What is the relationship between pain relief, stimulation of the reward-reinforcement circuit, and play and pleasure-seeking? Which of the three, or what combination leads to addiction? We explore the question, and look at some of the history including the way we have increasingly given opioids for chronic pain, only to see the pain not get better – but worse! This leads us to the various issues around treatment – highly functional, highly paid execs who are just resigned to addiction because the tradeoffs for treatment would be so high. And related – the reality show that masquerades as treatment – Dr Drew Pinsky’s Celebrity Rehab. We consider the latest death – the fifth – among the regulars on this reality show, and the way the show contradicts traditional ideas of treatment, especially anonymity and the way that the shame and guilt that addicts often suffer is exploited for entertainment value.
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Transcript (edited):
HOWARD: Welcome to the CNS Podcast featuring Dr. Darryl Inaba, research director for CNS Productions, I am Howard LaMere. There are many topics in the news this week so it is going to be a potpourri. I noticed another story about pill addiction by executives, highly functioning, high income, folks that become addicted, usually it seems, because of an incident involving pain. This is so common that it makes me ask about pain versus the reward system versus the play aspect of drug use. So, let me lead with a slightly off the wall question, Darryl what do you believe the inner relationship between the three things are?
DARRYL: Actually thats a good question, Howard, its something we’ve talked about in several podcasts and something thats becoming more discussed in the field. The axis between pain and addiction and how that intersects involves pain and the relief from that pain as a result of a strong opiate or a potentially strong addictive drug I still believe that those are two separate things. Pain is a signal that you need to take care of something that is damaged and needs repair. But pain – even chronic pain is not something a person is meant to continue to suffer. And what is clear is that when somebody takes an addiction substance, like an opiate, Vicodin, Oxycontin, morphine, or whatever, they get such positive relief that it goes beyond the relief of pain best described as a euphoria. Maybe euphoria is just a simple release or relief of pain – physical or emotional. One of the early studies that confirmed that for me involved the medication propoxyphene which is no longer being offered in the United States. Darvon, a pain killer, was studied in the laboratory and found not to relieve that much pain. It didn’t really ease pain, but when the astronauts were asked which pain killer they wanted to take with them on the first trip to the moon, they overwhelmingly picked Darvon. So, why would they pick something that isn’t very good at relieving pain? Well, the reality is Darvon really makes you feel good. It actually produces a better euphoria or feeling of well-being and therefore, I was wrong. Its not used for the relief of pain, but for another different feeling all in itself. We’ve had opiate addicts who were in long-term recovery and developed some sort of carcinoma or some chronic pain situation and were worried about it. In one case, the person needed relief for his pain so he took his prescription and within less than a week, he found himself saving up his pills in order to experience the euphoria rather than take them for the relief of pain. He was willing to put up with the pain so he could collect enough pills to take them all at once to experience the euphoria and found himself relapsing to mainstream addiction for opiates. So, addiction and pain sort of start off hand and hand, but quickly they turn into different things. Addiction is way beyond the experience of pain and addicts are willing to endure pain in order to experience the euphoria delivered by the opiates. The other big thing we’ve often talk about here and the focus of many recent conferences chronic pain and the management of chronic pain. Treating chronic pain with opiates is contraindicated. They don’t continue to relieve the pain. They initially provide relief but if pain gets worse and worse you don’t heal from it. You actually start suffering pain as a result of a chronic reliance on opiates. So, therefore, there is a difference and I think that within the treatment field, within the addicts themselves and within medicine, were just now beginning to understand that nexus between pain and euphoria and addiction. How can we help people and be compassionate so that they don’t suffer pain, but at the same time, not make things worse. You don’t give something that will make things worse. You’ve got to seek all of the different alternatives that are being developed especially non-opiate treatments for pain.
HOWARD: The story that I mentioned about high functioning pill addicts is from CBS News … a clinical director that was interviewed as part of the story said, “you know, I cant, in good conscience as an academic and a researcher, accept the notion that we have 3 times or more pain than we did 20 years ago. I mean, theres something different at work here.” I thought that was interesting.
DARRYL: Well, there may be an explanation …we are now in an era of compassionate treatment for pain, so freely give out pain pills to people we consider to have chronic pain. But with
HOWARD: ..the quote from the article is “theres no accountability.” He just calls up his doc the doc says okay, writes a prescription or calls the pharmacy, he goes to the pharmacy. There are none of the checks and balances.
DARRYL: Well, thats all coming to a halt. Do people with chronic pain want to continue to satisfy the need for that sense of well-being or are they going to really treat their pain.
HOWARD: It is all across the country.
DARRYL: Yes..and we cant allow this to happen. The number of deaths from prescription opiates, the number of addiction, the number of problems
HOWARD: Very high, yeah.
DARRYL: And so now there is more scrutiny and monitoring of pain medications and prescription drug addictions and .every state seems to be computerizing the information so anybody who gets a prescription for any of these addictable opioid substances will be tracked to see how many and who is prescribing their pills. This is to eliminate a person’s diversion of prescription drugs for their own addictive use. And, of course, the unintended consequences of that, in terms of younger people is that they’re turning to illicit opiates in order to feed their addiction. But this is all coming to a head along with our understanding of more effective treatment of pain and I hope the more effective treatment of pain actually wins out quicker than increasing the scrutiny of people who are on pain medications.
HOWARD: Another thing I mentioned earlier is the introductory phase, the curiosity, the..something to do for fun… which is how a lot of drug experimentation starts for many people. In the context of pain pills at least in the very early stages is the sense of doing something for fun – how do you see that playing out?
DARRYL: Actually it is a bit more complicated because there’s an element of therapeutics involved, an element of people believing that what they’re doing is correct medically. They’re seeking a doctor’s advice, getting a prescription because it is therapeutic. When they take the medication and experience the euphoria or experience the feeling of well being things can get muddled up. Some look at it less as a therapeutic thing and more like recreation or play or a get high thing. And, if they are prone to such things because of genetics or circumstances, that feeling of well being is more positive than the actual pain relief. When people chose Darvon over morphine or anything else, it is a pure indicator of that. Its that feeling of well being that does distract you from the pain youre suffering, but its a separate entity than pain relief and thats important for people to realize.
HOWARD: Yes and I think its important to make the connection that they’re all linked and interwoven in a complex way. Some of the other stories this week include news of another death related to Dr. Drew’s program the country singer that recently died, committed suicide, and she was also on Dr. Drew’s show, so I guess Dr. Drew made a statement because people have been kind of taking it out on him, asking whats really going on with your show here?
DARRYL: Well, as we discussed a few weeks back ..its time to pull the plug on Dr. Drew Pinsky and in many ways I feel thats correct. Mindy McCready died recently and she had been on his show – she is the fifth person who was on his celebrity rehab show to die. He is actually correct with the statement that we have to make to all of our clients who come into treatment, that addiction is a fatal disease. Its going to kill you if you don’t do something about it, if you don’t get yourself in rigorous treatment, you’re not going to win. And one of the outcomes of being an addict is death and it happens all the time. People complete a treatment program and go off and die within the year. He is saying that reality does exist – that death is a consequence of having the disease of addiction. Now whether the rate of people appearing on his show and then dying is higher than the rates for people who have completed treatment within the same period of time, I kind of think it is. I kind of think it has to do with his show its primary thing is exploitation. Its really not about portraying good treatment. Its not about being effective for people. Its not trying to be
HOWARD: Right. Its entertainment.
DARRYL: Yes, maybe it is attempting a noble mission but the bottom line – its entertainment and that is totally different from what we seek to do when we open a rehab center and try to treat people. The other thing about it is that you have this whole, I guess, bedrock belief in addiction treatment that sets forth that addiction treatment should be anonymous. There should be anonymity. We shouldn’t exposed people because the severity of this condition has catastrophic consequences on the lives of these people – they have deep shame, deep guilt, tremendous pride, depression problems that already push them to the brink of suicide. A good portion of clients entering treatment are depressed and suicidal and a good number of them have already tried suicide, so you don’t want to expose them to any more trauma that could cause them to go over the brink, I don’t see that protection happening on TV shows at all.
HOWARD: In spite of the fact that they are celebrities and are used to and seek that that notoriety what can be furthest from anonymous than being on a reality TV show.
DARRYL: And theres a problem with that too, Howard. A celebrity wants notoriety to show themselves to the world. If they’re an actor, they want to show that. If they’re a sports star, thats what they want to be known. They don’t want to be known for something that they want to hide from the world and addiction is a very stigmatized and very embarrassing situation.
HOWARD: So this type of exposure introduces the shame aspect which is already present by virtue of the fact that these individuals know they’re addicted and are attempting treatment. Seems like these shows just exacerbate it. Personally, I have some problems .with the concept.
DARRYL: I also have a lot of problems with the concept and I didn’t like some of the things that Dr. Pinsky said. While defending his show, he said that Ms. McCready was doing okay until the death of one of her significant others, the father of her son and she spiraled into depression…she should have done this and she should have done that. Well, I have a problem with that because he lays it all on her whereas in treatment, its part of our responsibility to make sure the people we are treating understand what the resources are and are able to link up with them. The problem with a celebrity rehab show is – the person comes on one time and exposes themselves to the world, without any follow up, without consistent work to resolve a chronic persistent disorder – its a one time..one shot type of thing. That is totally inappropriate and I do think its time to pull the plug on the exploitation of an addicts life.
HOWARD: Well, all of reality TV is a strange version of television that a lot of people find it entertaining. Anything else for this week?
DARRYL: Well, I don’t know if its dynamic, but after the last show where we talked about the woman who was addicted to eating cat fur
HOWARD: Oh right….this weeks strange addiction
DARRYL: I shared that in my group and they told me
HOWARD: Were going to make this a regular feature strange addiction of the week!
DARRYL: Well, they were saying, “Darryl don’t you ever watch TV?” There is a regular program on strange addictions that profile some pretty weird things – talk about exploitation! People who are addicted to eating ice, to eating dirt.people are addicted to tanning, exercise. There are people who have unusual obsessions and have a survival need to do or eat whatever. The good thing that show has done for my clients has been to reinforce the understanding that addiction isn’t about getting high. Its not about getting relief. Its about this compulsivity that starts off in the unconscious portion of the that part of the brain that is out of whack I mean, really – who wants to eat cat fur and stuff like that? Well, as we looked into it with my group, we found out that there are many odd behaviors and some have specialized medical names Trichotillomania is pulling out your hair, and rhinotillexomania is an addiction to picking ones nose! Then theres Automucophagy which is ingesting the mucus from your nose.
HOWARD: And every.every grade school boy has this addiction!
DARRYL: Well it also signifies that the frontal cortex the stop control executive function area of the brain is also involved with addiction, because most kids grow out of that. Theres geophagi, which is eating dirt. Theres xylophagia, compulsion to eating wood. Hyalophagia, is eating glass. There are people who are addicted to cosmetic surgery – addictions are pretty weird things.
HOWARD: Were getting pretty out there.
DARRYL: Alright, alright I’ll stop.
HOWARD: someone was addicted to stinging themselves with bees, she actually carried around bees in her purse.
DARRYL: Wonder what that would be.
HOWARD: Well have to work on the name for that. Anyway.thats all the time we have this week. Thanks for visiting the CNS Podcast. You can drop us a note on our website and please check back soon for the next in the series. www.cnsproductions.com