The Drug War Inquisition

The following is part of a current dialogue on the LISTserve "The Project on Pain and Chemical Dependency" (TPPCD) which, founded by Russell Portenoy MD, is now over 30 years old and until four years ago was supported by Beth Israel Hospital (until it got too politically hot for them.
-----------------------------------------------------------------------------------

On Fri, Jul 31, 2009 at 11:01 PM, Sara wrote:

To all,
While sitting and watching "Cops" and other such shows on TV, I am struck by how much more frequently drug busts these days seem to feature psychostimulants (cocaine and methamphetamine, mainly) and potential anti-anxiety drugs (benzos and pot), with a corresponding decrease in frequency of opioids. You still see plenty of IV heroin and other opioid users, but not many that pop opioid pills. This leads me to wonder about something. We have always speculated about how many opioid users wouldn't use if they just had an adequate amount of opioid for their somatic pain. (Pseudo-addiction) Along that same line, I am wondering how often the illegal use of these two classes of drugs reflects a legitimate medical need for them.

The huge frequency of the anxiety disorders has been well documented for the past 30 years. And still is grossly undertreated, with useless drugs like BuSpar, or inferior ones like the antidepressants, being foisted on the patients for much the same reason that gabapentin, tricyclics, antiseizure drugs and tramadol are dumped onto the pain patients. The safest, surest, most effective drugs --- the benzodiazepines --- are denied due to addiction myths and hysteria.

And even more, I wonder how many people on illegal pschostimulants or cocaine have some form of ADD, narcolepsy, or resistant depression that these drugs actually help. The numbers of such people are far less documented than are the anxiety patients, but their numbers may be just as large.

My wife has a severe anxiety disorder that would leave her in a constant and absolute hell were it not for a combination of SSRI, atypical antipsychotic, and Xanax. (Thank God her metabolism is such that only a tiny dab of Xanax will do the job, enough for her panic-stricken doc to prescribe!) Numerous attempts to wean down any of the three are met with prompt dysfunction, but she functions OK with them. But it has often occurred to me: For all I know, a couple of joints a day might eliminate the need for two of the three. Not that we would dare, but I have to wonder how many other people functioin well for just that reason, as long as their employer doesn't do drug screens.

I would welcome anyone's opinion on this. Joel's perspective as a psychiatrist and Stu's as an addiction specialist would be especially valued, but I'd like to hear from anyone. What percentage of people currently labeled as abusing psychostimulants or pot are actually "pseudo-addicts" just like with pain treatment?
Joe Talley, M. D.

OK. Let me reflect a bit. I have been a psychiatrist for 39 years. I have over 100,000 hours of clinical experience. I have treated approximately 10,000 patients (in and out-patient) and 4,000 intractable pain patients. So, how many patients have I seen with:

1. opioid (for pain treatment) induced addictions
2. benzodiazepine addiction
3. cannabis addiction

The answers are:

1. 0 I have seen hundreds of patients who came to me for opioid addiction (mainly heroin) who were not pain patients (methadone candidates in the 70's, 80's and 90's, now Suboxone candidates). But I have NEVER seen a patient who developed an addictive disorder from taking opioids for pain. I understand this because the pain perception mechanism lies in the periaqueductal grey area of the brain and pleasure is mediated in the nucleus accumens. Apparently the neurophysiology is very different. Stimulating pleasure by exogenous opioids requires dose escalation at the nucleus accumens. Controlling pain at the P.A.G. does not. Once you reach containment the patients remain stable in dose and schedule for decades (unless the underlying pathology becomes significantly worse or the patient does things that aggravate the pain).I have followed 204 cases now for over a decade whose data absolutely demonstrates this.

Footnote: If Mr. Craig Dietrich will ever finish his commitment to
analyze the data and complete our manuscript I will have a ground-
breaking,peer-reviewable article to establish this once and forever.Craig
works at a major hospital here in Houston. His employment contract
states that he cannot do research or analytical work for anyone else.
They insisted on reading the manuscript and then told him if he published
it he would be fired. He has repeatedly promised to bring me the finished
m.s.and all the data and reference material I have sent him. To date
he has not done this. I am having a fit.

2. 1 When I was doing in-patient psychiatric medicine I once got a patient
through an emergency commitment who was strung out on benzos (Xanax 6 to 8 mg/day). It took about a week to resolve the case by officially diagnosing his Anxiety and Panic disorder, migrating him to a longer-acting drug, Klonopin, and initiating an effective anti-depressant treatment. I followed him for four years afterward and he never had another problem.

3. 0 I have seen hundreds (if not thousands now) of patients who experimented
with cannabis, smoked it regularly when they were younger, or continued to use it for decades. The results of a five year study I ran at UCLA were published in my book, "Marijuana and Social Evolution" (Prentice-Hall, which is still available on Amazon.com) reviews the extensive data developed in this multi-million dollar NIMH sponsored study at UCLA.) It destroyed my academic career, for which I have been eternally grateful.

As my data analysis of the Drug Czar's (and the FDAS's) own data on the "epidemic of drug diversion and abuse" demonstrates beyond any rational doubt, all this current brouhaha about "drugs" is a pile of you know what. It serves the vested interests of politicians, law enforcement, right-wing ideologues, troglydyte Board of Medicine members, judicial-correctional-legislature entrepeneurs. Michael Jackson was, statistically speaking, about four standard deviations outside the norm in the bell-shaped curve of human behavior. But, of course, all the above will attempt to use his sad life as evidence to support their cynical and/or self-deluded hysteria. All we can do is sit patiently in the middle of the riot and keep repeating our mantra - "two plus two is four. It is not six or 104. It is four." Of course we run the risk of being burned at the stake, because truth, rationality and reason are not popular in Inquisitions (ask Gallileo).
JSH