The Opioid Epidemic: A Clinical Perspective
By Elizabeth Weinberg, MD
Carrie Fisher died at the age of 60 on December 27, 2016. This June, the coroner’s report showed the presence of several different drugs, including cocaine, Ecstasy, and heroin. While it is not known if the drugs contributed to her death, it is plausible to think they could have played some role, and it is clear she had relapsed at some point in her serious opioid addiction. Similarly, the performer, Prince, died in April of 2016 of an accidental overdose of the opioid fentanyl despite having been an outspoken proponent of complete sobriety. According to The New York Times, drug overdoses are now the leading cause of death in adults under 50. Throughout America, individuals, families, and clinicians are struggling to make treatment available to those who need it. Meanwhile, the deaths of successful and wealthy celebrities demonstrate how extraordinarily difficult overcoming opioid addiction can be, as well as making it clear that addiction does not discriminate based on social status or economic means.
For those who have not experienced addiction, it may be difficult to comprehend the strength of the compulsion experienced in an opioid addiction. The American Society of Addiction Medicine recommends that opioid addiction be considered a “chronic brain disease,” best treated by medication. This view of opioid addiction is consistent with recent findings on the action of opioids in the brain, and on changes in the brain with long-term use of opioids. However, this data, in itself, doesn’t tell us what it’s like to be an opioid addict, and it does not entirely explain why people who are not yet addicts begin patterns of habitual opioid misuse or why those who have become sober with or without the use of medications still often relapse. While attention to the neurobiologic correlates of addiction may be useful, treating addiction as a “brain disease” alone threatens to oversimplify the struggles of those who suffer with addictions, and may fail to enhance our understanding of their humanity.
Patients I have known who have had opioid addictions tell me that when they started to use opioids, they felt at peace in ways they never thought possible, that for the first time they felt that they were “okay.” Opioids, of course, relieve physical pain. This is why so many physicians prescribe them. An insidious side-effect of opioids is that they also relieve emotional pain. The experience of abusing opioids can involve an illusion of being able to buy or control happiness. Inevitably, however, this solution breaks down, as regular opioid use leads to tolerance and the inevitable cycle between experiences of intoxication and painful withdrawal. Opioids, particularly intravenous opioids, offer intense, rapid emotional relief as well as euphoria, leading to the potential for the rapid development of an addictive process. Those who are already suffering from emotional difficulties and psychological pain are most vulnerable to this dynamic.
Emotional pain may be the most difficult aspect of the painful experience of opioid withdrawal. In addition to the diarrhea and body aches experienced in withdrawal, there is also an experience of profound dysphoria, of emotional pain, loneliness, and emptiness. The experience of withdrawal triggers the activation of the body’s stress response, which includes the psychological dimension of stress, and also what has been called the “antireward system” – that is, the opposite of experiencing ordinary feelings of reward, happiness, and pleasure that we depend on for a sense of well-being in daily life. Over the long term, opioid withdrawal can be associated with persistent alterations in mood and reaction to emotional situations that can last for months. The opioid addict, then, struggles between the initial experience of blissful relief, followed by prolonged misery during periods of acute or long-term withdrawal.
Caroline Knapp, the accomplished writer and journalist, chronicled her struggle with alcoholism in Drinking: A Love Story. In this memoir, she related the experience of addiction to being in love. It is generally accepted that known addictions occur at least in part through common neurologic pathways that include endogenous opioid systems and dopaminergic reward systems. An interesting, newer theory of addiction is that addiction, perhaps opioid addiction in particular, occurs through the same brain circuits as those that mediate attachment and bonding – in other words, love.
What if loneliness and heartbreak are key vulnerabilities that underlie the opioid crisis? Fragmented families and communities, regions where loss of local industries threaten experiences of belonging, transgenerational transmission of trauma and neglect – perhaps these are the sources of pain for which addicts seek relief. This isn’t to oversimplify the problem, or to let physicians off the hook. It’s clear at this point that well-intended efforts to ease physical pain led to over-prescription of oral opioids, which eventually created a market for illegal opioids, particularly heroin. Moreover, pharmaceutical marketing contributed to the false belief that use of prescribed opioids was unlikely to lead to addiction. There are a range of pathways to addiction, and it would be naive to assume that addiction always is the result of an attempt to manage emotional pain. Nevertheless, it’s not a secret at this point that intravenous opioid use can be life-threatening. Those who run this risk are motivated in part by the inexorable logic of addiction, which often can be initiated through the use of prescribed oral opioids, but also may be motivated by the desire or perceived need to escape from emotional pain. One of the knottiest questions for those of us who work in mental health is how to help our patients and society-at-large engage with emotional pain. As clinicians, we would like to relieve the burden of pain, and sometimes we do help with the management and treatment of physical and emotional distress. Nevertheless, by focusing on the tasks of relieving physical and emotional pain, we may have contributed to the fantasy that it is possible to live a pain-free life through pharmacologic intervention. Recovery from opioid addiction involves, in addition to navigating withdrawal, finding a way to live with messy, painful, human experiences, a task that involves much hard work, patience, and learning, in a context that can support the work that must be done.