First what is a drug?
The classic definition states that any substance with the ability to
alter ones state may be defined as a drug.
With this definition, even water qualifies as a drug. Indeed water can actually be lethal if
ingested to excess. Diabetes insipidus
creates such inordinate thirst that patients literally drink water to death. Excessive consumption of water severely dilutes
the electrolytes in the blood and leads to brain edema (swelling) causing death
by herniation of the brain stem. It is
not uncommon to remove the faucets from the sinks in the hospital rooms of such
patients to prevent them from drinking. I once had to treat my sister’ acute renal
failure when she returned from a medical spa.
She was hyponatremic (when sodium level is too low) and hyperkalemic
(when potassium level is too high) from over hydration. Her sodium and potassium had been so altered
that she fainted and needed emergent resuscitation with aggressive intravenous
fluids and electrolytes.
If something as seemingly inoffensive as water can be so
potentially dangerous, what are we to say about sleeping pills, marijuana and
Vicodin? I will focus the remainder of
this article on those three as they seem to be the most sought after
prescriptions.
Ambien and Lunesta boast non-addictive properties, but in
fact, these were designed for short term use and were approved by the FDA for
such labeled use. In reality, most
patients using Ambien and Lunesta have done so for years and refuse to stop
using them. The refrain is a well
rehearsed chorus, “I don’t use them every night!” I have yet to find this retort convincing or
satisfying. The truth remains whether
chemically addicting or addiction by habituation, these individuals have become
chemically dependent and will not stop their; not every night routine. Of note, if recollection serves me well,
non-addiction was based on a six to twelve week trial. I can count on one hand the number of patients
who request sleeping pills and use them for a short term.
Marijuana has the reputation of being a benign drug;
really? As one of the on-call ER
admitting physicians at Saint John’s Health Center in Santa Monica, California,
I can assert by actual experience that marijuana is not a benign drug. The fact that most people would think that it
is remains most alarming to me. Very
little is said of THC related intractable nausea and vomiting. I recently admitted a 27 year old gentleman
whose career was taking off with a once in a lifetime job offer. He was brought in to the emergency room by
ambulance after being found down and unable to come out of the fetal
position. Initial evaluation revealed a
severely dehydrated young man in acute renal failure. His main complaint was intractable nausea and
vomiting so severe that he was now throwing up blood. He was aggressively resuscitated with
intravenous fluids and given large doses of Zofran (anti-nausea medications)
but alas, this treatment which would suffice to treat chemotherapy patients did
not alleviate his symptoms in the least.
Other than treating him with sedatives and narcotics, there was little
else we could do. Had he been unable to
reach help, he could have died. So short
answer, marijuana is not as safe or benign as one might think. Like a lot of things in life, personal
experience of others is not a predictor of your actual life. I drive across railroad tracks often. I have seen cars pulverized when struck by a
train, it has never happened to me, most likely won’t, but am I one hundred percent certain that it
can’t or won’t?
Finally let me address pain killers; and leading the pack,
the one with the catchy name Vicodin. I
think it is helpful to understand how pain is perceived and why narcotics
although very potent and powerful medications have such a narrowed useful
range. Most common pain conditions
result from acute trauma, chronic aches and pains, surgery and cancer. Acute pain occurring in the setting of kidney
stones, chronic back aches and arthritis actually respond poorly to narcotics
and are much more effectively treated with non-steroidal anti-inflammatory
medication like ibuprofen and naproxen.
All NSAIDs have common side effect profiles including gastrointestinal
bleeding and renal mediated hypertension among others, but they are
non-addicting and actually treat inflammation; the cause of the pain. The use of narcotics for these types of pain,
although effective in the short run because they address the pain perception
centers in the brain, do nothing to treat the actual cause of the pain and do
not alter the course of the disease causing the pain. So what are we actually achieving with
narcotic use? We don’t treat the
disease, we don’t address inflammation and in the case of the kidney stone, it’s
still in the urinary tract, it still hurts, you just don’t care. Compare that to using an NSAID like Toradol
which when given intravenously actually relaxes the ureter and releases the
stone and treats the inflammation mediated pain. I am not averse to the use of narcotics in the indicated setting,
immediately post surgical, in cases of rib trauma in order to be able to take
deep breaths to prevent pneumonia, but the rampant “I have a boo boo reach for the Vicodin”, when
an ice pack would have done the job is an abuse of the drug.
Parting story, beautiful 34 year old young woman with
history of severe emotional trauma seen by a pain specialist for severe back
pain which developed shortly after her husband’s death. MRI of her spine revealed a 10 mm disc
herniation in her lumbar region and she was consequently placed on increasingly
large doses of narcotics to include Percocets, Percodan, Vicodin as well as
Fentanyl patches. To my amazement, these
did not fully address her pain. She came
to see me wearing high heels seeking my help.
The instant I saw her I told her that it would be quasi impossible for
that disc to be an issue at the present time if she was able to wear high
heels. We repeated the MRI and in fact
the disc herniation had resolved as most would with time, but what was causing
her pain now? The addiction to the
narcotics created a pathway where as soon as the drugs wore off, she would
experience a phantom like pain that was indistinguishable from the initial pain
and only high doses of narcotics would keep the pain away. She agreed to undergo detox and has been
narcotic free ever since. She is but
one among many such stories.
My advice is simple; narcotics only when absolutely
necessary for the shortest duration possible and only when no other modality is
suitable. Two exceptions, it is true
that narcotics do not tend to be addicting when used for the treatment of true
pain for short durations, and in patients facing end of life issues where
comfort measures supersede all other concerns, narcotics are perfectly
appropriate.
I welcome your comments.
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