Tuesday, September 20, 2011

How Drugs Affect Us!

I have wanted to write this blog for a long time, but recent events and troubling conversations with patients compel me to address this issue now.

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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