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How dangerous is opiate dependence?

Posted Dec 25 2009 8:56pm

I frequently point out the lack of outrage over the epidemic of opiate dependence and the consequence of that epidemic.  I live in ‘middle America,’ and sometimes it seems that everyone I know has some connection to opiate dependence– a relative who is an addict, a friend who died, a parent who is in prison.  My perceptions are admittedly distorted by the work that I do, but I don’t know who has the more accurate perceptions; me or the people who seem surprised to hear that most high school kids know where they could get heroin.  Addicts who I treat who come down from the U.P. of Michigan tell me that heroin is very easy to get up there now, even cheaper than oxycodone.  I guess that’s to be expected, given the horrible economic situation up there.  One thing is certain though– SOME people are making money!  In my part of Wisconsin, oxycodone generally sells for 60-80 cents per milligram;  the average user that I see tries to find one or two ’80’s’ per day, ending up with a habit that costs over $100 per day.  Given the number of people actively using, there is a LOT of money going into someone’s pockets!  Of course much of the oxycodone on the street is bought by insurance coverage and then stolen from grandma’s medicine cabinet by her granddaughter, who replaces them with plain tylenol tablets…  but the herion money is probably leaving town, eventually finding its way back to Chicago.  Sorry, Chicago.  We have to blame SOMEBODY.

Many diseases have prominent celebrities who put on pink ribbons and fight for funding.  Not so for opiate dependence, even though the deaths from opiate dependence must rival those from breast cancer.  I’ll have to look at the numbers.  But celebrity opiate addicts tend to end up like Kurt Cobain or Michael Jackson– or slink off to rehab and later proclaim themselves cured.  Anyone who watches knows that there is no cure for opiate dependence, and the celebrity addicts only go back to rehab again as society goes ‘tsk tsk’.  Society doesn’t say ‘tsk tsk’ when someone’s breast cancer comes back.

I found an interesting web site called ‘informationisbeautiful.net’ where information about a variety of topics is presented in visual form.  Below I have a couple images from the site using data from the UK on deaths from overdose of a number of substances.  The images are relevant to the current discussion, as he compares the death rates to the reports about deaths due to the substances in the National media.  At the web site he discusses data collection;  I won’t make conclusions on the data but rather simply let is provide ‘food for thought.’  After viewing the first image be sure to contine to the next image down.

Opiates have the highest death rate of a range of substances.

In the next image he manipulates the data slightly to add a denominator to the information– he provides the number of deaths per user of the substance.  Again, I will let people truly interested in his findings visit his web site to look into whatever assumptions were made and which data sources were used.  I would like to again leave the data without much comment, in part because I don’t really know how to explain the high rate of fatalities among methadone users.  I will point out that use of methadone in the UK may be quite different than in the US, because in the US the medication is prescribed in two ways– as a cheap opiate for chronic pain management, and as a maintenance agent for opiate dependence.  In the latter case, prescriptions for the medication are regulated very closely (actually ‘prescription’ is not even the right word, as addicts must personally pick up their dose of methadone each morning for at least the early part of their management by a particular clinic).  I should also point out that Heroin is a pain medication in the UK that is prescribed by physicians (as well as a ‘black market’ substance), whereas in the US all Heroin is illegal and cannot be prescribed for ANY indication.  Finally, paracetamol is the Brit’s term for acetominophen, or Tylenol.  The graphic:

Methadone deaths per user lead the pack for deaths from substances in the UK.

I do have a couple final comments.  On other blogs or in response to my videos I sometimes come across remarks by people who are ‘anti-suboxone’ that ‘the problem with treating addicts with buprenorphine is that you then can’t get them off buprenorphine, and you have another problem to deal with’– that the addicts are ‘addicted to buprenorphine.’   I find that argument to be faulty for a couple reasons.  First, ’addiction’ is not so much about the taking of the substance as it is about the obsession with the substance.  An addict who is properly treated with buprenorphine loses the obsession for opiates– something that is amazing to witness at the first follow-up appointment, when the addict sometimes cries over how wonderful it is to be freed from the obsession to use.  So I don’t see buprenorphine as a ‘replacement’, and I don’t see the physical dependence on buprenorphine as ‘addiction’ any more than people taking effexor or propranolol are ‘addicted’ to those medications (which also have withdrawal symtoms of stopped abruptly).   But even beyond that consideration, given the high mortality rate for opiate dependence, when people complain about taking buprenorphine I am always tempted to say ‘compared to what?’   People are DYING from this disease– frankly I don’t CARE if they get dependent on buprenorphine.  I am on the record here over and over with my opinion– that buprenorphine should be a long-term medication.  Use it to keep a person alive during his or her 20’s, and then worry about tapering off– and if the person cannot taper off, so be it!  It beats death.   And any parent of an addict in his or her 20’s knows that a string of ’sober’ treatment centers and repeated relapses is NOT a great life… assuming the person even manages to stay alive.  We are left with comparing the two options of taking buprenorphine and living or avoiding it– and likely dying.   A pretty easy choice to make in my opinion.    I have to wonder what the people making arguments about ‘the problem with buprenorphine’ think about all of the problems with chemotherapy…   if a person’s child develops leukemia, if you treat him with chemotherapy he may end up sterile, and with an increased risk of a different cancer years later.   Would you recommend avoiding using chemotherapy to save his life now?  What’s the difference?

As always I am interested in your comments here and over on the forum .  We’ll talk again in 2010!

JJ

     www.sajithmr.com


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