March 29, 2004 issue
Copyright © 2004 The American
Conservative
In Praise of
Laudanum
For some, “addiction” may be the only
cure.
By Jim Pittaway
One of the elements of
dramatic tension in the wonderful Master and Commander series of books is the
relationship between the brilliant and resourceful ship’s surgeon, Dr. Maturin,
and the laudanum with which he self-medicates. Author Patrick O’Brian is widely
praised for the authenticity of his rendering of the language, behaviors, and
mores of Napoleonic times, but here he projects contemporary issues onto his
characters and their circumstances. A real Dr. Maturin, like his contemporary
Capt. Meriwether Lewis—with his famous “melancholia”—would have been perfectly
free to medicate himself to his heart’s content without enduring either social
opprobrium or shame and self-doubt. If Rush Limbaugh lived in any other era, we
would not be having a national conversation about his behavior and the state
would never be pursuing his medical records for evidence of crimes he may or may
not have perpetrated upon himself.
Over the decade I have spent as a
practitioner licensed by my state to treat, among other things, addiction and
addiction-related disorders, I have become increasingly troubled by things other
than my patients’ actual use. As I have transitioned from in-patient addiction
treatment and private practice to working with head-injured and often severely
disabled patients, I have become less doctrinaire about use itself and more
aware of complexities of circumstance as they affect individuals. The cases
causing me the greatest concern have one common element: they involve pain
medication.
Until the great government power-grab of Franklin Roosevelt’s
New Deal, Americans were assumed competent to treat themselves for chronic or
acute pain, as well as for what we now imperfectly describe as chemical
imbalances of the brain—such as bipolar disorder—by simply stopping at a corner
apothecary and purchasing such tincture of opium as they judged appropriate for
their needs. This actually went on for centuries without generating serious
social or moral problems. Undoubtedly, many individuals became “addicted” and
the opportunity for drug “abuse” abounded, but such excesses were the business
of family and community. No tyrannical European king or dictator even dreamed of
so intruding on the private lives of individuals as to interfere with access to
pain relief and psychological equilibrium. At least not until FDR’s Harry
Anslinger [Editor's note: actually
Anslinger was appointed head of BNDD in 1930, by Herbert Hoover], of
the Bureau of Narcotics and Dangerous Drugs, set about criminalizing vast tracts
of human behavior in his push to build a crime-fighting empire on behalf of the
state whose power he and his boss were so dedicated to expanding.
I
should point out that the development of highly refined opiates such as morphine
and, later, heroin in the early 20th century changed opiate use, and serious
social consequences emerged that were not present in the earlier age of
laudanum. Also the proliferation of powerful stimulant, sedative, and
hallucinogenic drugs with no significant medical application, but with enormous
potential for abuse, contributes to a horrible national and international drug
problem. The idea that the family and community, in decline if not
disintegration, could provide a bulwark against these problems is laughable. But
it is equally fair to say that the magnitude of the drug problem in society
coincides with the blanket criminalization of medical as well as non-medical
drug use, and the preposterousness of Limbaugh’s pain treatment as a public
obsession and a license for abuse of power by the state shows that the “drug
problem” is not always just about use.
As I become a more experienced
therapist, I am less sanguine about treating addiction as such and not entirely
sure that I know what addiction is. The term has been so widely misapplied as to
become, like “terrorism,” essentially empty of meaning except in terms of the
biases and agenda of the person using it. Addiction is applied to tobacco use by
the anti-smoking crowd, to fast food, exercise, sex; so many things, in fact,
that if I am going to treat addiction, I may as well be treating Original Sin
but, of course, only those elements of the Fall currently out of favor with the
state or organized groups and constituencies. This is not healing art; this is
the therapist in some Orwellian nightmare as manipulative enforcer of conformity
and adversary of spontaneity and individuality. But in a society where choice
has come to mean the taking of innocent life as a matter of personal
convenience, I guess the idea of the individual actually choosing anything as
mundane as how to treat his own physical or psychological pain has no value at
all.
Over time, I have come to view my work in increasingly simple terms:
consequences. I factor in, but do not really weigh, what a patient uses, how
much he uses, how often he uses, what his spouse, mother, boss, or society
thinks about his use. These are problems only insofar as they generate
consequences for the patient as an individual. If a patient is experiencing
serious consequences related to his use that he is incapable of dealing with
rationally, then that patient has a problem and I can help. But if the patient
is fully functional and the consequences are related entirely to supply, then
I’m beginning to have a problem. And these are the people this piece is
about.
It didn’t used to be that way. I bundled consequences related to
supply right in with consequences related to use, as I was trained to do. Thus
the fully functional guy with the landscaping business experiencing legal
consequences as a result of altering a Loritab prescription was in the same boat
as the professor whose life was falling apart and had legal consequences from
his second DUI. One is a mess because of the effects the drug has on him, the
other has no problems caused by the drug itself, but his life is a mess because
he has the arrogance to think that he knows what he needs and the impulse to
take serious risks to get it. But I would see them both the same, insist on
total abstinence, and send them both back to the slammer when they screwed up.
(Yes, we do have that kind of power, lots of it, and it is arbitrary and
unreviewable.)
For me, the problem began to emerge in the out years. I
live and work in a small city where I regularly run into former patients. When I
see the professor, my sense of professional satisfaction is enormous. Now
something of an AA elder, he’s the picture of social and emotional health,
happily remarried, his life fully restored. He is a beacon of recovery to others
likewise afflicted. He sees treatment as an instrument of his liberation from a
horror that was killing him while destroying, one ugly episode at a time,
everything that mattered in his life. This man was very sick, and now he’s
better.
Once a year I hire a crew from the landscaper because it remains
the best-run business of its kind in town. The boss always comes by to check. He
too is clean and sober but the recovery that the professor radiates is not
available to him. Not because he wouldn’t do anything to have it, but because
abstinence is not the cure for his affliction. Treatment has helped him find
ways to cope that have enabled him finally to get the correctional people out of
his life. But I see in him deep sorrow and loss, and I despise a piece of what I
do. This man remains unwell and doubly afflicted because though he knows exactly
how to get well, the means are simply not available to him.
So, after a
few years, a line began to emerge differentiating ostensibly successful
treatment outcomes as I was able to observe the longer-term realities of the
business I am in. The treatment failures are not a problem for me. They are
fewer than the layman would imagine, but I have my full fair share of drunks who
won’t stop destroying themselves and everyone around them; speed and coke freaks
who wind up in prison because they won’t stop cooking, dealing, and acting out;
potheads who squander their God-given potential in delusional hazes; barbiturate
users wallowing in the pathos of their petty neuroses. Such things are about
life and human weaknesses, so let God sort them out, I say. But with some of my
opiate patients, something else is going on, and I began to connect this to the
fact that opiates, unlike liquor, speed, coke, and pot, have remarkable,
powerful, unique, and irreplaceable medical efficacies.
My melancholia
patients represent a small portion of my patient population—about one in 30
overall, and 20 percent of my opiate load—so it would have been easy never to
stumble on this line. But once stumbled upon, it had to be explored, and the
line has become much brighter as I have contemplated the body count. Among the
patients I have treated over the last ten years who have had successful
treatment outcomes, five committed suicide. These five have one thing in
common—opiate “melancholia.” In addition, all were high-functioning, bright,
imaginative people with intact lives, families, and careers. Each reported
reactions to opiates that mirror giving ADD kids stimulants to calm them down:
the opiates energize rather than sedate; they organize rather than disorient
thinking. These patients had explored the vast new pharmacopeias of
anti-depressant drugs now available—and so efficacious for so many—but without
result for them. All had been clean, sober, and ostensibly in recovery for at
least two years. They faced recovery with diligence and commitment, but with
stoicism rather than more common resistance or enthusiasm. Importantly, each was
introduced to opiates by physicians in the course of legitimate medical
applications. And the consequences related to their use were legal in nature and
had solely to do with securing supply.
So the line differentiating some
of my pain-pill people from all the other substance-dependent patients I treat
has become brighter as time clarifies outcomes. Just now it is blinding me a
little bit because I have one of these patients, whom I believe will not
survive, and I am not enjoying much success in my search for a solution. He is
known to have committed the now infamous crime of “doctor shopping,” so we have
a problem. No doctor in this town will even talk to me about this man.
I
can’t help noting the sad irony here: it is unthinkably politically incorrect
for a doctor to hold a patient responsible for a basket of conditions—STDs,
Hepatitis C, AIDS, alcoholism—in which the patient’s own behavioral choices play
an important causal role. But when the survival instincts of these melancholia
patients, awakened by legitimate medical procedures, start to take over and they
begin seeking opiates, they are not only judged, they are cast out as moral
lepers. This is not only socially acceptable but encouraged.
It’s hard
not to sympathize with the box the doctors are in. Untold billions spent by
pharmaceutical companies over the past century have failed to produce anything
remotely as effective as opiates for acute pain relief. Doctors, who have a
moral and ethical imperative to reduce the suffering of their patients, have no
alternative but to prescribe opiate-based pain medication. Thus my melancholia
patients are exposed, in the normal course of medical care, to a substance that
not only relieves pain but also acts as a wonderfully effective antidote to
problems derived from the peculiar chemistry of their brains. Feeling competent,
functional, and emotionally stable for the first time in their adult lives,
these patients can become quite devious in efforts to secure their supply—not to
get high, as the doctors assume, but to feel functional. Fearing addiction, the
doctors inevitably cut the patient off, and the patient either begins doctor
shopping or seeks supply on the illegal market. Eventually, the patient’s
schemes collapse, and he winds up in the care of people like me, cast into the
mix with other substance-dependent people and provided undifferentiated
abstinence-based treatment. Of course it doesn’t work and, worse, when treatment
appears to work, the results can be lethal.
The appalling problem for
doctors and patients alike is that this is a game with no rules—only dire
consequences, arbitrarily applied. Unless this is to remain some kind of deadly
game of gotcha, protocols and procedures must to be established that kick in
when opiate-based pain medication is prescribed for more than two or three
weeks. This would not be complicated. Patients would agree to provide a clean
urine sample every two weeks, which would require them to abstain for 48 hours
or so and prevent buildup of tolerance. In return, the patient could determine
the length of time opiate treatment, whether for pain or melancholia, would
continue and, within reasonable limits, the appropriate dosage. Something this
simple would work for 90 percent of chronic pain patients as well as all of my
dead patients, along with those for whom successful treatment was just another
mile marker on hell’s highway. And it would relieve doctors of trying to figure
out which patients are conning them, who has legitimate need, and who is going
to get strung out and come back and bite them, which is what they evidently fear
the most.
So the question becomes, why bother with defectives that have
the gall to self-medicate? Well, take Limbaugh, for instance. Never mind his
beliefs or character—we can all agree he demonstrates extraordinary vitality,
talent, capability, and effectiveness. The crazy uncle in the attic that no one
really wants to talk about here is that, while admittedly using very large
amounts of opiates, he remained vital, talented, capable, and effective. I
suspect that he fits my profile because if his brain functioned normally, and he
was doing that much opium for any length of time, he would be slothful,
disorganized, incompetent, dysfunctional, and probably dead. (All of my dead
patients were people of unusual vitality, talent, capability, and effectiveness,
too.)
One of these “addicts” was lost to us on a rainy Tennessee day in
the spring of 1809. Meriwether Lewis was the greatest national hero of those
times and the designated political heir to Thomas Jefferson. He was,
presumptively, the sixth or seventh president of the United States. In
historical terms, his suicide marked the passing of the torch from Jeffersonian
to Jacksonian democracy and had a profound impact on the nature of our country.
The continental vision he shared with Jefferson was replaced by “manifest
destiny” and the Trail of Tears. Conquest by force of arms replaced diplomacy
and guile as the hallmark of American expansionism. Slavery ceased to be an
abomination that we had to be lead out of and became, instead, a bargaining chip
to be cynically used, always to the accrual of federal power. The loss of this
junkie was transformational and, in the aftermath of his suicide, when his
personal effects were sent home to Virginia and inventoried, there wasn’t any
laudanum to be found.
_________________________________________________
Jim Pittaway is
a licensed psychotherapist. He resides and practices in Missoula, Mont