Chapter 6:

The Long Haul

THE NATURAL HISTORY OF DRUG ADDICTION
FAMOUS DRUG USERS
RESEARCH
MORTALITY IN DRUG USERS
PAINFUL DISORDERS
PSYCHIATRIC CONDITIONS
OTHER MEDICAL CONDITIONS

THE NATURAL HISTORY OF DRUG ADDICTION

An old aphorism called the 'ten year rule' holds that most addicts consume drugs for a period of ten years before giving up. While not hard and fast, it seems to apply as much to smokers, compulsive drinkers and heroin addicts. Some have died before the ten year mark, but those who make it may have a bright future if they play their cards wisely.

When done at the right time, withdrawal from drugs can be relatively painless and quite rewarding. For the addict, detoxification is a positive and active process. The timing and motivation are both important to success. It is during this time that dependence upon the drug must be replaced by other positive things in daily life.

Another old saying goes: 'Once an addict, always an addict'. This is often stated by drug users themselves, and it may be more relevant than it sounds. Like 'recovering' or 'ex'-alcoholics, many dry alcoholics still state that they are alcoholic until the day they die. It is true that heroin addicts who have not used the drug for a number of years are still at risk of returning to drug use should certain circumstances arise. This may mean easy availability of the drug or painful life situations, or both.

Throughout history there have been waves of drug and alcohol use. When new drugs are introduced into naïve populations, there is a sudden rush of enthusiasm, followed by a learning process as the drug is assimilated by the community. Substances with the greatest market penetration are the stimulants caffeine and nicotine, contained in coffee, tea and tobacco.

Opium was so popular in China in the nineteenth century that in some provinces over 80% of adult males were addicted. In Victorian England there were enormous amounts of narcotic consumed, amounting to tons of Turkish opium imported each year. Australia has also had an enormous appetite for narcotics in the forms of mixed analgesics.

It is said that alcoholic spirits were first used by large numbers of Americans during the prohibition period. Previously popular only with the rich, spirits were the best way for individuals to smuggle enough alcohol for a party. And the party continues today, for better or for worse!

FAMOUS DRUG USERS

Thomas De Quincey (b.1785) was the first to describe his own addiction in detail. In his 1821 classic, Confessions of an English Opium Eater, he broaches most of the issues faced by addicts today. Even the title was shocking to readers of the time, as it was believed that only Asians could become addicted to opium. Reworked and expanded by the author in 1856, the book's wordy style is a little heavy for the modern reader but De Quincey's detailed self-analysis is absolutely fresh and relevant to the human condition of all ages. He covers the intense feeling of well-being imparted by the drug as well as the ambivalence often experienced by opium users.

He contrasts the relatively minor adverse consequences of opium with the destructive effects of alcohol. In his introduction he also describes the rabble encountered in a rural apothecary at opening time and the seemingly enormous doses of opium dispensed to the addicts. The urgency with which the customers, mostly agricultural workers, jostled for service is typical of what happens in some methadone dispensaries today.

First prescribed opium for a dyspeptic condition, De Quincey lived a long and productive life, dying in his seventies after more than forty years of drug use. He was just one of many prominent people who we know were addicted to opioids. There was a group of nineteenth century poets and philosophers whose members took to opium. Some were known to be addicted, others partaking on a more casual basis. While some facts are known, other details remain speculative.

Dr William Stewart Halsted (1852 - 1922) is known as the father of American surgery. He pioneered the cancer saving operation, the mastectomy, at a time when cure from the disease was unknown. He popularised the use of rubber gloves in the operating theatres and introduced several other important advances in surgical technique including improved blood transfusion. He used daily morphine for most of his long life.

Other famous people who took opium included Roman Emperor Marcus Aurelius who suffered with joint pains, William Wilberforce (1759 - 1833), Samuel Taylor Coleridge, Timothy Leary (d.1996), William Burroughs (b. 1916) to name but a few.

Numerous practising doctors, lawyers, politicians and business people use heroin and some have become addicted. A proportion of these are nowadays on methadone treatment, mostly unbeknownst to their colleagues and clients.

What is important from our standpoint is that such people are productive members of society at the same time as using large quantities of opioid drugs. Most of them only use drugs for limited periods but some consume their drugs regularly over many years.

RESEARCH

Twin studies show a higher rate of addiction in identical than fraternal siblings, proving a genetic component to this behaviour. The high concordance in siblings generally is partly genetic and partly environmental. Adopted children brought up by alcoholic parents may also grow up with alcohol problems, indicating an environmental component.

A previous attempt to find a gene for alcoholism found a preponderance of some particular sequences, but failed to account for the narrow ethnicity of the subjects. When fully examined, this invalidated the would-be exciting results. Future work in this area will have to be more rigorous by utilising a broad cross-section of ethnic groups and strict scientific methods.

Much new work is being done in the field of DNA typing. It is highly likely that there are multiple genetic factors in the development of drug addiction, including personality, behavioural, metabolic and other effects. When these are added to environmental factors, the causes for drug addiction may be better elucidated.

Studies in Britain prior to the HIV epidemic showed that after seven years, about a third of narcotic users have ceased all drugs, 10% are dead, 10% are in jail and approximately 40% are still in receipt of a legal prescription, mostly methadone ⁹. Comparable results have been found in Australia more recently. In the United States, the nature of the society and limited availability of treatment make comparisons more difficult.

MORTALITY IN DRUG USERS

Lives are lost frequently in the drug using population, and very often it is not the victim's drug-of-choice which kills them. Substitute drugs, harmful additives and unknown concentrations or alternative routes of administration are all possible causes of death. Even with tobacco, few, if any die from nicotine poisoning, but nearly 20,000 Australians perish every year from the consequences of smoking.

Studies of untreated narcotic users show an annual mortality between 1.5% and 7% ^{2, 7}. A proportion of patients have hepatitis and HIV contracted before treatment commenced. One study found that patients on methadone maintenance had mortality rates close to that of the non-drug using population ¹⁰.

In a large Scandinavian study, it was found that death rates in street heroin addicts were 63 times greater than for matched subjects who did not use illicit drugs ¹¹. They also demonstrated an eight-fold reduction in deaths of those going into methadone treatment. Those leaving treatment voluntarily had death rates of half that again. Some patients who were discharged from treatment due to various 'infringements' had mortality rates which returned to 55 times those predicted for non drug users. We now know that these were the very patients most in need of treatment services, being at highest risk of death and other complications. Involuntary discharge should no longer occur in ethical treatment services.

Although it was probably sub-optimal by today's standards, the methadone treatment given to the Scandinavian subjects was still dramatically effective in preventing deaths due to all causes.

In a study of all 152 New South Wales heroin related deaths reported in 1992, researchers found that only 2% of these occurred in patients currently enrolled in methadone treatment ¹². Another 26% of the victims were previously registered for methadone treatment, which was relatively freely available at that time. Thus over two thirds of such deaths occurred in those who had never been registered for methadone treatment. A number of these may have been on waiting lists, some may have lived in areas without treatment services while some occasional users may not have qualified for treatment.

These high mortality rates are thus very largely preventable by the use of methadone where appropriate. Each death represents an enormous cost to the community, not to mention the dozens of non-fatal overdoses which occur for each fatal one. Methadone is a relatively cheap and simple medical treatment, costing as little as $7 per day and utilising services already available in the community.

In Amsterdam, (pop. 700,000) it was estimated that 80% of 7,000 regular heroin users were in touch with treatment services. Of these, approximately 3,500 were on methadone at any one time in 1995 ¹³. The total annual drug-related mortality (direct and indirect) in both 1992 and 1993 was 1.9% of the estimated drug using population.

A number of heroin overdoses apparently occur in patients who have recently left treatment. Another common overdose scenario is in those recently released from prison. They may have little or no tolerance and the street drugs may be of unaccustomed strength. In some jails there is now a move to permit prisoners to commence or recommence methadone treatment before release. Other prison systems still do not permit methadone treatment despite the evidence of its practical benefits to those incarcerated and to society generally. The denial of methadone in this way may breach international treaty obligations and it effectively punishes addicted offenders twice for their crimes.

Sporadic deaths of patients have been reported in the stabilisation period of methadone treatment. These may be minimised by graduated dose increases and regular clinical assessments.

The finding of an eight-fold drop in the death rate of heroin addicts entering methadone treatment translates to a massive saving of lives. More than a quarter of victims in the New South Wales heroin overdose study had previously been on methadone treatment, but were not afforded its protection at the time of death.

It can be conservatively extrapolated from the studies that of the 17,000 patients on methadone Australia-wide in 1996, in excess of 250 lives are saved annually. This is in addition to the other substantial benefits already seen in areas of employment, reduced criminality and the prevention of viral disease transmission. At a modest cost to the community methadone treatment easily pays for itself in all these ways.

Only a minority of these patients fit the 'junkie' stereotype and some are very young, emphasising the tragedy of these largely preventable deaths. Such observations further justify the continued expansion of ethical prescribing of methadone by doctors in the treatment and control of heroin addiction.

PAINFUL DISORDERS

A number of addicts date their first drug use to pain killers prescribed by doctors for common conditions like back pain, migraine or shingles. Injected narcotics are also commonly used after motor accidents involving fractures and soft tissue injuries. Subsequent scarring can also lead to chronic pain syndromes which may sometimes require narcotic pain killers.

For those who are already using heroin or other narcotics, opioids will only relieve pain if prescribed in substantially higher doses than the regular daily intake. Drug withdrawals will invariably worsen such pains.

Where possible, corrective treatments are preferable to the use of pain killers. These include physiotherapy, arthritis medication or surgery. Alternative treatments such as acupuncture and manipulative manoeuvres may also help a proportion of cases.

When all such attempts fail to control symptoms narcotic analgesics may be required. Many non-addicted patients show no signs of addiction and can use the drugs when needed depending on the degree of pain. Others develop the addiction syndrome. Patients who lose control of their analgesic drug use often respond well to treatment given in much the same manner as when used for illicit drug use.

Methadone is now a popular modality with pain specialists due to its long half-life, oral absorption, safety and economy. Patients also find it very acceptable as a simple alternative to what may have previously been complex combined therapy.

It is a great pity that a number of doctors are still reluctant to prescribe strong pain killers to addicts who are suffering from painful medical conditions. These patients deserve pain relief just as much as other medical patients, and since they have an established tolerance to narcotics they may require higher doses for the same analgesic effect. The main factor against the more liberal use of opiates, the risk of addiction, is academic in these patients.

PSYCHIATRIC CONDITIONS

Numerous heroin addicts suffer from depressive, anxiety, and psychotic disorders. Some may pre-date the substance abuse, others accompany it and in others still, the psychiatric illness comes on after the addiction is well established.

Schizophrenic symptoms may be helped, at least temporarily, by opioids. Like other unpleasant sensations, delusions may be quelled and a sense of relaxation induced. It is said that prior to the introduction of major tranquillizers in the 1950s, opioids were occasionally used in treating these disorders. It is thus not surprising that some schizophrenic patients who are introduced to heroin develop a habit on the drug. These patients are less organised and may be more prone to complications of intravenous drug use. Such patients, however, only rarely have the resources to obtain large quantities of illicit drugs and they may also be more readily able to cease such drug use than other addicts.

People who abuse alcohol or tranquillizers often become depressed. This depression responds best to withdrawal of the agent causing the symptoms. Those who develop a true 'endogenous' depression whilst using other drugs may go un-recognised for a time. Opioids such as heroin and methadone are not anti-depressants. Depressed patients respond well to normal medical interventions, and should never be denied treatment just because they are 'recovering addicts'. The principles of Alcoholics and Narcotics Anonymous uphold the right of the addict to receive all normal medical treatment, as long as this does not entail the consumption of alcohol or narcotics.

Those with such true depressive illness usually respond well to anti-depressant drugs such as tricyclics (eg Sinequan, Prothiaden), tetracyclics (eg Tolvon), MAO inhibitors or the newer agents, serotonin-specific re-uptake inhibitors (SSRI's e.g. Prozac, Aurorix, Zoloft). Those with 'situational' or 'exogenous' depression should receive counselling, psychosocial support and careful adjustment of their methadone doses.

OTHER MEDICAL CONDITIONS

The incidence of hepatitis C infection amongst injecting drug users is over 90% in some studies. No immunisation currently exists. Only a minority of patients develop symptoms of fever and yellow jaundice. This means that most cases were unrecognised or 'sub-clinical' hepatitis C infections.

The long-term natural history of this illness is still unclear since it has only been tested for since 1990. Some alarmist media reports have played on this uncertainty, causing unnecessary anguish in patients and their families. What is clear is that over half of these cases get over the infection rapidly with no sign of on-going liver damage. A proportion, however, have continuing liver inflammation which shows up in blood tests. This 'chronic persistent hepatitis' is often of no consequence short term. A unknown proportion of these patients will develop cirrhosis or liver cancer up to 20 years later.

The means of transmission of hepatitis C usually involves blood or blood products. However, there are a number of reports of transmission in patients who seem not to have shared syringes or have other risk factors. These people have nearly always used drugs in the presence of others and it is possible that the means of spread involves the skin, droplets, spoon, tourniquet or even the drug itself. Current treatment is only marginally effective at suppressing disease activity.

Hepatitis B can also cause a chronic active or persistent hepatitis in drug users. It is found in about a third of those who injected heroin in Australia in the 1980s. Like hepatitis C, it is often a sub-clinical illness, but it can also occur as a serious, acute infection with profound fatigue, jaundice, weight loss and fever. This can also lead to cirrhosis, chronic liver failure and, in rare cases, cancer. Although liver failure can now be treated successfully with organ transplantation, the rare liver cancer called hepatoma is usually fatal. Immunisation is protective.

The human immunodeficiency virus (HIV) has not spread in the Australian drug using population as it has elsewhere. In some parts of Europe and America the incidence is between 30% and 50% amongst injectors. In Australia this figure has remained below 2%, despite HIV spreading to Australia very early in the epidemic. This was due to a co-ordinated strategy including the availability of syringes, methadone treatment and an education campaign.

Methadone is relatively safe during pregnancy. While it is desirable for all pregnant women to be drug free, the risks of heroin use are very high, and easily outweigh any theoretical drawbacks of methadone. In heroin users, miscarriage, still-birth, pre-term delivery and failure to thrive occur with greater frequency. This is in addition to the risks of overdose, viral infections, thrombosis and social consequences. Studies have shown that the majority of babies born to women on methadone are healthy. Outcomes are greatly improved when compared with women who are still using illicit drugs.

Babies may have a temporary narcotic requirement needing reducing doses of morphine for withdrawal effects. Breast feeding is now encouraged by most specialists, even for mothers on higher doses of methadone. The long term effects of such exposure in early life is unlikely to be significant while the benefits of breast milk are substantial.