Tuesday, June 17, 2014

The psychopharmacological interchangeability of narcotic pain killers, anti-anxiety agents, psychostimulants and ordinary success in maintaining sense of well being in addictive personalities

I treat quite a few opiate addicts with Suboxone (buprenorphine). Buprenorphine is an opiate too, but with a very unique property. Unlike regular narcotics, such as Vicodin, Oxycontin, heroin, morphine etc., the patient does not become habituated to Suboxone, and does not keep increasing the dosage to get the same effects.
And Suboxone is not just for preventing the horrible withdrawal symptoms, which, by the way, is the main reason the addicts shudder at the thought of giving up opiates, despite knowing that it is destroying their body and their life, it also - unlike Methadone - helps patients resume their pre-addiction life style. Quite a few are able to start working again, take up family responsibilities,  emotionally respond to others, and start feeling like their normal selves. In many it ameliorates their anxiety and depressive symptoms better than antidepressants. 
Despite all these wonderful properties, Suboxone cannot be used indefinitely. It cannot be viewed as a drug like insulin that a patient must take for the rest of his life for his diabetes. While many so called addctionologists want addiction to be looked upon as a physical disease - so they can maintain their belief that they know how to treat these complex problems without knowing a whit about depth psychology - addiction, or for that matter all mental diseases, are fundamentally different from physical illnesses. Mental illnesses can accentuate and wane remarkably with the aid of just psychological inputs and life circumstances.  And therefore however well the patient is doing on Suboxone, it is natural for the psychiatrist to be biased towards getting him off of such a medical crutch. One knows not what harm, in the long run, such brain altering medications do to the person. And so a good doctor is always pressuring his patient to keep cutting down on his Suboxone dosage, with the aim of eventually making him totally drug free. 
But here one runs in to a problem. Suboxone itself is incredibly addicting. The patient tolerates its tapering to a point, and then refuses to go further. At a certain threshold, which is different for different people, in some surprisingly as homeopathic as half a mg.a day, the symptoms return, and not just the physical ones of body aches and pains, diarrhea, sweating etc., but the psychological malaise too. Depression, anxiety, sleep problems, easy distractability, diffidence, emotional withdrawal, even something so basic to human nature as taking care of one's own children, they all start raising their ugly heads. In short the patient falls back in to his or her doldrums.

It is difficult to say whether these withdrawal symptoms are due to some property of buprenorphine itself, which the addicts cannot do without, or the return of the underlying psychopathology which drove them to get addicted to the opiates in the first place. Perhaps it is both.
Now an interesting feature, and which is the reason for this blog entry, is that these symptoms can be ameliorated to a great extent if Suboxone is supplemented with an anti-anxiety agent or a psycho-stimulant. Addition of Xanax or Ativan or Adderall considerably reduces the need for buprenorphine. 
Why does this happen?
I have a far fetched theory.
 People take drugs when the ego-syntonic heterosexual outlets for their love needs get blocked. Humans basically live for love. If they have no one to love, or do not feel loved by anybody, they might as well curl up in a corner and die. And when they (rather their system) cannot find love in an adult genital fashion, their libido (love need) regresses and starts emerging through autoerotic activities (through pregenital channels).
Generally this regression of psychosexual organization occurs silently and invisibly, and has to be deduced. For the patient himself is not aware as to when and how the regression is taking place. Furthermore, the slipping back into autoeroticism primarily does not occur at the physical plane but in fantasies, and  in displacement, so their true nature remains obscure, and to make matters even more difficult to decipher, the fantasies which bring about the discharge of sexual tensions, are mostly played out in the unconscious.
The narcotic analgesics, the antianxiety agents and the psycho-stimulants, despite their acting upon different aspects of the brain/mind, and through different neurotransmitter systems, facilitate this regression.
How do these drugs  do it?
Once we reach the genital stage, our body creates psychological and physiological barriers to prevent  sexuality from finding easier discharge through pregenital channels. These barriers are basically  psychological and physical reactions that follow when a person indulges in pregenital sexual satisfaction.  The libido has very many ways of discharging sexual tension through pregenital channels. But they all have one thing in common: the use of one's own body instead of somebody else's, as the sexual object. And herein lies the trouble. At the end of the sexual act one does not feel fully liberated and unbound, with the spirit soaring, but rather in throes of mixed feelings;  some relief of tension and paradoxically some increase of it.
For autoeroticism requires playing both the masculine and the feminine roles. And there is always a conflict over that. The superego/conscience objects to playing the feminine role in man and vice versa in woman. So after the autoerotic/pregenital sexual activity, whether done through actual masturbation (physical action), or through (conscious and/or unconscious) fantasies, or even done in dreams, the person emerges from it with all kinds of body aches and pains, and whole range of mild depressive and anxious affects.
This dysphoria and pain occurs for two reasons. One, when non-genital somatic points of the body are used as genital organs they show inflammatory response. Not quite full blown inflammation, but some processes akin to the tumescence and detumescence of genital organs, corresponding to sexual excitement and its discharge, and since these body parts are not primarily designed to play the role of the genitals, the inflammation like process that takes place there leaves the body sore and in fibromyalgia-like state.
The muscular spasms and mucosal secretions  at the deepest level are masculine (active) and feminine (passive) sexual responses. The destructiveness of narcotics towards one's physical appearance - one can always spot the unhealthy looks of those who are strung out on drugs -  perhaps owes to this use of non-genital organs as genitals - surge of auto-eroticism over genital sex - in drug addicts.
There is also anticipation of physical and mental punishment for finding sexual satisfaction through pregenital routes, which adds psychic malaise to the physical misery.
Now when we examine these dysphoric physical and mental states which are physical and mental responses to autoeroticism and anticipation of punishment, we find some interesting correlates to the sexual fantasies that are indulged in to achieve the sexual discharge.
 If the associated fantasies to autoeroticism are oral cannibalistic in nature, then the inflammatory response and the punishment emerges through the sensations of disgust, repugnance, nausea, vomiting, stomach acid secretion, teeth grinding, migraines etc.
If the sexual fantasies resort to anal-sadistic designs then the punishment for sadism occurs through  increase in motor restlessness and spasms of the GI, urinary and respiratory tracts, while the passive masochistic fantasies cause the reaction of excessive mucosal activity of the colon, respiratory tract and the linings of paranasal sinuses [continuation of the opthalmic mucosal lining, and in essence an extension of crying].
These pathological reactions are like "undoing" of the gratification.
Now this painful reaction and overactivity of the GI tract and other mucosal tracts and muscular system is inhibited when one takes narcotics. Disgust, nausea, vomiting, migraines, spasms and excessive secretions of GI, respiratory and urinary tracts which would have put brakes upon indulging in forbidden pregenital sexual behaviors are put on "off mode" by the narcotics, giving free reins to the addict to indulge in autoeroticism. It does so by suppressing the pain reaction to such behaviors. Popularity of narcotics, in no small measure, lies in this easy way out for one's sexual needs; discharging them upon one's own self instead of going out and finding a heterosexual partner and competing with others for his or her love.
While narcotics are par excellence in enabling one to indulge in forbidden fantasies and autoeroticism, anti-anxiety agents and dopamine enhancing drugs can also be used for the same purpose. Narcotics do it by blocking the psychological and physical pain that follows on doing the forbidden. This is based upon previous experiences of painful consequences that occurred after such deeds (that were risky and dangerous) and which not infrequently led to actual physical punishment, or at least scolding and threats of doing so from the parents. It is kind of simple Pavlovian response - classical conditioning - pairing of pain with indulgence in off-limit activities.
Benzodiazepines achieve the same end by taking away the fear of the consequences. Here the pain that follows on indulgence in autoeroticism is not blocked, only the anxiety over treading in to the forbidden territory is wiped out. With GABA blocking drugs, the person ceases to fear the tomorrow, lives for the moment so to speak, and gives into forbidden behaviors. The dread of the consequences is taken away from the psyche as the drugs put the highest cognitive centers of the brain in sleep mode.
Dopamine enhancing drugs like Adderall work by a completely different mechanism. They shift the attention from the pain and suffering to finding pleasure in whatever one is doing at the moment - hyperfocusing upon the immediate. So the malaise, fibromyalgia like pain, headache and guilt feelings that follow the indulgence are pushed in to the background and the person can go on with the activities of the day instead of crawling into bed and sleeping through the suffering. The energy that emerges from this artificial boosting of dopamine acts like a separate fountain of mental activity. So while the body is smouldering in the subterrain the person continues to feel good on the surface.
At this point it may not be inappropriate to add that ordinary success has the same effect upon lessening the need for opiates as the taking of psychostimulants. As one of my patient put it: "As long as I am busy I don't feel the need for Suboxone. As long as things are going good drugs are furthest from my mind. As long as I am making money, getting tips at work, and I have enough money for my children I have no need for Suboxone. But the minute I have fight with other waitresses or the boss is mean with me, I start getting withdrawal symptoms."
This phenomena of success, which no doubt secretes dopamine in the brain, and reduces the need for Suboxone and other opiates is exemplified by the fact that professional people like doctors, lawyers, nurses and other high rankers of society have far greater success in kicking their habit and getting off the Suboxone faster than people who are in low paying jobs or are unemployed.
Am I then suggesting that one should routinely put people who come for Suboxone therapy on benzodiazepine and amphetamines as well? Or at least make use of them as adjunctive therapy to get off Suboxone?
This is a hard call. We know addition of Xanax reduces the need for Suboxone and so does the addition of Adderall. But by doing so in the long run are we going to make the patient dependent upon three classes of drug?
I think it depends upon the personality of the patient. In some the combination of all three at low doses may be better strategy for keeping them off the street drugs. In some Suboxone alone at higher doses and longer tapering off period will be the ideal strategy
My main point here is that clinically the requirement for opiates and Suboxone are lessened when the patient is given benzodiazepine or Adderall concurrently.  Whether in the long run this makes him  more or less prone to addiction I do not know.   

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