THE DARK SIDE OF PRESCRIPTION DRUGS
"I lost everything when the police raided my house looking for prescription drugs. My husband and two little children were home that night. I was so ashamed I couldn't even look at them. I was arrested, put in handcuffs and locked up. My husband divorced me. My children were taken away from me. I knew I had hit bottom."
Sylvia* is a 44 year-old radiologist, former president of the PTA, and prescription drug addict.
An Invisible Epidemic
A great deal has been written about alcoholism and drug addiction over the last two decades. However, information regarding prescription drug abuse and addiction only seems to surface when someone famous has a problem and needs treatment or dies.
Historically, prescription drug addiction has been the most underreported drug abuse problem in the nation (National Institute of Drug Abuse). It is also the least understood. Addiction to and withdrawal from prescription drugs can be more dangerous than other substances because of the insidious nature of these drugs.
Two types of the most commonly abused drugs are opioids and benzodiazepines. Opioids are generally used to control pain. Benzodiazepines, or tranquilizers, are used to manage anxiety. These drugs are prescribed for short-term use such as acute pain and anxiety that is in reaction to a specific event. They may also be prescribed for chronic pain or generalized anxiety.
Like many other people, Sylvia's doctor put her on Vicodin because she suffered from chronic migraines. The pills worked effectively. They took away her headaches and allowed her to live her life. But, like other narcotics, Vicodin lost its effectiveness over time. Sylvia began to increase her dosage. She had built up a tolerance to the medication. She was physically dependent on Vicodin.
Fearing that her doctor would stop prescribing the medication if she told him that she had increased the dosage, she kept it a secret. She did not believe that she would be able to function without the pills. She began to change the numbers on the prescriptions so that she would get more pills, with more refills.
Over the next two years, she went from a physical dependence to a physical and psychological addiction. She had to continue to take this drug in increasing dosages in order to feel "normal." She went from taking the medication as prescribed to a drug habit of 30 pills a day. She started to "doctor shop" in order to obtain several prescriptions at a time. She would make appointments with a number of doctors to get what she needed. She switched pharmacies often so that she could drop off each prescription at a different one. She went to a number of pharmacies in different neighborhoods so that no one would become suspicious.
She could not use her insurance since she was buying several prescriptions of Vicodin at one time. She used different names at each pharmacy. She spent hundreds of dollars a month. She kept a careful record of who she was at every one. As her habit increased, she had to find new ways of getting pills. She stole a prescription pad from one of her doctors and began to forge her own prescriptions. One day, she made the mistake of writing a date on the forged prescription that happened to be a Sunday. The pharmacist became suspicious and confronted her about it. She quickly left the store. He called the police.
By the time the police raided her house, she had hundreds of pills hidden in the bathroom, the kitchen, and bedroom. The police thought she was selling them. They had no idea that the amount she had wouldn't even last her two weeks.
This may seem like an unbelievable story, detailing extreme measures to obtain narcotics. Unfortunately, Sylvia's story is not unusual or unique. The National Clearinghouse for Alcohol and Drug Information reported in May of 2001 that approximately four million people aged twelve and up misuse prescription drugs. That is roughly 2-4% of the population, four times the amount it was in 1980. Prescription drug addiction accounts for roughly a third of all drug abuse problems in the United States.
Donna, a 34 year old lawyer suffered from extreme anxiety, coupled with panic attacks. She sought the help of a psychiatrist who put her on Xanax. It helped with the symptoms for a little over a year. She then noticed she was beginning to feel more and more anxious in between doses. In addition, the dose she was taking barely helped anymore. She reported this to her psychiatrist and he responded by increasing her dosage. In less than three years, he had increased the dose to five times the amount she was first prescribed.
She was honest with her psychiatrist and he increased the dose to what she said she needed. She had convinced herself that prescription drugs were safe. She rationalized this by saying to herself, "if her psychiatrist prescribed them, they must be okay. And besides, a reputable drug company developed the pills in a nice clean laboratory, so how could they be dangerous?"
She began to feel increasingly depressed. She dreaded leaving the house. Her panic attacks increased in frequency whenever she did venture out. She did not want to see her friends. She did not answer the phone. Her world was becoming smaller and smaller.
Donna called her doctor and told him she wanted to get off the pills. He suggested a slow tapering off process and they decided that her partner, Beth, would give her the agreed upon dose each day.
She really wanted the tapering off to work, but she began to feel sick in between doses. She tried to follow the schedule, but she couldn't tolerate the withdrawal symptoms. She would wait until Beth left for work in the morning and then tear the house apart looking for the pills. When she found them, she "stole" a few and put the vial back where Beth hid it. She pretended to continue the agreed upon tapering off process.
Donna panicked when she realized she was taking more than twice the amount she was supposed to take. Feeling like a failure and filled with shame, she did not tell her doctor. She went to another psychiatrist to get another prescription. Her partner begged her to get help. Donna didn't feel that she could live without her pills. Her life had become completely controlledby Xanax. She would panic when she was beginning to run out.
Donna's world was now focused on conning, getting, and taking the pills. She would count them over and over again when she picked up a new prescription. One night, several months later, Beth found Donna unconscious on the floor by the bed. She was rushed to the emergency room. When she regained consciousness, the resident informed her that the Xanax had become toxic in her bloodstream and that she would not have lived more than two weeks had she continued taking them. She had no choice but to stop. She was medically detoxed in the hospital and sent to a treatment facility to continue the process and begin to learn to live drug-free.
What leads a person to become addicted to prescription drugs?
Prescription drug addiction is no different from alcoholism or an addiction to any other substance. However, no one is prescribed alcohol or cocaine for medical reasons. People who suffer from chronic pain are in a very difficult position. Painkillers do relieve pain. For people who suffer from constant and chronic pain, narcotics may be necessary to allow them to have any quality of life. The downside is becoming physically dependent and risking the possibility of addiction.
While it is true that the drugs themselves are highly addictive, not everyone who takes painkillers becomes an addict. The statistics of those suffering from chronic pain who become addicted to these drugs are actually pretty low according to the Chronic Pain Advocacy League, a grass roots organization dedicated to helping those who suffer the debilitating effects of chronic pain. However, this is not to say that those who suffer with chronic pain are not at increased risk of prescription drug addiction.
According to the Journal of the American Medical Association, the area of pain and chemical dependency has become an increasingly important issue. Although chronic pain affects over 45 million Americans--more than either cancer or heart disease--treatment is a low priority in the current health care system (Chronic Pain Advocacy League).
A recent survey by the National Institute on Drug Abuse at Columbia University indicated that approximately 50% of primary care physicians have difficulty speaking with their patients about substance abuse ( FDA Consumer Magazine, Sept.- Oct., 2001).
Drug tolerance is basicallythe body's ability to adapt to the presence of a drug. When narcotic substances are taken regularly for a length of time, the body does not respond to them as well. Tolerance then becomes defined as a state of progressively decreased responsiveness to a drug as a result of which a larger dose of the drug is needed to achieve the effect originally obtained by a smaller dose.
Dependence or Addiction
There is a difference between dependence and addiction. Dependence occurs when tolerance builds up and the body needs the drug in order to function. Withdrawal symptoms will begin if the drug is stopped abruptly. On the other hand, when a person turns to the regular use of a drug to satisfy emotional, and psychological needs, they are addicted to that substance. Physicaldependence exists as well, but the drug has become a way to cope with (or avoid) all kinds of uncomfortable feelings.
Many prescription drug addicts do begin by needing the drug they are prescribed for medical reasons. Somewhere along the line, however, the drug begins to take over their lives and becomes more important than anything else. Nothing will stop them from getting their drug of choice.
It may be difficult to understand how someone could let this happen. How could someone who is reasonably intelligent and sophisticated in regards to drug addiction become an addict? Addiction has nothing to do with intelligence. And addiction to prescription drugs is no different than any other substance abuse problem. Many people in the medical profession abuse prescription drugs. Health care providers may have a slightly higher rate of addiction due to both the stressful nature of the work and their relatively easy access to supplies of narcotics. Clearly, the potential risks and dangers involved with taking narcotics are not unknown among health care providers. This, however, doesn't stop someone from becoming an addict. Some 12-step members have described addiction as a disease of the emotions.
Along with addiction, there are addictive behaviors that are quite common among addicts. Lying, keeping secrets, hiding pills and obsessively counting them, making unnecessary emergency room visits and constantly "doctor shopping." As the addiction escalates, engaging in such illegal activities as stealing prescription pads, committing forgery, and buying drugs off the street is also quite common behavior.
These behaviors usually stem from the desperation an addict feels regarding getting, securing, and taking their drug of choice. Under other circumstances, the individual would probably not engage in the behaviors listed above, unless they were previously partof his/her personality structure. In other words, addictive behaviors are limited to the addiction itself and are generally dissonant with the person's beliefs and values in any other area of their life.
Paul* is a 29 year old advertising executive who was first prescribed medication for a relatively minor neck injury caused by a car accident. While hospitalized he was first treated with morphine and then was switched to Percocet. He left the hospital with a prescription for a week's supply of pills.
The pills took awayPaul's pain. They made him feel calm and a little distant from his emotional pain, as well. Paul welcomed the relief from the emotional pain he was going through following the break-up of a serious relationship. It seemed to him the pills made him feel less lonely and needy. In addition, he found that the pills allowed him to feel more confident at work; he got more done, felt less stressed, and believed he functioned better.
Paul was upset when he finished his prescription. He called his doctor, telling her that he was still in pain. She prescribed more Percocet. She also let him know that if the pain continued any longer, she would prescribe Motrin. Paul felt elated that he could get more pills for now but also. decided he would stop taking them after this latest prescription was finished.
Two months later, Paul had to have oral surgery. All he could think about was how he'd now be able to get more Percocet. He found himself looking forward to, rather than dreading the surgery. After this newest prescription ran out, he began to devise aches and pains that would lead to more pills and was able to con several emergency room doctors into giving him further prescriptions.
Paul began to notice that the pills did not have quite the same effect. The initial euphoria he once felt was gone. He took more. He kept trying to "chase" that first high, but could not achieve it again.
A friend turned him on to Oxycontin. He loved the feeling the pills gave him and began to buy them from his friend. He no longer missed his ex so much. The pills made his emotional pain tolerable and filled the empty feeling he had inside.
Soon, he began to screw up at work. He was missing deadlines and no longer competed for the most prestigious and high-paying ads. Paul began to sink into a depression. His self-esteem plummeted because of his growing need for the drug and the extremes to which he would go to get it. He didn't want to think about how his life was beginning to fall apart. He could not tolerate the negative feelings he was having. He began chewing the pills so he'd feel their effect sooner.
Paul sank further into a depression and believed that the only thing that made him feel better was to take more pills. His friend expressed concern that Paul was becoming too dependent on Oxycontin. He pointed out that the pills seemed to make Paul more depressed. He told Paul that he felt very uncomfortable supplying him with any more pills. Sensing that Paul needed help, he suggested going to an NA or AA meeting. Paul was angry that his connection to Oxycontin was going to be cut off. He thought his friend was overreacting. He was just using pills, not something dangerous like heroin or cocaine.
Paul realized, however,that he didn't feel he could function without his pills. It was the only thing in his life he felt he could depend on. He began to chew them by the handful. One morning he woke up in a stranger's apartment not knowing how he'd gotten there. He couldn't remember anything. He called his friend who said he must have had a blackout and that he needed to get off the pills before he self-destructed any further. Paul finally agreed and went into an inpatient detox and rehab program.
He began to get in touch with the empty void the pills filled up. He felt a great deal of shame about becoming addicted to them. He also felt a great deal of remorse about the behaviors he engaged in to feed his addiction.
Shame and Guilt
Both shame and guilt are feelings that are very common to the experience of addiction. No one wants to be a drug addict. There is tremendous shame in having your life ruled by a vial of pills. There may also be a tremendous amount of shame and guilt about the type of behaviors you can become capable of engaging in to get drugs. The way one behaves on pills--falling down, slurring one's words, blackouts--are all shameful experiences.
A person whose become addicted to prescription drugs may feel guilty about the way they have treated others, particularly those closest to them. There's a great deal of guilt associated with lying and betraying the people they love.
Neither shame or guilt is conducive to getting the help that is needed. In fact, these feelings can be quite destructive. Shame can prevent you from getting treatment. Guilt can lead to all kinds of self-destructive behaviors that will interfere with sobriety. Bottomline: shame and guilt lower self-esteem and foster self-hatred.
There are many treatment facilities located throughout the country. Many insurance plans cover inpatient detox. Some insurance companies will pay for a week, maybe two. Some may pay for rehab as well. It's important to get help and not to try to get off pills on your own. Some people may feel that they can't afford to take a week or two out of their lives to spend in a treatment facility, detoxing. The demands of children, a job, school, or other responsibilities may make inpatient treatment seem like a luxury. It is not. It is unquestionably better to leave the routine responsibilities of your life for a week than it is to suffer the inevitable outcome of prolonged drug addiction.
When an individual becomes physically dependent on painkillers or benzodiazepines, they should not just suddenly stop taking them. Stopping suddenly can cause seizures and possibly even death. The risk of a seizure is actually quite high. Dependency might be dealt with by tapering off the medication. Some people have been successful using this approach. Addicts have often found tapering to be unsuccessful because their addiction is both physical as well as psychological. If tapering is done inpatient, it has more of a chance of success.
Withdrawal symptoms can be, and often are, difficult. Benzodiazepines, for example, are stored in the tissues and fat cells. Getting the drug out of your bloodstream can take a long time. Drugs that go through the digestive tract are more quickly excreted.
Even when someone detoxes inpatient, the symptoms often feel unbearable. While the acute withdrawal symptoms generally last a couple of weeks, the prolonged withdrawal, called Post Acute Withdrawal Syndrome (PAWS) lingers. These symptoms have been known to last a year or longer.
In addition, the person who suffers from chronic pain may initially be in more pain than they were before they began to take painkillers. Painkillers and benzodiazapines repress the body's natural production of dopamine and endorphins (the "pleasure center of the brain") and take over their function. After the drug is detoxed, it takes some time before the body's natural pain receptors "wake up" and begin to function normally again.
What other options does someone who suffers from chronic pain have? After becoming drug-free, this issue still needs to be addressed. Some people believe that they can never take prescription narcotics again and need to remain abstinent for life. Other methods of pain relief like meditation, breathing exercises, yoga, or biofeedback may provide some relief. For recovering addicts who need to be on narcotic painkillers, having someone else responsible for the medication may be a good idea.
Who's at Risk?
The elderly are particularly at risk; misuse of prescription medications may be the most common form of drug abuse among the elderly. According to the National Clearinghouse for Alcohol and Drug Information, as many as 17% of adults 60 and over abuse prescription drugs. While elderly people comprise just 13% of the population, this age group represents as much as 30% of the number of prescription drug abusers.
There is less likelihood that an elderly person will comply with the directions on the prescription bottle. There may be confusion regarding the dose or the frequency with which to take the medication, or difficulty reading the small print. Unintentional misuse can lead to addiction. Compounding this problem, many health care workers may prescribe an addictive substance to an elderly person more than they might to someone younger.
Another at-risk segment of the population is women. One reason is simply that women are more likely to go to the doctor when they are feeling anxious or in pain. Both women and men abuse prescription drugs at approximately the same rate, however, women are twice as likely to become addicted as men. Specifically, females between the ages of 12 to17 and 18 to 25 have shown the largest increase of prescription drug abuse over the past two decades (NIDA). In addition, young girls aged 12 to 14 report that painkillers and tranquilizers are one of the most popular drugs used to get high.
Many recovering prescription drug addicts become involved in 12-step programs. Groups like Pills Anonymous can be very helpful and supportive. The meetings can help alleviate some of the guilt and shame through hearing and sharing the similarities of yours and others' experiences. Unfortunately, there are very few PA meetings around the country in comparison to the numbers of AA or NA and so many pill addicts go to those meetings in addition to or instead of PA meetings.
Some people struggling with pill addiction enter therapy at this point in their lives. Therapy can help you find out what emotional need the pills served and what will fill that need now. Grief is a common feeling among addicts when giving up their "drug of choice.
" Like learning to cope with other kinds of losses, the addict needs to grieve over what had become the most important thing in their life. Therapy groups can function as a safe and supportive place to deal with some of the emotions a recovering addict is likely to feel. Individual therapy can be a very effective way to deal with a lot of the underlying issues that may have led to becoming addicted to prescription drugs.
All of these forms of help can alleviate the isolation an addict may have created when they were using. No one has to deal with sobriety and recovery alone. The feelings that were hidden by the pills will begin to surface and can be frightening to deal with on your own. Having support during this time of a person's life is crucial.
What happened to Sylvia, Donna and Paul?
Sylvia began to go to NA but felt she couldn't relate because no one shared her addiction to pills. She found it difficult to connect with others who used street drugs. She found a PA meeting not far from her job and began to attend on occasion. She also decided to enter therapy to deal with memories that started to come up when she was no longer numbing herself with pills. In exploring her migraine headaches and what usually triggered them, Sylvia realized that the headaches often followed an argument with her husband or difficulty with her kids. She began to make the connection between anger and migraines. With time, when a headache came on, she no longer felt overwhelmed with feelings of anger, rather she just felt the pain of the headache.
Anger was not an acceptable emotion in Sylvia's family. As a result, she did not allow herself to feel it. She began to work on this issue in therapy and started to remember other times in her life when she had felt angry. After exploring this issue for some time, she began to open up about the sexual abuse she'd experienced from her uncle following her father's death. She'd been eleven when her father died of complications due to alcoholism. Her uncle "consoled" her for months. Sylvia had kept the secret of the sexual abuse inside her for years and, prior to therapy, she'd never told anyone about it. The pills had helped to keep the feelings, as well as the event, hidden.
Along with therapy, Sylvia began to use meditation and deep breathing to deal with the stress that generally preceded a migraine. Her migraines began to lessen and she was able to get sufficient relief from over-the-counter pain relievers.
After Donna left in-patient treatment, she continued with after-care. She attended group sessions three times a week. Her counselor stressed the importance of 12-step programs. Donna realized that she needed the support she could get from attending meetings regularly for those times in which her cravings began to surface. She liked the availability of AA and, by thinking of pills as dehydrated alcohol, could see the similarities between herself and the other members.
When her outpatient group ended, Donna sought out individual therapy. She focused on her anxiety and felt she needed to go back on medication. She went to see a new psychiatrist who specialized in substance abuse. Donna's new psychiatrist prescribed an anti-depressant that helped lessen her anxiety.
In therapy, Donna explored what might be at the root of her anxiety. In time, she discovered she had always felt anxious as a child and throughout adolescence. For example, as a teenager, Donna had experienced difficulty accepting her lesbianism and would often go on dates with boys so she would appear "normal."
After Donna came out and moved in with Beth, her anxiety returned. She did not understand the connection between the anxiety she felt as a teenager and what she felt once she made a commitment to Beth. Instead, she began to use Xanax to avoid facing any of the unsettling feelings that had begun surfacing and so, while on drugs, the anxiety-invoking feelings remained buried. Once off the drugs, they resurfaced and she began to deal with them in treatment.
Paul left inpatient treatment and felt lost. He went to a few NA meetings before he went back to work. When he returned to work a month later, he cut down on the number of meetings he attended.
After six months, Paul entered into another relationship. Feelings of fear and dependency started to arise and he found the feelings intolerable. He was terrified of losing this relationship by appearing too needy. After a couple of months, he had a relapse on Darvocet. He thought that if he switched medications he'd be safe. He believed that this time he could control it and resolved to only take pills on the weekends.
In just a month Paul was taking Darvocet everyday. He realized he needed help and went back to AA. Paul elected to re-enter the treatment facility and detoxed in a few days.
He returned to NA, found a sponsor and began to attend meetings regularly. He opened up to the other members and felt more comfortable accepting his addiction.
Paul went back into therapy to confront his deep feeling of emptiness. He knew that he needed to work on his feelings of dependency and neediness that seemed to push people away. He explored where these feelings came from and worked hard to keep his new relationship.
How do you know when someone needs treatment?
If you are unsure whether you or someone you know has a problem with prescription drugs, here are 20 questions that can help you become clearer about whether or not you'd benefit from help:
1. Has your doctor, spouse or anyone else expressed concern about your use of medications?
2. Have you ever decided to stop taking pills only to find yourself taking them again contrary to your previous decision?
3. Have you ever felt remorse or concern about taking pills?
4. Has your efficiency or ambition decreased since taking pills?5. Have you established a supply for purse or pocket or to hide away in case of emergency?6. Have you ever been treated by a physician or hospital for excessive use of pills (whether or not in combination with other substances)?7. Have you changed doctors or drug stores for the purpose of maintaining your supply?8. Have you received the same pill from two or more physicians or druggists at approximately the same time?
9. Have you ever been turned down for a refill?10. Have you taken the same mind- or mood-affecting medication for over a year only to find you still have the same symptoms?11. Have you ever informed your physician as to which pill works best at which dosage and had him adjust the prescription to your recommendations?12. Have you used a tranquilizer or a sleep medication for a period of months or years with no improvement in the problem?13. Have you increased the dosage, strength or frequency of your medication over the past months or years?
14. Is your medication quite important to you; e.g., do you worry about refills long before running out?
15. Do you become annoyed or uncomfortable when others talk about your use of medications?
16. Have you or anyone else noticed a change of personality when you take your medication, or when you stop taking it?
17. Have you ever taken your medication before you had the associated symptom?
18. Have you ever been embarrassed by your behavior when under the influence of your prescription drug?
19. Do you ever sneak or hide your pills?
20. Do you find it impossible to stop or to go for a prolonged period without your pills?
(Reprinted and slightly adapted from "There's More to Quitting Drinking than Quitting Drinking" by Dr. Paul O.)
If you have answered YES to three or more or these questions, you may be at serious risk of having a problem. The good news is that treatment is available.
There are many avenues for treatment. Inpatient treatment, under complete medical supervision is a safe and effective way to detox. This will cut down the risk of seizures and other health-related concerns.
Outpatient group therapy can be an effective way to transition back to a sober life.
Individual psychotherapy can be very helpful in dealing with all of the feelings involved in letting go of prescription drugs, not to mention discovering what led one to become addicted to them in the first place.
Not everyone succinctly stops using drugs, gets clean, and begins recovery. Getting past the denial and resistance common to most addicts is difficult. Some people need to "hit bottom" before they are willing to quit. Others may be more fortunate and embrace recovery before losing everything and everyone in their lives. Unfortunately, there are still many addicts that never make it back and die before they can ever get help.
*The examples used in this article are composites of several people. The names were changed to further protect their anonymity