Archives for posts with tag: addict

Oh, just, subtle, and mighty opium! [T]hat to the hearts of poor and rich alike, for the wounds that will never heal, and for “the pangs that tempt the spirit to rebel,” bringest an assuaging balm; eloquent opium! that with thy potent rhetoric stealest away the purposes of wrath; and to the guilty man for one night givest back the hopes of his youth, and hands washed pure from blood; and to the proud man a brief oblivion for Wrongs [unaddressed] and insults unavenged ….. Thou only givest these gifts to man; and thou hast the keys of Paradise, oh, just, subtle, and mighty opium!

Thomas de Quincey[1]

 [This is Fred. Phil’s out with exhaustion, heat and otherwise, and asked me to take over today’s lesson. This isn’t an easy thing to do, because he has a list of heavy-duty subjects to cover some day, but most are not in my area of interest, and I don’t know enough to lecture about the rest. It would take too long to research “Philosophical Aspects of Modern Rap,” or “A Linguistic Analysis of Feminist Theory,” or “Will Ancient Spells Work on Mars?” [Although that last one really looks interesting.[2]]

But we’re not blazing new paths today; there’s a deadline; so let’s look for an old subject, one we know something about. How about opioids and our collective addiction to them? Heroin, an opioid, has been around and afflicting people in this country for some time.[3] Opium, the original opioid, has caused problems in the East for centuries and has addicted folks in the West for generations. Most of us kind of know about these things, but ignore them. The current furor about opioids only erupted because there are synthetics now loose in the drug economy. They’re very potent, and deadly, and their users die at a high rate.

So why not frame our current situation with some history? Did you know that opium was a big problem in England in the 18th and 19th Centuries? And what’s the evidence for that? Well, for one thing there’s a very famous book, first published in London Magazine in 1821, that chronicles the opium addiction of an upper class Englishman. My friends in sociology say it’s a classic. The book tells us quite a bit about how the author got addicted, who supplied the stuff, and how many users there were.

It says London had a well-established opium trade in the early 19th Century. The author reported: “Three respectable London druggists, in widely remote quarters of London … assured me that the number of amateur opium-eaters … was at [that] time immense; and that the difficulty of distinguishing those persons to whom habit had rendered opium necessary from such as were purchasing it with a view to suicide, occasioned them [the druggists] daily trouble and disputes.”[4] So why would druggists back then worry about would-be suicides? I don’t know. Perhaps it was a legal requirement. But apparently the prospect of suicide didn’t inhibit sales all that much. The population of users “was immense.”

Also, opium addiction was not just an upper class London phenomenon. Blue-collar types in other parts of England were getting into it, “so much so, that on a Saturday afternoon the counters of the druggists were strewed with pills of one, two, or three grains, in preparation for the known demand of the evening.”[5] The author said this happened because, for a time, opium was less expensive than alcohol, so the working class went with the new thing. But, he said, if the pricing reversed, the new addicts would not follow. “[T]hose eat now who never ate before; [a]nd those who always ate, now [will] eat the more.”[6] That is, opium addicts, once made, would not go back to the old vices simply because the market ordered it.]

The book is Confessions of An English Opium-Eater: Being an Extract from the Life of a Scholar, written by Thomas de Quincey.[7] He lived from 1785 to 1859, and was severely addicted from about 1813 until 1819. If you want to know more, there are some web-based biographies available[8]; but in my view they pretty much track the book; so that’s where we’ll concentrate. As to why De Quincey was a user, look at the quote that opens this piece. Opium held the keys to Paradise.[9]

De Quincey’s Life and Addiction

Or at least it did when he used opium sparingly, and at great intervals, for recreation. But I’m getting ahead of the story. Let’s look at the milestones on his road to and from addiction:

  1. Thomas de Quincey was born on August 5, 1785. His father was a merchant, just starting out, and had good prospects until he died, 7 years later. By my count, that would have been in 1792.
  2. Young Thomas had 4 guardians after that, and was shipped off to various schools for his education, apparently including Eton and an unnamed school at Oxford. “I was sent to various schools, great and small; and was very early distinguished for my classical attainments, especially for my knowledge of Greek. At thirteen I wrote Greek with ease; and at fifteen my command of that language was so great that I not only composed Greek verses in lyric metres [today, “meters”], but could converse in Greek fluently and without embarrassment …”[10]
  3. He tried opium for the first time at age 18, which would have been in 1803. He liked it, and over the next 10 years continued to use it “for the sake of the exquisite pleasure it gave me ….”[11]; but, he said, he spaced out the doses to preserve their effect, and that protected him “from all [the] material bad consequences”[12] of addiction. Or perhaps he just didn’t have the money to buy in quantity. Who knows?
  4. The situation changed in 1813, when he was 28. He had an eruption of a gastro-intestinal problem that first had hit him when he was a teenager. Apparently it was both painful and chronic; so much so that he began to treat himself with daily doses of his favorite drug. “It was not for the purpose of creating pleasure, but of mitigating pain in the severest degree, that I first began to use opium as an article of daily diet.”[13]
  5. He continued until he was thoroughly addicted, and didn’t kick the habit until 1819, six years later. How did he escape? By incrementally reducing his intake until he achieved a zero dose rate; and that wasn’t easy! He tried to do it in the early days, but failed. And he was a mess even after he succeeded. “Think of me as one, even when four months had passed, still agitated, writhing, throbbing, palpitating, shattered, and much perhaps in the situation of him who has been racked …. Meantime, I derived no benefit from any medicine, except one prescribed to me by an Edinburgh surgeon of great eminence, viz., ammoniated tincture of valerian.”[14]
  6. Valerian is an herb you can buy today at the vitamin store, but I’m not saying it will help you conquer opioids. So far as I can tell, there still aren’t any easy cures. Right now a cynic might say our technology isn’t much more effective than what was available to De Quincey 200 years ago. Reports are that there may be a vaccine in our future, but they’re speculative and a subject for a different blog.

Conclusion

His milestones sound pretty contemporary, don’t they? De Quincy, an occasional user of opium, the opioid of his day, liked it so long as he didn’t use a lot. Then one day he used it as a pain killer, began to take daily doses, and went straight down the toilet. And today what are our most popular pain medications? Opioids, for the most part. And where do we get them? Why, from druggists, doctors or street vendors, depending on our budgets. Oh brave new world, you look pretty old to me! I wonder, did 19th Century Londoners have street druggists like ours? If so, did they call them “pushers”? Or was everybody just a druggist?

I’m guessing it’s as hard to kick an opioid addiction today as it was for Thomas de Quincey. He said it was like being born:

[Some conjecture] that it may be as painful to be born as to die.  I think it probable; and during the whole period of diminishing the opium I had the torments of a man passing out of one mode of existence into another.  The issue was not death, but a sort of physical regeneration …. [15]

And once regenerated it was possible for him to be happy again. “[A]nd I may add that ever since, at intervals, I have had a restoration of more than youthful spirits, though under the pressure of difficulties which in a less happy state of mind I should have called misfortunes.”

Opium and its modern relatives can be very attractive until they take control of our lives. Thomas de Quincey discovered that, got out, and was better for it. Myself, I think it’s better not to get in.

See you next week!

 

[1] This quote is from Thomas de Quincey, Confessions of an English Opium Eater, Being an Extract from the Life of a Scholar. Believe it or not, this book is currently in print from the Oxford University Press.  It was first published in 1821 in London Magazine, then was picked up in 1886 by George Routledge and Son. You can find the hard copy on Amazon. However, in keeping with blog policy, we have found an alternate, free source for the text, this time in an eBook from Project Gutenberg.  Go to http://www.gutenberg.org/files/2040/2040-h/2040-h.htm “This eBook is for the use of anyone anywhere at no cost and with almost no restrictions whatsoever.  You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this eBook or online at www.gutenberg.net .” Henceforth the eBook will be cited as “Opium Eaters at __.” Page numbers, if given, will be approximations. The eBook version doesn’t appear to have such things. See Opium Eaters at Part II, The Pleasures of Opium, p. 28-29 for our quote. Even our quote is just a small part of what he actually wrote.

[2] I also like his partial draft of “Faces and Other Things on the Planets,” in which he argues that with modern digital technology any collection of pixels can be morphed into anything else, so why believe NASA’s pictures of celestial objects or any pictures at all?

[3] Check out the Wikipedia posting at https://en.wikipedia.org/wiki/Heroin for more information on this subject.

[4] See Opium Eaters at To the Reader, p. 3.

[5] Id.

[6] Id. “… I do not readily believe that any man having once tasted the divine luxuries of opium will afterwards descend to the gross and mortal enjoyments of alcohol ….”

[7]  See note 1.

[8] See, e.g., the home page for the most recent printed edition of De Quincey’s book, at http://robertjhmorrison.com/thomas-de-quincey/ ; and the Wikipedia entry for him at https://en.wikipedia.org/wiki/Thomas_De_Quincey .

[9] The Oxford Dictionary of Quotations has a ridiculously shortened version of the original. See Knowles [editor], Oxford  Dictionary of Quotations (6th Edition, 2004) [hereafter, ODQ at __]  at Thomas de Quincy, p. 264, n. 20. “Thou hast the keys of Paradise oh just, subtle and mighty opium.” That reads like someone’s note on a page, next to the real thing, rather than a genuine effort to reflect the original.

[10] See Opium Eaters at Preliminary Confessions, p. 5.

[11] See Opium Eaters at Preliminary Confessions, p. 4.

[12] Id.

[13] See Opium Eater at Preliminary Confessions, p. 4-5

[14] See Opium Eaters at Part II, June 1819, p. 46

[15] See Opium Eaters at Part II, June 1819, p. 46

The easiest, most effective step that the federal and state governments can take to stem the tide of deaths from opioid overdoses is to make naloxone easier to get …”

Megan McLemore of Human Rights Watch, as quoted in The Lancet[1]

 

[This is G. Sallust again. It’s said that more than 90 Americans die every day from opioid overdose.[2] That simple fact makes opioids truly blog-worthy, and worth an update, so I asked for volunteers to do the job.  Unfortunately I didn’t get any. Instead my loyal staff told me to write it myself. This isn’t a democracy; but everybody here is a volunteer, so I have to listen when they yell at me. And this time they made a good case.

It’s true that I’m uniquely qualified to talk about opioids. And no, that’s not because I’m a heroin addict. Actually I don’t take anything unless it’s prescribed by a doctor, and I especially I don’t like pain killers, no matter who wants me to take them, because they make us stupid.  I’m qualified because I (i) live in a rural area that has a horrible problem with opioids and (ii) am morally offended by the situation.

Actually they didn’t say it that way. Fred says I’m loud and abrasive, and an attention-getter, and that’s what’s needed. Phil says I often sound reasonable, even when I’m not, and that might help with some readers, the ones who are not too far gone in politics. And Larry, bless his heart, says that I can be persuasive when I stick to the facts, which isn’t always the case, and if I do that I might do a passable job. All of them had other pressing business, and none of them wanted to get involved. I call that mutiny, thinly disguised.

So I’m writing this myself. And speaking of politics, which I just did, let’s start by saying that in my opinion Donald J. Trump, is not responsible for the opioid epidemic. He’s been President only since January 20, 2017[3];  and the problem predates him by several years. Of course, the same could have been said of Barrack Obama, when he first took office in 2009. The economy had collapsed in the second half of 2008, and threatened to go belly-up. That pretty much gave the election of 2008 to the Democrats. Conservative pundits then argued that Obama, who wasn’t President at the time, was actually responsible for the 2008 crash, because the mere fact that he might be elected had upset the market. A few months later they followed up by complaining that the recovery was taking too long.

Well, that was then and this is now, and today we’re talking about crimes, the criminal law and public health, not about the economy. So far no one has blamed Trump for the opioid problem, but they will. At some point the loyal opposition is going to start asking why President Trump hasn’t done more to solve it. But before we go down that road, it might be best to take a look at where we are, medically speaking, in the battle to restrict opioids. Luckily there are a couple of recent articles, one in The Lancet[4] and the other in the New England Journal of Medicine[5], to help us understand the situation.]

The Lancet Says

Let’s take first things first. Heroin is an opioid, as are morphine, opium, and various synthetics, such as fentanyl and its numerous cousins.[6] One can overdose on any of these, but it’s more likely with street drugs because those are frequently mixed with one variety or another of fentanyl. Some versions of fentanyl (I don’t know how many) are extremely potent, and can kill with very, very small quantities. So if a dealer is an amateur, he can easily kill a lot of people.

Naloxone is an antidote that reverses the effect of overdose. (In my neighborhood it’s also called Narcan.) Many jurisdictions are equipping their first responders with it, so that they can treat an overdose on the spot, rather than cart the victim off to an ER. That’s a good thing, because [apparently] it saves lives. But that doesn’t necessarily reduce the addiction rate. In fact, one can speculate that the more addicts survive overdose, and if new addicts continue to enter the population at the usual rate [whatever that is], the total number of addicts will grow over time. And as the numbers increase, the addiction rate will as well.

So that brings us to the bigger problem: How do we, in the U.S., treat addicts to reduce their numbers? Well, the Administration resolved to study the matter, which sounds like a good idea, and interim recommendations are due the 27th of this month. That sounds like something we ought to read. In the meantime The Lancet reports that a policy is beginning to emerge. So far –

  • The president’s budget for the next fiscal year (FY 2018) calls for a $279.7 million increase in funding for drug control efforts;
  • That includes a $103 million increase to the Department of Justice’s budget to “fight against opioids and other illicit drugs”.
  • Last March, the new Attorney General said “we need to focus on…preventing people from ever taking drugs in the first place”. On May 13 he ordered federal prosecutors to utilize mandatory minimum sentencing for heroin offenses. This would “prescribe that possessing any amount of heroin would be a minimum fine of $1000 and 1 year in prison.”[7]

So far none of those initiatives sound like slam-dunk wins. Do they?

Then, of course, there are the current Congressional efforts to repeal and replace Obamacare. That effort, if successful, might throw many of the addicted into the ranks of the uninsured. “The American Society of Addiction Medicine, a professional society of physicians, warned that [if so] a ‘critical lifeline for people with addiction’ would be severed.”[8] That’s interesting, but speculative. So far Congress hasn’t really done anything. I’m going to wait until there’s actual legislation on the table before I start an argument.

Science from the NEJM

OK, from what little we know of President Trump’s program, he doesn’t seem to be counting on any scientific breakthroughs to solve the opioid problem. How about the scientists? What do they think? Well, the National Institutes of Health say that since April of this year they have been working with pharmaceutical industry in three important areas:

  • Overdose Treatment. Naloxone is good, and has saved lives, but other, more effective overdose treatments are possible. The NIH/ industry objective is to develop “better overdose-reversal and prevention” therapies[9];
  • Curing Addicts. Currently “sustained treatment over years or even a lifetime is often necessary to achieve and maintain long-term recovery.” There are only three medications available for treating Opioid Use Disorder. These are methadone, buprenorphine and extended-release naltrexone. We need more and better medicines in this area.[10]
  • Managing Pain. For many, addiction starts with opioids prescribed by a doctor to relieve chronic pain. If we develop “safe, effective, non-addictive interventions” to deal with pain, we can greatly restrict the use of opioids in medical practice. That should reduce the rate of addiction as well.[11]

The NIH expect “some advances” may occur rapidly, “such as such as improved formulations of existing medications, opioids with abuse-deterrent properties, longer-acting overdose-reversal drugs, and the repurposing of treatments approved for other conditions.[12]” Others may take longer. Nevertheless, the goal “is to cut in half the time typically required to develop new safe and effective therapeutics.”[13]

Conclusion

To date the new Administration seems to have focused primarily on law enforcement to control the opioid crisis. That’s short-sighted. Addiction is a problem for doctors and scientists, as well for the police. I’m not in a position to judge the validity of the initiatives the National Institutes of Health have proposed, but they are our experts; so perhaps we should fund their initiatives, or over-fund them if necessary, to see what they can do for us. The problem with addicts is that they’re, well, addicted. There’s no talking them out of their addiction, and locking them up doesn’t seem to be helpful. Speaking for the public, we need a damned cure!

[1] See The Lancet, Reinl, Trump administration and the opioid epidemic in the USA (June 17, 2017), available at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31543-X/fulltext?elsca1=etoc (The proper citation for this, I think, is Reinl, Trump & Opioids at 389 World Report 2181 (June 3, 2017). We’ll just call it Trump & Opioids, until someone corrects us. To access this article [apparently] you need to register with The Lancet. Do that [it’s free] and you can download a pdf version.

[2] See New England Journal of Medicine, Volkow & Collins, The Role of Science in Addressing the Opioid Crisis (May 31, 2017), available at http://www.nejm.org/doi/full/10.1056/NEJMsr1706626#t=article There are no page numbers; henceforth we will cite this as Opioid Crisis at __ and reference the § in which the quote appears.

[3] See the President’s inauguration speech at https://www.nytimes.com/video/us/politics/100000004863342/donald-trump-full-inaugural-address-2017.html

[4] See n. 1.

[5] See n. 2.

[6] For a more full discussion of the subject, take a look at the Wikipedia entry at https://en.wikipedia.org/wiki/Opioid .

[7] All quotations are from Trump & Opioids.

[8] Id.

[9] See Opioid Crisis at Overdose-Reversal Interventions.

[10] See Opioid Crisis at Treatments for Opioid Addiction.

[11] See Opioid Crisis at Nonaddictive Treatments for Chronic Pain .

[12] See Opioid Crisis at Public-Private Partnerships.

[13] Id.