A painful decision: When to use opiates

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To prescribe, or not to prescribe: That is the question that many physicians will now face in light of a recent report published in the Archives of Internal Medicine, which claims that doctors are too trigger-happy when it comes to prescribing potent painkillers, especially opioids. These drugs include commonly prescribed Vicodin and Percocet, as well as long-acting Oxycontin. This class of medication has lately undergone increased scrutiny. For instance, in 2007 alone, 11,500 deaths were attributed to misuse of prescription opioids, which researchers say is greater than the number of deaths from heroin and cocaine combined. In addition, deaths due to prescription overdose have climbed fourfold in the last decade, with hospitalizations up fivefold.

Though sympathetic to the problem, Dr. Lisa Schwartz of Dartmouth Medical School in Hanover, New Hampshire, believes there is a problem at the opposite end of the spectrum as well, where drugs are actually underprescribed to patients who require powerful pain relief, including cancer patients.

This sort of conundrum is what Dr. Nora D. Volkow, a neuroscientist in charge of the National Institute on Drug Abuse, battles in her ongoing research on drug addiction. In an article for The New York Times, Dr. Volkow describes how surges of the neurotransmitter dopamine, especially when acting on certain genetic vulnerabilities, fuel opiate addiction by fundamentally altering the brain s workings.

As Dr. Don C. Des Jarlais, an expert in drug addiction and director of the Baron Edmond de Rothschild Chemical Dependency Institute at Beth Israel Medical Center in New York, points out, [Dr. Volkow] is as responsible as anyone for showing that addiction really does cause changes in brain function. Her work is a primary basis for considering it a disease, rather than poor choices or immoral behavior.

However, says ACSH's Dr. Josh Bloom, this process rarely begins as an addiction. It usually starts with a bad decision. Following the consumption of a certain quantity of the drug, a process called receptor down-regulation begins, where the brain changes physiologically. He adds, After this, the remaining receptors will eventually require more and more of the substance in order to trigger the pleasure response or avoid withdrawal symptoms. This is when addiction really begins.

ACSH's Dr. Gilbert Ross agrees wholeheartedly that addiction is in fact a disease, and thanks to research using high-tech PET scans of the brain, researchers have determined that the brain becomes hardwired to produce different pathways for pleasure so that drug addicts will continue to respond to certain cues even if that substance is absent from their bodies, he says. What he wasn t so pleased about, however, was that any mention of nicotine-related smoking addiction was absent from Dr. Volkow s discussion. People addicted to cigarettes have issues similar to those who are addicted to prescription drugs, and each should be addressed as a disease that requires treatment with medications rather than simply telling people to just quit which, as Dr. Ross points out, is completely ineffective. As a former smoker who quit in 1990, up until a few years ago, I would still reminisce about having a smoke after my morning cup of coffee the association is that strong.

A different perspective on autism screening

Yesterday s Dispatch contained a story on the drawbacks of diagnostic screening for autism. Concerned about a possible misinterpretation, ACSH advisor Dr. Chic Schissel shared his thoughts:

In [yesterday s] Dispatch you say about autism: what can one do for a disorder that has no treatment?" So far autism has no cure but has treatment, not all of it quackery. It seems that sound early intervention considerably improves a person with autism s ability to deal with life. Of course false positives are a peril, but how else can one utilize early intervention without an early diagnosis? Much more must be discovered about this.