It strikes me that calling trends in opiate dependency and polypharmacy overdose deaths an “opiate epidemic” is a misnomer, akin to calling the Industrial Revolution an epidemic. While the term may effectively rivet pubic attention on the problem, characterizing the drug dependency and overdose crisis an “epidemic” undermines a deeper public understanding of it.

An epidemic is often sparked by a newly emerged infectious disease, usually a bacteria or virus. As such, mitigations are usually focused on the single agent that is placing communities at risk. Effective initial solutions may include the isolation of infected individuals, so they do not expose the general population to risk of infection. Or perhaps a vaccine to prevent infection or an antibiotic to treat those who are already infected. On the other hand, it is virtually impossible to isolate our populations from the knowledge of and exposure to pain relievers, and because drug dependency evolves over a lifetime, simple solutions are elusive.

The newly emerging threat in an epidemic is external to society. In contrast, like the Industrial Revolution, the drivers of drug dependency and overdoses are intrinsic to the evolving structure of society. The causes are complex and are, at least initially, deliberate. Research confirms that socioeconomic and educational disparity, unemployment, global policies, cultural incongruity and a health care system that is focused too much on profit have all been major contributors to the evolving problem over the past century.

This raises the question of timeline. As the years and decades pile up, it begins to become apparent that many of the trends we see have occurred before. Before your next breath, note that this is not cause – nor call for – despair. But it does remind us to learn from past experience and past mistakes, if not by our own generation then by earlier ones. From Prohibition in the 1920s, to the Rolling Stones Mothers Little Helper in the ‘60s, to crack cocaine in the urban U.S. in the ‘80s, to methamphetamine in the ‘90s, and now prescription and non-prescription pain relievers and opiates, the trend has been indolent and relentless over generations.

Because the drug dependency and overdose problem is imbedded in our social fabric, the solution is necessarily complex. To make criminal justice interventions the only solution to the drug dependency and overdose crisis would be like building a more robust fire department in response to climate change. Both strategies are destined to fail unless vigorously partnered with public health research and interventions that work upstream to limit the factors that incubate criminal behavior and modify human behaviors that contribute to climate change.

©January 2008

Snowfall has a captivating ability to slow us down.  Some of this effect is surely mediated by an interest in self-preservation while driving in traffic on snowy roads, but some of the effect seems almost metaphysical, more closely related to the silent fascination that we have with those snowy scenes in a freshly shaken glass ball.  To a person experiencing a snow day, the satisfying therapeutic effects of slowing down is hard to ignore.  Why then do we find ourselves in a society so hopelessly dependent upon caffeine?  In light of recent research that raises new questions about the safety of caffeine, it may be worthwhile to wipe frost from the window for a clearer look.

Coffee, along with the oil industry, has historically been one of the greatest contributors to our trade deficit with the rest of the world.  The average American consumes almost 8 pounds of coffee per year.  If there is any question about the adulation bestowed upon caffeine, consider the burgeoning “energy drink” industry.  With names such as “Full Throttle,” “No Fear,” “Rockstar,” “Monster,” “Red Bull” and “Adrenalin Rush,” one might think we have entered the world of  Pinocchio’s “Pleasure Island.”  If any message floats to the surface, it ought to be an appeal for moderation.

An impressive amount of research has been done to explore the risks of caffeine consumption.  Judging from the data, “excess coffee consumption” can be defined as over three cups of regular coffee, or approximately 300 mg of caffeine per day for an average adult.  However, it should be remembered that each patient has a different tolerance to the negative effects, such that for certain individuals even one cup of coffee, or 80 to 100 mg of caffeine, may be too much.  One ounce of espresso contains approximately 65 mg of caffeine, and, contrary to popular intuition, dark coffee usually yields less caffeine because of the effects of increased roasting of the beans.  Tea contains about half as much caffeine per cup of caffeine-bearing tea.

Caffeine is a stimulant, closely related to a number of medications and mediators in our bodies that modify our cellular “carburetors” to increase the rate at which we burn fuel.

The dangers of excessive use of caffeine to people with heart rhythm abnormalities, to pregnant patients and to people with sleep and anxiety disorders are well documented.  The occasionally head-splitting consequence of caffeine withdrawal when a regular coffee devotee abstains is convincing evidence that our bodies quickly learn to mourn the loss of a regular caffeine dose.  The effects of caffeine on increasing blood pressure have been inconsistent but probably also significant.  Recent studies have raised new questions about the safety to diabetics, and medication interactions abound.

Because of it’s effect upon appetite and activity levels, caffeine is a common component of diet or “weight loss” tablets.  The tendency for companies to present caffeine-rich tablets and beverages as some sort of healthy way to achieve a performance “boost” is both deceitful and misleading.  Such a solution is no more healthy than applying additional pressure to the accelerator in the car without regard to need.

The bottom line is that we live in an over-caffeinated society.  In the interest of full disclosure, regular sips of coffee on this snowy morning have accompanied the recording of ruminations in this column.  Nevertheless, the risks of allowing the triad of social trend, corporate capability and marketing expertise to propel us towards over-consumption of caffeine-rich beverages and over-the-counter medications only makes the need for deliberate personal moderation all the more important.  If you have any doubts about the benefits of taking the world a little slower, take a few moments to absorb the silence that follows a fresh snow.

©April 2008

Perhaps the most important part of practicing medicine is to gain the capacity to see through your patient’s eyes.  To fully comprehend the experience of a patient as expressed in a chief complaint is often the most important clue to a diagnosis, no matter whether the goal is to understand the subtle characteristics of pain, to visualize a rash according to the patient’s description, to empathize with the distress of a spouse during a partner’s illness, or to anticipate the reluctance of a patient to take a medication as prescribed.  It is for this reason that the words of a patient are necessarily accepted, at least initially, as a basic truth.   But it is not often recognized how destructive it can be when a health care provider is deceived, either purposefully or inadvertently, about the best interests of the patient.  Perhaps the most serious example of the breakdown of the physician-patient relationship is the abuse of prescription drugs and the temptation to over-prescribe medications designed to relieve suffering.

First, it is important to emphasize that the recognition and treatment of pain is a critical responsibility of physicians and providers.  In 2001, California passed a law requiring all physicians to receive 12 hours of pain management education because of a perception that there was a gap in general knowledge of the subject.  However, since that time there has been a well-recognized increase in prescription drug abuse paralleled by an unprecedented increase in the prescribing of narcotics.

Pain is actually our friend.  It turns out that when the first protozoan recoiled from a hot object, the nervous system was born.  Responding to noxious stimuli only requires the memory of this event to inspire learning.  As memories of positive and negative experiences accumulate, the capacity to understand Shakespeare is only a few million years away.

A complex nervous system is designed not only to pull the strings that operate our machinery, but also to protect our bodies from injury.  Several disorders can cause individuals to lose the capacity to experience pain.  The end results of such conditions include joint destruction, bed sores, and infections, any of which can be life-threatening.  Indeed, there are many maladies that one should prefer to the loss of the ability to experience pain.

Prescription drug abuse is only encouraged by technological progress that has made it possible to both mass produce and market pharmaceuticals.  Every culture on earth has discovered substances that either relieve suffering or provide temporary pleasure.  If there is any doubt about the capacity of substances to place the brain on autopilot, simply observe a cat indulging in a patch of catnip.  In the past, pharmaceutical production was limited by the ability of farmers to grow and harvest poppies, plants and the like.  However, it is relatively recently that synthetic narcotics have become available in a wide array of doses, formulations and colors to pharmacies throughout virtually every corner of every community in the country.

Except for marijuana, tobacco and alcohol, prescription narcotics are now the most commonly abused drug in the local student population.  Most of these either come from prescriptions that have been diverted from the intended user, or are “extra” medications that were salvaged from previous prescriptions.

Tuolumne County had the second highest rate of drug-induced deaths in California during the period 2003 to 2005.  We simply must begin the process of re-educating ourselves and future generations to be comfortable with the idea of sometimes being uncomfortable.  While we must validate and treat pain when it is a part of illness, we must not substitute the illness of an anesthetized society for pain – both physical and mental anguish – that is serving a healthy purpose.

©May 2008

Keeping waste separate from sources of drinking water has been a practice of civilizations throughout recorded history.  Before we bashfully attribute this behavior to our scientific brilliance and responsible environmental stewardship, we must recognize that cautious sewage management is not unique to humans.  The ease with which cats and dogs can be house trained suggests that cautious handling of waste has somehow been hard wired into our lesser companions.  Even raccoons are known to maintain “latrines” in a location separate from food and water sources.  However, commercial medications pose a new challenge to safe disposal of sewage.  Our septic system technology has not been designed to remove many pharmaceuticals from our sewage stream.  We are told not to dispose of unused medications down the toilet or drain, but at the same time we find medicine cabinets engorged with unused and potentially dangerous medicines.  How do we safely dispose of old drugs and unused narcotics?

This problem is more than just a nuisance.  Prescription drug misuse is now the fourth most common form of substance abuse, following tobacco, alcohol and marijuana.  Prescription narcotics create the illusion of safety because of their legitimate use in health care.  While the benefits of pain relief to patients suffering from illnesses can not be overstated, pharmaceutical products come in a wide variety of doses and drug delivery systems which can be as dangerous as a firearm in the hands of an untrained person.  Deaths occur every year in our communities as a result of unexpected effects of prescription medications when they are not used in accordance with their intended purpose.

It should also be pointed out that the greatest contribution of drug contamination to our sewage stream is not from inappropriate disposal of medications down the drain, but rather from the medications that pass through our own kidneys.  It is more than a little exasperating to consider that a good portion of your pharmaceutical co-payment ends up going right into the plumbing fixtures after a quick trip through your personal subway system.

Back to the point.  Now is a good time to go through your medicine cabinet to locate unused or old medications in order to avoid the potential dangers they pose.  Check expiration dates and remove those which have expired.  Remove those which have been discontinued, or which were prescribed when you were pregnant with your college-aged son or daughter.  Remove those with the name of relatives who are memorialized on the trunk of your family tree.

Medications, except for controlled substances like narcotics and tranquilizers, can be discarded during community Hazardous Waste Collection campaigns.  Information is usually available from local Environmental Health offices or from your local sheriff or law enforcement agency.

There are currently insufficient provisions in the United States for the disposal of unused prescription narcotics, tranquilizers and stimulants.  Law enforcement agencies are currently the only legal entities that can receive controlled prescription medications for disposal, but such drug disposal programs are not currently funded.  Nevertheless, efforts are now underway to provide residents with other options.

Until then, it is important that unused prescription medications either be discarded during local hazardous waste collection campaigns, or, for controlled medications like narcotics, stored safely in a secure location where they cannot be diverted for misuse and abuse.  If you have a specific challenge relating to the disposal of controlled substances, you may call your local health department or law enforcement agency for advice.