I’ve written more than a few times about the long-term use of drugs, and pain, and family and friends’ attitudes to medication and the shame that always seems to come with being dependent, and Bruce Alexander’s Rat Park Experiments, as compared to how GPs seem to think about addiction, and even about overdose, but I’ve recently realised that most of these are buried at the bottom of posts about my own situation, rather than standing on their own.
So here’s some kind of masterpost of my thoughts on drugs. I might have directed you to this because you asked a flamingly obvious question, or because you were generically ignorant, or because you were spreading hateful misinformation. Please, read on and be enlightened.
GPs and medication
For some reason, some GPs seem to think that they are are be-all and end-all of medical knowledge. Even when a consultant, or a surgeon, or a physiotherapist, or a headpoker has told them otherwise, they will always insist on sticking their neb in and fiddling with a patient’s prescriptions. They pad their ignorance of the case-in-hand by talking about side effects, the dangers of addiction, and just “not being comfortable…” with particular courses of action. Even though, usually, all of these things have been talked through between the patient and the specialist, and the prescription suggested is the one with the best chance of causing the most improvement with the least unacceptable side-effects. If they are somehow persuaded to just issue the prescription, they’ll try to reduce the dose, or reduce the number of tablets given, or insist on reviewing it themselves every month, in spite of having no useful input since they never take useful notes on the patient and never trust what the patient is telling them about their condition.
Addiction is pretty much always presented as a) likely and b) the worst possible thing that can happen to a long-term opiate or benzodiazepene user. The truth is that it’s been pretty conclusively proven, in multiple studies, that substance-mediated addiction doesn’t really exist. So a patient taking morphine for pain, even for years and years on end, won’t become addicted. They might become tolerant, and need a higher dose to achieve the same effect, and they might suffer physical withdrawal effects when they initially stop taking it, but they will not become addicts.
I maintain that addiction is still only a problem if it puts the user in danger. If the drug supply comes from a reputable source, and the dosage is kept low enough to not cause physiological problems, and the user’s normal functioning isn’t impaired, who cares if they motivate themselves to go to work in the mornings with the knowledge that they can get high when they get home?
It’s a popular myth – That someone starting out on a small dose of opiate painkillers will have to take larger and larger doses over time to get the same effect. It’s just, fortunately, not true. There’ll often be a large increase in the first year, whilst the doctor and patient work out together what the right dose is for the patient to get all of their symptoms under control, and indeed what the right type of pain relief is (Lots of PRN? Slow release? Patches? Combinations? Multiple families of drugs or just one? How do they conform to their routine, do they need something simple to remember, or can they handle a dozen things with a dozen different dosing parameters?) but developing such a tolerance that a drug just won’t work is rare.
It’s sometimes hard to work out what’s a detrimental side-effect of a condition, and what’s a detrimental side-effect of medication. It’s personal to the person with the condition, especially in what someone will tolerate – Some people would rather feel slightly queasy all the time because of a drug that disagrees with them, whereas others would rather put up with the original condition. The most famous of these dilemmas is probably with SSRIs, when used to treat “simple” depression – Some people prefer to deal with the depression on their own or with talking therapies alone, rather than to have their sex drive and performance ruined by SSRIs, which is one of the more common side-effects. And the same applies to painkillers, and even with PRN painkillers, from dose to dose; On Monday, Jim might prefer to be in more pain, but more clear-headed, whereas on Saturday he might give himself a “day off” and take enough to no longer be in pain, even if it’s enough to make him floppy all over and to want to tell his friends about a lovely imaginary cow called Grenache.
The Fabled Morphine High
It goes away. Someone on slow-release morphine won’t really be “always a little bit stoned”, they’ll just not be in pain. For the first week or two, they might feel a bit weird, but that’ll probably be the all of it. Someone taking their prescribed dose of PRN morphine, after a few times, won’t feel a high from it, they’ll again just suddenly be in less pain. Occasionally, the appropriate amount of morphine for a situation will still get you high, even after years of use. It’s not unpleasant, it’s no more dangerous than the amount of pain that it’s masking, and frankly it’s often difficult to untangle it from the pain-relieving effect. Various opiates and opioids have different effects – Some are extremely soporific, some are extremely efficient at only effecting the nociceptors, some have a gentle antianxiolytic effect, some just make the pain feel less urgent, as if the mind is floating away from the body. They’re all components of how they relieve pain.
There’s no grand moral imperative to not take drugs. That’s not a natural law, it’s some kind of conservative anxiety about other people getting an easy ride, or a puritan anxiety that people might be enjoying themselves, or possibly an anti-technological anxiety that drugs are science and science is bad. Sometimes, it’s a bigger act of willpower to say “No, I’m going to stop doing the [fun or necessary thing] and lie down and take my medication and rest instead. Even though I don’t want to,” than to try to continue as is nothing was wrong. Society hammers into us from an early age that we have responsibilities which must be discharged before we can rest, and some of those make sense – You have to get the bairns home from school, or turn off the open gas flame on the hob, because those are things which will be unsafe if not attended to – but some of them are not sensible; There is no reason why you must vacuum the living room carpet or go out to a dinner party if you’re exhausted and in pain and just want to lie down. They’re not as fundamental on Maslow’s Hierarchy as not being in pain. And for that matter, there is nothing wrong with delegating. Sometimes it’s fine to say “No, you can make the tea, I need to take a load of pills and lie down in a dark corner for a while.”
It is not up to anyone but you how you take your medication. Anyone saying “Just take less of it! I hate it when you’re on morphine!” is saying “I prefer it when you’re in pain, because you’re more useful to me like that!” Work out what it is that they want – Whether that be housework, a share of your wages, sexual performance, more attention or any of the other billion things that one human can want from another – and make it abundantly clear to them that, without your painkillers, you won’t be able to give them more of what they want, you’ll just be disappointing them whilst in pain, rather than disappointing them whilst in relative comfort.
Being in pain, long term, causes damage. Pain causes spasms, which can rip muscles out of insertions and snap bones (An orthopaedic surgeon once memorably told me about a muscle spasm snapping someone’s femur. It may have been a diseased femur, but it was a femur. Think how thick a femur is.) even before you come down to the way that a muscle spasm will make you drop whatever you’re holding, make your paintbrush wobble across the page, or make you slam the throttle of your bike so hard that you fly forwards at a hundred miles an hour. Pain causes hypertension and an increased heart rate, which can lead to heart attacks and all sorts of other things. Pain causes lack of appetite, resulting in long-term weight loss and often tooth decay from never chewing, so never producing sufficient saliva. Pain causes anxiety and depression and frankly can just make you into a horrible person to be around. This is not to mention the number of people who kill themselves every year due to being in untreated, long-term pain.
Long-term opiate use is safe and effective. The constipation is treatable, easily and safely. The chance of liver or kidney trouble, if taken within prescribed amounts, is infinitessimally small and can be tested for long before it becomes a problem, if there are any warning signs.
This post will get longer over time. Thank you for reading.