Wednesday, November 15, 2017

Some Thoughts on Our Addiction Epidemics

Newspapers are full of stories about the U.S.'s opioid epidemic. It's only one of several addiction epidemics that are ravaging the country, although it's the one that is getting the most attention from politicians and the media. The root cause of all these epidemics is profits.

Approximately 10 percent of the population is thought to be predisposed to addiction, from a combination of genetic and early environmental factors. Such persons can become addicted to anything--drugs, food, sex, shopping. Persons without this predisposition can abuse substances, and will develop a physical dependence to a substance with certain chemical properties if they use it regularly enough--but it's a matter of opinion whether these persons can truly be called "addicts." But even if only 10 percent of the population are truly addictive personalities, that's enough, more than enough, to create an epidemic. Since that percentage doesn't change, why do addiction epidemics appear and disappear in societies?

When evaluating any phenomenon, it's important to ask the question "Who benefits?" The current  identified culprit for the opioid epidemic is the pharmaceutical industry. Some states are suing pharmaceutical companies for engaging in allegedly deceptive marketing practices. This may be a valid allegation, and it makes for good politics, but the main culprit is doctors. Medical training includes extensive study of anatomy and physiology. There is no way a licensed M.D. doesn't know that an opioid is addictive. I don't believe for one second that any M.D. was bamboozled by a pharmaceutical company into believing that a new opioid wasn't addictive. Doctors prescribed these pills because they wanted happy consumers.

There are many ways to manage or cure pain--physical therapy, surgery, acupuncture, massage therapy, ergonomics, nutritional counseling to lose weight and yes, psychotherapy (because mental pain increases physical pain). But there's an old saying, "If your only tool is a hammer, every problem looks like a nail." Only M.D.s and a couple of other professions are licensed to prescribe pills, so that is what they do. They don't do physical therapy or acupuncture, and even among psychiatrists, few do psychotherapy anymore--they leave that job to non-medical therapists, because prescribing pills is more profitable. Primary care physicians and psychiatrists increasingly use only one tool--pills.

A good primary care physician refers patients to necessary adjunctive treatments, but many do not do these referrals, partly because insurance often doesn't pay for them, but also because many doctors want to believe that what they do is the "real" treatment. It's also what is profitable for them.

Opioids aren't the only substance causing an addiction epidemic. There has been a worldwide plague of addiction to benzodiazepines that has flown under the radar because it seemingly has not caused an epidemic of overdoses or crimes. But that's probably because there's no illegal alternative to "benzos." People don't overuse benzos and turn to an injectable street drug because such a drug doesn't exist. They also don't necessarily think of themselves as "high" on benzos. Although a  drug is classifiable as "addictive" based on whether it is likely to cause tolerance and dependence, the general public and perhaps some doctors identify addictive substances by whether they cause a "high." But life experiences can cause "highs." In the field of prescribing, the issue of concern should be whether the substance causes physical tolerance and dependence. What pills am I talking about? Benzodiazepines include Xanax, Klonopin and other commonly prescribed anti-anxiety medications. Other sedating drugs that aren't benzos, such as Ambien, may also induce tolerance and dependence.

A few years back I saw a new patient who appeared "strung out." She denied illegal drug use. I took a look at her list of prescribed medications, and saw that it included daily Xanax. I suggested she talk to her doctor about discontinuing this medication, and she told me that she had done so but that her doctor had advised against it, because, he told her, it would take her a year to taper off the medication. I've learned that this is indeed true, it takes patients months or years to detox/taper off such medications (detox from heroin takes about 8 days in an inpatient facility). Is such use of these medications, originally developed to treat severe anxiety, justified? I do not believe so. Panic disorder is often well-controlled with SSRI anti-depressants or a combination of SSRIs and psychotherapy. SSRIs may become less effective over a very long period of use, but do not create the kind of tolerance and dependence created by controlled substances.

But the worst epidemic of our time is the obesity epidemic. The culprit is the food and beverage industry, and few politicians have the courage to attack this industry. Junk food is more popular than opioids. The media directly benefits from advertising by the food and beverage industry, not from advertising for controlled substances (it may be illegal; I'm not sure). Yet the obesity epidemic kills millions more people than the opioid epidemic.

Other addiction epidemics of our time include video game addiction and online pornography addiction (a subset of sex addiction). The Wall Street Journal and other publications recently reported  about a study that found that a main reason for declining participation in the workforce by young males was video game addiction. Other studies have found evidence for sexual dysfunction caused by online pornography, and there's no question in my mind that online porn has contributed to a general cultural misogyny, stories of which I hear in my practice. I don't see any political crusades against video games or online porn. So far the general public seems to believe that these are harmless activities, and the companies that produce these products--some of which are multinational, powerful corporations--don't appear to answer to anyone.