As some Dopers know (and isn’t that an interesting title to use for folks while in this thread?) I worked at a methadone clinic for four years back in the early 90’s. I can’t speak from personal experience, since my only addictions have been caffeine and books, but I got to observe several thousand people on illicit substances of all sorts.
Heroin withdrawal = a bad case of the flu: I heard this one my first day at the clinic. It was related with a dismissive tone, as if the addicts were complaining about nothing worse than sniffles and a few aches. I came back with “well, doesn’t the flu kill people sometimes?”. Oh, I was *such * a smarty-pants! (Actually, the flu is much, much more likely to kill you than opiate withdrawal)
In my opinion, there’s a key concept here called individuality. Everyone has a slightly different pain tolerance, and different things affect people differently. As an example, I’ve walked around for two weeks with a broken rib without realizing it was broken, but I’m a complete baby about the least little dental pain (thank God I have really good, low-maintenance teeth!). My husband has an incredicbly high pain tolerance – except for tummy aches, the least of which will bring him to his knees in whimpering misery. Likewise, different addicts will perceive withdrawal pains differently. Two different addicts may, from an objective viewpoint, suffer the same sypmtoms wth the same intensity but one will perceive it as unmitigated hell and another as awful but bearable.
Keep in mind, too, that we’re talking about a group of people used to obliterating the least pain with one of the most potent pain-killers known to man. As a rule, they do *not * have a high tolerance for pain or discomfort. So their perception of a pain stimulus (say, a minor paper cut) may be far different from that of a normal, non-addicted person.
Heroin/opiate vs. nicotine withdrawal: Since we were in the drug treatment/rehab business, I saw a lot of people get off drugs, and a lot try to and fail. Saw hundreds of folks with both opiate and nicotine addictions. Yes, it was common to see Joe Junkie in the smoking lounge going >puff< “I just don’t get it” >puff< “I gave up the smack” >puff< “and I’ve been clean for 3 years now, and” >puff< >puff< “I still can’t give up these damn cigarrettes!” >puff< On the other hand, we had plenty of folks who claimed giving up cigarettes was easy compared to quitting heroin. Now what’s going on here?
Different people are different. It’s not just a matter of how high a dose the addict was taking prior to cleaning up, either. You have to factor in body chemistry, environment, mental adaptability, length of addcition, and so forth. If someone comes from a family where everyone does heroin (and such families do exist, I’ve met them) a person from such a family will find it almost impossible to quit unless they move out and cut contact with their relatives. You can’t stay clean when everyone around you is getting high, and after dinner “dessert” involves everyone pulling out their “works” and strapping on a tourniquet or having a snort or a smoke. We had one gal who was introduced to heorin by her father at the age of eight (she stumbled across him and his buddies getting high, and they thought it would be amusing to shoot up an eight year old to see what would happen). Starting that young, she doesn’t have much memory of “normal” with which to motivate her to quit - in contrast, say, to someone who first got high at 35 and prior to that had a wonderful, safe, secure life that they very much would like to return to. Folks from the worst family environments - where everyone used drugs heavily - seemed to find giving up heorin harder than giving up smoking (if they ever smoked nicotine at all). But the late-blooming addict may have been smoking since the age of 12, not perceiving it as the same sort of addiction, and viewing cigarettes as part of that “normal” they want to return to. Such a person may find it easier to give up heroin than cigarrettes.
Then there’s the whole legality issue - you do not find heroin for sale in attractive, cellophane wrapped packages in vending machines, bars, grocery stores, “drug stores”, or gas stations. You DO find cigarettes everyone. It’s a lot easier to avoid reminders of heroin in daily life than to avoid cigarettes. Some people are more vulnerable to visual triggers - and some more vulnerable to advertising. Such a person may give up both heorin and nicotine, but find it much harder to avoid a nicotine relapse just because it’s available all over the place and you can see people partaking in public all the time.
I would say about one-third of the addicts at our clinic found it harder to stay off cigaretes than to stay off heroin. That’s an off-the-cuff sort of thing, but it was clear to everyone that while MOST people thought heroin harder to kick than nicotine, there were a significant minority where the nicotine had the stronger hold.
I just want to note that there is nothing logical about addiction. People do not sit down and rationally make decisions in these matters. Its much more about physical sensation and emotion - never of which touches logic much, if at all. If someone finds they can give up heroin, but can’t seem to stay off the cigarettes, then to them nicotine is more addicting than heroin. It’s not a matter of logic but of personal experience. WHY this situation occurs probably has more to do with mental and environmental issues than physical symptoms or reasoning.
Also, as several posters here have mentioned, not everyone reacts the same to opiates. In fact, there is a whole category of opiates - the kappa opiates - that have little or no effect on men, but are quite effective for women. Some of these differences are physical/genetic in origin. So there may, in fact, be people who are insensitive to opiates but very sensitive to nicotine for whom nicotine really would be more addictive. On the flip side, there are people who are extremely sensitive to opiates - they good news might be that they require less than usual to relieve pain. The bad news is this trait might also make them more prove to addiction. The effects of genes on drug use/sensitivities/reactions/side effects is a relatively new field but in the long run it may result in both more effective pain relief and more effective treatment for addictions that do occur.
Long term pain, medical use of opiates, and addiction: Here you have to remember a very, very important distinction: addiction vs. physical dependence (or physical tolerance, or any number of euphenisms)
Addiction is a mental state which may or may not be accompanied by physical symptoms. Sure, you can throw any addict in a padded room for a week, get the drugs out of their system, get them past withdrawal symptoms… but it’s not a cure. All you’ve got from that is a sober addict (and probably a really pissed off one, too). They’re still an addict. Let them out, the first thing they’ll do is go score a bag or a joint or a pill and get back on the merry-go-round.
Physical dependence means the body has adjusted to a certain amount of a substance being regularly ingested, and will show physical withdrawal symptoms if the substance ceases to be ingested. This is separate from the mental effects. There are people who, through medical necessity, acquire a tolerance for a medication (maybe opiates, but they aren’t the only drugs with this characteristic) and, when quitting, show unpleasent symptoms. BUT - and this is a very important idea to grasp - such a person may well simply put up with the symptoms and have no desire to take another dose of that drug to relieve them - even if they have access to the medication. Anyone who has taken an opiate for several weeks, stopped taking them, mentioned unpleasent side effects, but did NOT ask for another dose or something to ease the symptoms has done *exactly * that. It’s not an uncommon situation.
Here’s the rub - if you take an opiate on a steady basis for more than a week or two for any reason you WILL develop both a tolerance and a physical dependency. It may not be a huge tolerance or dependence, but you will have one. However, that alone does NOT make you an addict. You are one step closer, though. Which is why doctors need to be quite cautious about prescribing opiates (or other potentially addicting drugs).
If, for example, someone suffers a catastrophic injury and requires opiate painkillers for, let’s say, six months (it was a really horrible injury requiring lots of surgery and rehab) the patient will, without question, have a physical dependency. What to do now? Well, if you cut them off cold turkey the withdrawal will be unpleasent, no doubt about it. Might be so unpleasent the patient will seek out relief - in the form of an opiate. Uh-oh, that behavior is not good. Might lead to more of the same, and then you have an addict. Well, in theory, if you slowly reduce the dosage of drug, slowly enough that they don’t feel too uncomfortable, then they never experience full-blown withdrawal, they never “seek relief”, and in time (a couple weeks, most cases) they are off the drug and back to normal life. No harm done. Problem is, you have to deal with individual chemistry, pain/discomfort tolerance, past history (former addicts are far more vulnerable to new addictions), and so forth.
It might be more accurate to say that long term opiate use for legitimate medical reasons doesn’t lead to addiction - *mismanagement * of long term use leads to addiction. Except “mismanagement” seems to imply malice. I don’t think that’s always the case - doctors can’t know every variable in a particular patient and sometimes even with the best of care you get a bad outcome. But at least if this done under medical supervision the addiction might be caught early, before there are years of bad mental habits involved, and treated early.
In the past, part of the problem with medical use was giving pain medication on a rigidly fixed schedule. So you have folks who’d get relief from a shot, a couple hours later had pain, were told “no, you have to wait”, suffered more, then got relief from a shot… and the cycle repeated, over and over. So they became conditioned to want that shot, that pin-prick, that blessed relief. This is actually setting the stage for addictive behavior, it’s as if they’re getting a “mini-high” and a “mini-withdrawal” several times a day. And it’s also why patient controlled analgesia (PCA) is such a good thing. The patient doesn’t have to wait. They don’t go through this cycle. They don’t have to beg for relief. It removes a lot of mental anxiety. As a result, patients on PCA may, in fact, consume LESS of an opiate than they would from more traditional dosing schedules.
I’ve seen this in several people I’ve know who have used PCA. Typically, the little machine does dispense a regular dose on a schedule, but in between, if the patient feels the need, they press a button for a little more and it kicks in very quickly. There are controls to prevent overdose (push the button too many times it stops dispensing), but I’ve seen folks forgo the button during, say, visits so they’re a little more clear-headed, or if they’re distracted by something on the TV, but they all say that, when waking up in the middle of the night from pain it’s a wonderful thing to get instant relief and get back to sleeping. It certainly seem to avoid the agony/bliss cycle.
So, to sum up - if you DO have to take a pain killer for an extended period it won’t necessarially make you an addict - even if you have to eventually tamper the dose off gradually. It DOES put you at higher risk. Which is why, as Qadgop stated, it should NOT be a first-line therapy for chronic pain.
The purity (or lack thereof) of illicit drugs:
Worst case of adulteration I saw at the clinic involved a woman who had done something (I never did learn exactly what - she was hardly in condition to say after this incident occurred) to anger her dealer. He cut her next dose with Ajax. (Gas chromotography is soooo wonderful – it’s how it was determined that yes, it was Ajax brand cleanser)
This is a really, really ugly and protracted way to die.
Let’s face it, the people selling, cutting, re-selling, and re-cutting this stuff are not really nice human beings. They cut with whatever is cheap and handy, with no concern for sanitation whatsoever. On the lower levels, where you’re dealing with user/dealers, they might even be so high as to have little contact with reality when cutting down the drug. They may intend to use baking soda, but grab the rat poison by mistake. Or maybe not - it IS a way to commit murder, to put poison into something you know someone is going to take into their body.
With the pregnant addicts, medical management of opiate addiction involved two major points - keep them off street drugs, and prevent withdrawal (opiate withdrawal in a pregnant woman is more hazardous to both woman and child than maintaining them on a controlled, pure dose of opiates). Opiates aren’t wonderful for fetuses, but they aren’t inherently lethal, either. In fact, alcohol is more toxic to a developing baby than pure opiates. Problem is, street drugs aren’t pure. It’s the other crap, not to mention the risk of infection from IV drugs, sharing of works, and use of sex to obtain drugs, that poses the most danger to mother and child.
The phenomena of adultered illicit drugs is by no means confined to the opiates, of course. During Prohibition lots of folks went blind or suffered other catastrophic damage from “bathtub gin” involving things like wood alcohol or gasoline or other unhealthy things. It’s nothing unusual to cut one form of “speed” with another - meth in cocaine, cocaine in meth, various amphetatimines mixed together… Marijuana cut with all sorts of herbal substances, tobacco, lawn clippings (it’s grass cut with grass, man!). Also possibly sprinkled with speed, or heroin…
We used to bring the methadone to the clinic via armed guard. You see, not only was it an opiate (and therefore inherently valuable) it was also PURE…