Chapter 4: The Disease of Addiction, pt. 1

The universal nature of addictive experience
What I enjoy the most about having a presence on the internet is receiving comments from people from around the world.  The writers describe the same progression of symptoms that characterize opioid dependence, a disease that affects people from all cultures and socioeconomic groups.
I often think about how surprised most ‘normal’ people would be to learn the true extent of what can only be described as an epidemic of opioid use.  Writers, stockbrokers, artists, businessmen, doctors, lawyers, factory workers, photographers, teachers, students, IT professionals, waitresses, realtors, landlords, welders, professors, home-makers, mothers and dads… I have patients with opioid dependence from all of these occupations in my practice alone.  And in each patient, the story is the same…  the initial use, the loss of control, the assumption that the control will come back, the feeling of being ‘different’ from those ‘other people’ who get addicted, the assumption that what happens to other people won’t happen to ME, the repeated failures to control use, the repeated episodes of withdrawal, and the fear deep in the gut that maybe I really AM in trouble after all.  Each addict knows the deep shame that ‘I should have known better.’  Each addict makes a weak effort to blame someone or something else—a lie that even the addict doesn’t fully believe but that he still uses since the alternative– accepting all the blame himself– is intolerable. Each and every addict has done things that he never thought he would do—spending the family Christmas fund on pills, picking the kids up late from school because of a dope deal or from ‘nodding off’ at work, lying to friends, spouse, or children, stealing pain pills or money from family members, and eventually criminal activity and serious consequences that leave the addict thinking, ‘how did I become one of THOSE people?!’ At that point the addict often rationalizes that his constant guilt keeps him from getting clean, but that is just another excuse; he could just as easily say that being sick of hating himself is the reason he MUST get clean.
The first choice is the one that is taken, because for an addict, there is ALWAYS an excuse to use. The family is too distant… or is‘suffocatingly close.’  The weather is too horrible, or too nice.  The house is too empty or too full; my wife is too attractive and flirty, or too unattractive and boring.  There is always an excuse– which really means that there is never an excuse.  I run short on patience when addicts telling their stories get to the excuses; I have heard them all and none of them mean anything.  And yes, I have used many of the same excuses back in my own using days.
For the typical opiate addict, those first few weeks of using felt great.  He/she was stressed over a busy job and the opioids provided extra energy at home.  The spouse and kids were happy about the changes in attitude.  But after a short time the addict began to feel miserable inside (note:  even after years of sobriety I will hear addicts wonder if they can pull it off;  find a way to capture that initial euphoria without the misery that follows.  I can save them much trouble—the answer is ‘no’).  The addict retreats further and further into a world of secret thoughts.  His personality and interests grow smaller and smaller and he puts up a cocky façade, thinking he is fooling everyone. His kids might be the first to notice that something isn’t right, only because they lack the ability to ignore and repress thoughts that are too painful or frightening to acknowledge.
A parent living behind a façade is a set-up for causing borderline personality in the kids;  later when the kids talk to their own therapists they will say that everything seemed OK– there were no beatings, and dad was always happy…  but normal child development doesn’t do well with ‘fake’ personalities.  The kids internalize the growing distance from the addict (dad or mom) as somehow related to them.  To kids, everything relates to themselves… so the distance becomes part of low self esteem, mood swings, cutting, and impulsive behavior that is really borderline personality but that some shrink with 7-minute appointments will misdiagnose as ‘bipolar.’   The kid will be put on Depakote or Seroquel or Zyprexa and will gain 100 pounds, assuring a lifetime of self-consciousness.  It is hard to acknowledge, but our addictions are horrible for our children.
The good news is that sometimes the addict will get miserable enough to take action.  The bad news is that the damage will last a lifetime– not just the addict’s lifetime, but the kids’ lifetimes as well.

Brittany Murphy's medications and their interactions

A note of follow up:  According to TMZ, a variety of medications were found in Brittany Murphy’s apartment under her name and under the name of her husband and mother.  Of course it is possible that the medications actually belonged to her husband and to her mother– but as you read in my last post, I am not surprised that opiates were included on the list.  THe medication list:

Brittany Murphy used dangerous medication combinations
Was her death related to dangerous medication combinations?

1.  Topamax.  Topamax is an anticonvulsant that is also used to treat migraine headaches, and sometimes prescribed as a mild ‘mood stabilizer’–  say for someone who has symptoms of bipolar disorder but who instead has borderline personality or just ‘mood swings’ that don’t quite qualify as full blown bipolar disorder.  The medication is favored by some patients, particularly women with eating disorders, because unlike more effective mood stabilizers like Depakote (valproic acid), Topamax (generic name topiramate) causes weight loss instead of weight gain.  It has the nickname ‘dopamax’ because it can reduce cognitive function to a mild extent.
2.  Methylprednisolone.  This is a steroid anti-inflammatory medication, and I have no idea why she may have been taking it, if she was at all.  It is used to treat severe asthma, rheumatoid arthritis, and a wide range of autoimmune or allergic disorders.  It will create a brief euphoria in some people, and can also cause depression, mania, and even psychosis in others.  It tends to cause significant weight gain if taken for a long period of time.
3.  Fluoxetine.  Also known as Prozac, the well-known SSRI used to treat depression and anxiety (and to a lesser extent mood symptoms and irritability related to ‘periods’ in women).  Tends to decrease appetite slightly;  there is an ‘internet fad diet’ called ‘phen-pro’ which is a combination of phentermine (one of the phen-fen drugs from the heart-damaging diet of a few years ago) with fluoxetine.  Fluoxetine and other SSRIs are generally safe medications, but fluoxetine in particular can reduce the liver’s ability to metabolize some other medications, making the other medications more potent.
4.  Klonopin.   AKA clonazepam, a long-acting benzodiazepine (meds in the Valium or Xanax family).  These medications almost always start out small and become big problems in people with addictive tendencies, as I write here in my psychiatry blog.  They are great for short-term anxiety– say for a couple weeks for a death in the family.  But the person quickly becomes tolerant to the medication and then needs to take it to feel ‘normal’, eventually needing it all the time.  Benzos turn managable anxiety into an ‘anxiety disorder’.  They are also potent respiratory depressants when combined with opiates, and are often half of the equation in the case of overdoses.  They work at brain receptors that are also affected by alcohol, making them essentially ‘brandy in pill form.’  Do yourself a favor, and just say ‘no’ to benzos.  One last thing– the way that they block ‘anxiety’ is through their action as ‘amnestics’– they block the formation of memories.  A drug called ‘versed’ is widely used for dental work or colonoscopies to block memory;  that is what clonazepam and alprazolam (Xanax) do.  You can’t worry about what you cannot remember!
5.  Carbamazepine.  Also known as Tegretol, this medication is an anticonvulsant similar to Topamax but one that is potent enough to actually work for bipolar disorder and seizure disorders.  It is also prescribed for some chronic pain conditions, including a very painful facial condition called trigeminal neuralgia.   Not particularly dangerous with opiates except for effects at the liver where it also blocks or increases the metabolism of other medications in an unpredictable fashion.  It can have other uncommon but serious side effects on blood components.
6.  Ativan.  Also known as lorazepam, this is another benzodiazepine.  Works just like clonazepam but with a shorter duration of action– the half-life of lorazepam is about 12 hours and the half-life of clonazepam is 2-3 times longer.  Again, a lousy, addictive medication that is a disaster in people with addictions.
7.  Vicoprofen.  Ibuprofen combined with the opiate hydrocodone, which is a moderate-strength narcotic.  People who take opiates long term become used to them, and have to keep taking them to avoid withdrawal– as all readers here probably know!
8.  Propranolol.  This is an old, cheap medication used to treat a number of things.  It is a ‘beta blocker’, meaning it blocks the actions of adrenaline at ‘beta receptors’ at the heart and other brain regions.  It used to be used commonly for high blood pressure, but now many better medications are available.  It is used to prevent migraines, and to block the feeling of adrenaline in a person’s body– so it will be used in prisons as a non-narcotic medication to treat panic attacks or anxiety.  It is commonly used by musicians, politicians, and public speakers to help them feel calm during presentations or public appearances.  For example it will stop that ‘rush’ in a person’s chest, stop the hands from shaking, stop the heart from racing or pounding, and reduce the husky voice some people get when nervous.
9. Biaxin.  An antibiotic also known as Clarithromycin, used to treat a wide range of bacterial infections including acne, sinus infections, bladder infections… again, an old medication with many better modern substitutes.  The use of the medication is limited by the fact that similar to many of the other medications in this list, it interacts with many other medications, making the other medications more or less potent than intended.  The medication can also cause potentially fatal heart arrhythmias, particulary in combination with STEROIDS, such as the methylprednisolone on the list.
10.  Hydrocodone.  Not needing much explanation for readers of this web site, hydrocodone is a moderate-strength opiate narcotic.  It is a component of the Vicoprofen described above.  Like all opiates, it initially works very well to relieve pain.  Some people, though, find that it ‘fits’ very well;  it makes them feel whole, loved, happy, content, warm… at least for a little while.  It works just like heroin, but has a lower potency so more hydrocodone is required– but if enough is taken the same effects will occur.  The person becomes tolerant to hydrocodone fairly quickly, resulting in withdrawal if the medication is discontinued.
All in all, the medications, if they were all taken by Brittany Murphy, would be consistent with someone being treated for migraine headaches, anxiety or panic, and a mood disorder.  Just guessing, of course… and this would NOT  be the ideal way to treat these conditions.  For example, opiates are lousy ways to treat headaches, especially long-term, probably causing far more headaches than they get rid of.  Propranolol is a relatively harmless med for anxiety (providing the person doesn’t have asthma, which propranolol would aggravate).  If the carbemazepine, fluoxetine, and topamax were being used for a mood disorder like bipolar or a personality disorder like borderline personality, then taking the steroid methylprednisolone would be a risky thing to do, as steroids can cause pretty severe mood effects.
These medications have a number of dangeroud interactions, besides the addictive dangers of several of them both alone and in combination.  For those interested in a more detailed list of the dangerous interactions, I have prepared a list of the med/ med interactions in pdf format using the interactions checker provided by epocrates.
Suboxone Talk Zone