If you do much reading of medical blogs, you will come across the word narcotics a lot. Much of the lives of physicians (including myself) deal with medications, and a good portion of these drugs are controlled substances. It occurred to me that many readers might not know what narcotics and controlled substances are. The term narcotic for many people brings to mind the image of a junkie on the street or someone who is addicted to prescription drugs. So I thought it would be helpful to many for me to give an overview of narcotic drugs, as well as other controlled substances - discussing their appropriate and inappropriate use. I will also touch on the concepts of addiction and chemical dependency - as they are obviously closely related to these drugs.
Wikipedia defines narcotic as follows:
The term narcotic is believed to have been coined by the Greek physician Galen to refer to agents that benumb or deaden, causing loss of feeling or paralysis. It is based on the Greek word narcosis, the term used by Hippocrates for the process of benumbing or the benumbed state. Galen listed mandrake root, altercus (eclata) seeds, and poppy juice (opium) as the chief examples.
In U.S. legal context, narcotic refers to opium, opium derivatives, and their semi-synthetic or fully synthetic substitutes "as well as cocaine and coca leaves," which although classified as "narcotics" in the U.S. Controlled Substances Act (CSA), are chemically not narcotics. Contrary to popular belief, marijuana is not a narcotic, nor are LSD and other psychedelic drugs.
So basically a narcotic is a medication which alters the consciousness of the person taking it. The term is used by many medical professionals synonymously with the term controlled substance. When I use the word narcotic, I generally include the following classes of medications:
- Opioids - Potent pain medications, drugs in this class include Morphine, Dilaudid, Fentanyl (Duragesic), Oxycodone (Percocet, Oxycontin), Meperidine (Demerol), Hydrocodone (Lortab, Vicodin), Codeine, and Propoxyphene (Darvocet).
- Benzodiazapenes - "Tranquilizer" medications, generally used to treat anxiety. Common drugs in this group include Diazepam (Valium), Lorazepam (Ativan), Clonazepam (Klonapin), Alprazolam (Xanax).
- Barbiturates - These are prescribed infrequently - used to treat epilepsy and are also somewhat sedating. The main drug still used in this class is Phenobarbital
- Amphetamines - These are stimulant drugs, generally used for attention deficit disorder, although they have been used to help weight loss in the past. Drugs in this class include Methylphenidate (Ritalin, Concerta, Focalin), Dexamphetamine (Dexadrin), and Amphetamine Salts (Adderal, Vyvanse).
This list is not meant to be exhaustive; I just put what I encounter most commonly.
So what about controlled substances? The term comes from the Controlled Substances Act (a US law passed in 1969) in which potentially abused drugs were controlled to varying degrees. These levels are called schedules, and each schedule carries its own set of rules as to how these medications can be prescribed. The schedules are as follows:
- Schedule 1 - These drugs are illegal to prescribe (except with DEA permission) because, in large part, of their high addiction potential and low medicinal benefit. Drugs such as Heroin, LSD, and (to some people's consternation) Marijuana.
- Schedule 2 - These drugs can be prescribed by professionals approved by the FDA to do so. They carry significant abuse potential, and so have significant restrictions on how they can be prescribed. For instance, they cannot be called in or sent electronically and cannot have refills. Recently they have required the use of special (expensive) paper with these prescriptions, and many states require the use of a "triplicate" form for prescriptions. The main Schedule 2 drugs I prescribe are ADD meds (Ritalin, Aderall, etc.), and pain medications (Duragesic, Oxycodone).
- Schedule 3 - These drugs are "weaker" and overall have a somewhat lower abuse potential (although I am not sure how they made that decision). We can call in and fax these drugs (but for some reason e-prescribing isn't allowed), and they can be given with refills up to 6 months. Drugs on this list include anabolic steroids (testosterone preparations), as well as pain medications (Lortab).
- Schedule 4 - Supposedly lower abuse potential than schedule 3, but the medications of this class are some of the more commonly abused prescription drugs (such as Xanax, Valium, Ativan). Sleep medications (Ambien) and weaker pain medications (Darvocet) are also in this class. The rules for prescription are the same as schedule 3 (generally).
- Schedule 5 - Lowest abuse potential - includes cough medications with codeine, and (for some reason), Lyrica - the seizure medication used for fibromyalgia.
The significance of this drug schedule lies in the legal repercussions if they are distributed in an illegal manner. Prescribing them in a way that does not adhere to the Controlled Substances Act or giving them in an irresponsible manner can result in significant negative repercussions. If a patient begs me for an antibiotic when not indicated (they do sometimes) or for Viagra (ditto) and I give in to their begging, I am simply practicing bad medicine. However, if a patient begs me for a narcotic when they don't actually need it and I give in, I am committing a crime. Physicians with "suspicious prescribing behaviors" can come under review by the DEA. If guilty, they may get their DEA license revoked or even possibly be prosecuted for a felony.
This is why patients with legitimate need for these medications end up feeling like they are "getting the third degree" from their doctor's office when requesting them. No physician wants to come near "suspicious prescribing behaviors" and risk an investigation by the DEA. Even being investigated and acquitted can end up on your record.
The Good and Bad
Narcotic medications are often the best drug for the job. Morphine and its derivatives are some of the most effective pain medications, and so people with painful conditions may be best treated with these medications. Similarly, Valium and other benzodiazepines are very good at helping with anxiety. A person having a panic attack is often best treated with something like Xanax.
These medications work - and therein lies the problem. Repeated use of these medications can result in two serious problems: chemical dependency and addiction.
Chemical dependency is a physical phenomenon described by two criteria:
- Withdrawal - the presence of physical symptoms and clinical signs with the abrupt cessation of the substance.
- Tolerance (also called Tachyphylaxis) - decreasing effectiveness of the drug over time, requiring higher doses for the same benefit.
Most of the scheduled drugs can create chemical dependency (the biggest exception being amphetamines), but other substances can also do this. Alcohol and caffeine are two of the best examples of things that are not (generally) prescription drugs but can create chemical dependence. I personally get a bad headache if I don't have my coffee in the morning.
Addiction is different (although the term is sometimes used in place of chemical dependency); it is the development of compulsive behaviors associated with the substance or action. I think of addiction as being mainly a psychological phenomenon, as a person can become addicted to things they aren't chemically dependent on (such as gambling, shopping, and checking the traffic meter for your blog - heh). A person can become addicted to anything that offers significant intense pleasure. In general, the quicker the onset of the pleasure, the more the addiction.
So how does this relate to narcotics? In a huge way.
The Right Way and the Wrong Way
There are two factors to consider when approaching someone in pain:
- How much it hurts.
- How long it has gone on.
Patients with acute severe pain are unlikely to abuse pain medications, while those with chronic lower-level pain are at very high risk. So if someone comes in with a fractured arm, pain medication is fairly safe to use. Some physicians are still reluctant to prescribe narcotics even in this situation (being jaded by people who exaggerate or lie to get pain medications), leaving many patients to suffer needlessly. Having broken many bones (as a consequence of distractibility), I can say that pain medications make life much better when your pain is severe. So, for acute severe pain, short-acting medications are appropriate and low-risk.
Chronic pain is different. Some people have longstanding pain that is fairly severe - compression fractures in the back, chronic severe degenerative arthritis, and cancer pain can be relentless. It is very difficult for these patients to gauge the severity of the pain, as it becomes hard to remember what being pain-free feels like. It is very hard for the physician to determine the severity as well, as there is no pain-o-meter to stick on someone and measure how much they hurt. You have to take the patient's word for it - which can be hard if the stated pain is inconsistent with physical findings. The result is that some patients suffer silently, while those who report severe pain are held in suspicion by the physician.
The best approach to treating someone who is in significant chronic pain is to use long-acting medications as much as possible and short-acting ones as little as possible. The reasons for this are:
- It is easier to keep pain away than it is to intermittently get rid of it. Patients on long-acting pain medications end up using less medication than those who use only short-acting medications.
- The nature of short-acting medications is to relieve the pain quickly, but for a short period of time. This creates a repeated decision the patient has to make: "do I hurt enough to take a pain medication?" Since these medications have a euphoric effect along with the pain-relief (longer-acting medications with a slower onset don't have as much of a euphoric effect), the decision becomes even harder. This is what drives many people to addiction - they start taking the medication as much for emotional reasons as for pain relief. It is a very hard situation for the patient with true chronic pain. Long-acting pain medications on a schedule take away this decision and make the risk of addiction much lower while doing a better job on the pain.
Long-term use of any narcotic will result in chemical dependency, but that is not nearly as big of a problem as addiction.
This approach actually works for anxiety as well - with antidepressant/anti-anxiety medications like Zoloft or Paxil being used to minimize the need for benzodiazepines.
There are some people, however, who are simply addicted to the euphoric effect (translation: buzz) they get from these medications. Since we still haven't invented the Pain-O-Meter, they can claim they have significant pain and take advantage of compassionate (or just careless) physicians. Emergency physicians see a disproportionate amount of these "drug-seekers" and so tend to be very jaded toward anyone using narcotics. As a primary care physician, I am constantly measuring the likelihood that a patient is a drug-seeker. It is often very difficult.
This makes many people with legitimate pain get labeled as drug-seekers and/or not get adequate treatment for their pain.
There are also some physicians who play the role of "candy-man," handing out short-acting narcotics recklessly. This feeds the hunger the drug-seekers have for their substance of choice and make life much harder for the rest of physicians. In every town I have worked in, I have known who these physicians are - and cringe when one of their patients comes through my door.
Narcotics are a victim of their own success. They should simply be highly effective drugs for people with significant problems; instead, they are under-used in people with real need and abused by those who shouldn't get them.