practitioners. And later, as the director of a busy occupational clinic at United Airlines, my staff included two other physicians and three nurse practitioners. With immediate supervision and physician support, a medical team including nurse practitioners both was safe and efficient. I mention the inclination of the times, to reduce costs by using lesser-trained individuals and changing their title from “doctor” to “primary care practitioners”, because it supported the idea of treating the huge problem of addiction with “harm reduction strategies” rather than actual treatment.
Meanwhile doctors had continued to create opioid addicts by treating the acute, short-lived pain from occupational injuries and surgical procedures with too-lengthy out-patient prescriptions of highly addicting oral pain-killers like Percodan (ocycodone), over which they exhibited far too little control and supervision. One compounding error often committed to this day is that many doctors prescribe Percodan in the common medicinal dose of “once ever four hours, round-the-clock”, when the effects of Percodan last six hours, and when the recommended dose should actually be:…once every six hours, only as needed for severe pain.
Conservative physicians were in the habit of using addicting opioids only for very short-term problems, prescribing only a few pills at a time with no automatic refills, thereby keeping close tabs on the use of the medication. Opoids can addict a patient for life after only a very few days of use.
As a private family physician during this period, and later company doctor treating 2,000 employee injuries a month, I began to see increasing numbers of patients asking for Percodan and other opioid medication refills, who had been given the drugs for months by other doctors! The older guideline was that long-term use of addicting pain killers should be limited to patients with an illness expected to end in death within, say, a year or two.
The doctors who ran chronic pain clinics, often dealing with such controversial entities as “fibromyalgia”, began to exert pressure upon the medical community and the state licensing boards, to train all physicians to recognize and treat chronic pain with opioids, (or to refer patients to the chronic pain clinics). Physicians who took the more conventional conservative approach and used non-addicting medications and physical modalities to relieve pain were threatened with reprimand and discipline for “under-treatment” of patients in need if they failed to treat complaints of chronic pain with “adequate” doses and durations of prescriptions. Special courses were mandated by state medical boards for “reeducation” in the treatment of chronic pain.
Thus, chronic-pain and harm-reduction addiction clinics gradually carved out a comfortable economic niche for themselves in the medical market.
Now, after a couple of decades of treating addictions with “harm-reducing” prescriptions of the same or with other very similar addicting substances, we are seeing a huge wave of addictions to prescription pain-killers, along with an accompanying wave of overdose deaths. Duh!
From my later career as a general, addiction and forensic psychiatrist, I am aware that alcoholism and addiction are drivers of the suicide rate. Opiates and alcohol are depressant drugs. Suicide is most prevalent among the victims of major depression and those with the characterologic depression associated with personality disorders. Some of the people most susceptible to addictions and substance abuse are those with personality disorders.
Viewed from the other side, addicts often exhibit the personality traits of people with personality disorders, especially those in what is called Cluster B: Borderline, Narcissistic, Antisocial, and less obviously, Histrionic Personality Disorder. Addicts often lie to get their drug of choice, have little regard for those whose lives they impact adversely, engage in relationships based upon rage, are controlling and manipulative. Their denial looks a lot like grandiosity. Their treatment of the other people in their lives is described as expressing a “lack of empathy”. But on the other hand, disregarding the feelings of others is not easily distinguished from treating others as if you were angry at them. This kind of rage-based relationship to others is an explicit feature of some of the the Cluster B disorders, and one might generalize that it features to some degree in all the personality disorders.
In Karl Menninger’s famous and classic treatise on depression, the book called, Man Against Himself”, he describes depression as anger that, when deprived of its important external targets, reflects back upon the self. Suicide, he says, is acting out that anger against oneself (and others), and serves both as an expression of the anger, and simultaneously as punishment for any guilt one may feel because of one’s unwarranted anger towards others. Persistence of those dysfunctions over a lifetime is probably the reason why unresolved personality disorders are associated with a suicide rate as high as that of major depressive disorder.
It is probably not a coincidence that the 12 steps of AA can be an effective antidote to many of these dysfunctional personality traits. Ironically, when one chooses, “harm reduction” as the dominant official response to addiction, a strategy that looks suspiciously like enabling behavior, the addiction is simply not addressed, and neither are the personality traits that may well, if they fester long enough, lead to suicide. Thus, in this way, choosing what some call, “harm reduction” strategies to deal with addictions may, over time, tend to drive the suicide rate up.
The same flawed logic that lies behind “harm-reduction” forms of “treatment” of opiate addiction, is what some use to justify using nicotine patches and e-cigarettes for the treatment nicotine addiction. Nicotine is more quickly and firmly addicting than heroin. As few as four cigarettes can initiate an addiction that lasts for several decades. While the tars, like heroin needles, carry their own additional risk, nicotine itself is still the largest known risk factor for the arterial damage that underlies heart attacks and stroke.
In a world where addictions can actually be overcome and recovery achieved, maintaining addictions with the addicting substances themselves, or similar ones, is a problem masquerading as a cure. Utilizing 28-day inpatient programs, mandatory 12-step attendance and long-term monthly monitoring by FAA-appointed airline-physician Medical Monitors, the Human Intervention and Motivation Study (HIMS), conducted conjointly by the FAA, the Airline Pilots Association (ALPA) and several major airline medical departments, demonstrated a long-term recovery rate for alcoholic pilots of above 95%. The airlines applied similar programs to its other employees with a comparable long-term success rate. And the HIMS program became the model for intervention and treatment for physicians impaired by substance abuse.
One side issue mentioned in the suicide article: along with the number of suicides, the overall number of suicides by gun has increased in the past several years. However, while gun ownership has increased steeply during the period studied, the percentage of suicides by gun, for both men and for women, has decreased, once again mitigating against the prevalence of guns as a cause of the violence of suicide.