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The Axis of Suffering

Why is it so difficult to stop using heroin? Why is OxyContin now a leading scourge among young people in this country? Why is it said that one pill or one shot of or heroin can instantly make an addict? It turns out that none of these things is true, except the growing rate of OxyContin use in America. Heroin is not a devil drug but there is a good reason they can easily become an addiction. Before we address why these problems are so persistent, let’s take a closer look at the biochemistry of opiates.

Most people think opiates (drugs based on the opium poppy) work on pain. They are often called painkillers, but no, they don’t actually kill pain at all. The chemicals extracted from the opium poppy and others modified in chemistry labs to be even more potent, work to relieve suffering. The effect of these chemicals is to reduce the sensation of anxiety and distress that accompany pain.

Pain is a primitive signal of tissue injury or damage. Emotional pain can feel similarly distressing without the requirement for injury to the body. Some say it is a signal of damage or distress to either one’s social connections or to the self. If you want to relieve physical pain, the most effective medication is a local anesthetic. You’ve experienced this, probably, at the dentist office. Or if you’ve ever had a cut sewn by a doctor or nurse then you have probably received a small dose of local anesthetic. If you have had a cavity filled then you almost certainly have.

Block the signal

Lidocaine is a common example of a local anesthetic drug; Novocain is an older example that works the same way. In fact, many operations can be conducted on various parts of the body using only local anesthesia. Carpal tunnel surgery, a procedure to relieve nerve pressure in the wrist, can be done simply with local anesthesia. Local anesthetic blocks nerve conduction. The information regarding the tissue damage never reaches the brain. It never even reaches the spinal cord in the wrist example. In the case of an epidural or spinal anesthetic, the signal transmission is interrupted in the spinal cord. When the medication wears off the information flows again. Ouch.

As an anesthesiologist, I would not typically recommend having operation even of this small scale with only local anesthetic. The expected anxiety and distress caused by having a surgeon working on your hand while you’re awake in the operating room is usually more than people can bear. This gets to the heart of the matter of what opiates do. If you were to receive a small dose of opiate medication, along with the local anesthetic and the rest operation would probably go much more smoothly and you would be relaxed. You can see from this scenario that the opiates do not work on painting but they work on suffering and distress.

When people come in with an addiction to opiate medications, they report severe discomfort during the withdrawal process. Their symptoms are usually diffuse in character, and spread throughout the whole body. The two worst things that people describe are the inability to sleep, and the sense of dread or impending doom. They are literally in agony of the kind that isn’t physical. If you ask a person until they withdraw to pinpoint source of discomfort they can’t. It is a big all-over-terrible-feeling that is made worse primarily because it can’t be pinned down. Sure they complained of backaches and headaches and nausea and diarrhea but the real problem isn’t in the body – it is in the mind.

All pain occurs in the brain

If you were to touch a hot flame it would feel to you like the pain was obviously in your hand. But the perception of pain, the actual awareness of the sensation is not in the hand at all. The nerves carried information about the arm to the spinal cord and into the brain. The message goes past an area in the brain called the thalamus and onward toward a specific area of the brain responsible for tracking sensation in the hand. Finally, after thalamic tweaking it goes onto the forebrain for analysis and judgment.

The forebrain is the critical thinking and analytics center. That’s the part of brain that actually does the deciding. When you pull your arm away from the hot flame, before the brain sends a message over to the motor part of the brain causing your muscles to contract away from the fire, the forebrain makes the call. This acute pain analysis is accomplished in milliseconds. Nearly at the same time the brain releases powerful chemicals that have been engineered over millions of years to reduce your suffering.

These are called endorphins. They are literally “the morphine within.” Effect of endorphins is primarily on the brain itself. Specifically, they act quite a bit on the analytic and judgment centers. Now, imagine that you were not burned at all (isn’t that better?) Instead imagine that you have been taking opiate medications. These drugs work on the same receptors –tiny switches on the surface of a cell that control activity of that cell- as the endorphins. Opiates reduce suffering of all kinds.  A patient of mine once said that a Vicodin made folding the laundry bearable.

Opiates are especially good at reducing the sense of helplessness and lack of control that person might have especially with emotional pain. The nerves in the brain adapt very quickly to the super high levels of molecules addicts ingest. These receptors become saturated and reduce their sensitivity to the fake endorphins. The brain becomes so adapted that in short order it requires the presence of these chemicals in order to function normally.

Now let’s take them away. Welcome to rehab. The feeling of lack of opiates is not pain. It is suffering. Ordinary events of life in the relative absence of these natural or unnaturally occurring chemicals are perceived as tremendously uncomfortable and agony producing.

No wonder it’s so difficult to stop opiates. The body has two distinct pain sensing systems. One of them is the peripheral nervous system, all the nerves in the body that map to a specific area. The other system is much more vague and diffuse. The opiates worked relief pain on this somatic system, and during the time that the receptors are reorganizing back to new lower levels of opiates, whether endogenous or exogenous, the person will suffer.  A patient in severe methodone withdrawal once reported to me “my sweat feels like it has thorns.” That’s suffering.

It is very rare for a person to die from opiate withdrawal. Sometimes if they are otherwise in very bad health a heart attack, stroke or severe dehydration from vomiting and diarrhea can occur. Far more likely is the person will give up the quest for sobriety because the suffering is too great. Relapse back to opiates is extremely dangerous because the addict is often “opiate naïve” again and overdose is much more likely.

There are many other ways to relive suffering than trying to chemically alter the brain and mind. Simply connecting with a friend and remembering that withdrawal is a transition can dramatically cut the agony. Eventually the nerves will reset and the lack of opiates won’t be painful. You will have joy again, this time it will be authentic. Pain is unavoidable but suffering is optional.