A couple of weeks ago, I wrote about the difference between being dependent on opioids and being addicted to opioids. Whilst doing my research at the time, I came across a medical journal that said being addicted was the functionality of the brain and that got me interested and desirous of knowing more about addiction for people living with sickle cell.
The average man on the street does not see someone who is addicted as someone in need of help because it’s something to do with the brain. No, instead they are quick to judge and say the individual has low tolerance to opioid. This may be the case, however, we need to go back to the beginning. What was it that made this person become addicted to opioids? Was it some form of trauma in their lives? By this, I’m talking about pain trauma. As regards sickle cell, the trauma would be the trauma of the sickle cell crisis that is ongoing, and thereby becomes chronic.
According to the Sickle Cell Society, “There is a dangerous myth that people living with sickle cell are drug seekers and only go to the hospital for painkillers. This is completely false: a sickle cell crisis puts the person in agonising pain, and they need medication to be able to get through this. Sadly, the public and healthcare professionals alike believe that they are pretending to access narcotics.”
A medical article on ‘treating chronic pain in SCD,’ states that scientific research over the years has shown that addiction is a medical disorder that affects the brain and changes behaviour. Addiction is not pleasurable for the person who is addicted. Doctors talk about the compulsive use of drugs. However, for someone with SCD, a patient who is having a crisis or other complications of sickle cell isn’t having an irresistible craving for pain tablets, just for the sake of it. The problem is that these opioids that are highly addictive are prescribed by clinicians, who think just about pain relief. These tablets activate powerful reward centres in our brains. Opioids trigger the release of endorphins, which is the brain’s feel-good neurotransmitter. Endorphins muffle one’s perception of pain and boost feelings of pleasure. Sometimes, one experiences pain when the opioids are wearing off. One then has no choice but to take more medication, as prescribed.
Sickle cell is a chronic pain condition and by this, I mean one can experience long-standing pain that persists beyond the usual recovery period. Sickle cell pain may go on for well over six months. Some clinicians say chronic pain is the most common complication affecting anyone living with SCD. Pain profoundly affects people’s quality of life, functional ability, education, employment, and health care access. Over time, it is very easy to develop opioid tolerance that leads to addiction. The journal continued by saying that SCD is treated mostly as a haematologic problem, while overlooking the neurologic, psychological, and social aspects of this chronic condition.
The article further stated that prolonged or repeated episodes of nociceptive chronic pain does result in neural changes that enhance pain sensitivity, heighten pain anticipation and aversion, and causes synaptic networks involved in emotion and cognition to prioritise painful stimuli over pleasurable ones. In addition, emotional trauma is associated with pain experience. All these factors contribute to a subjective experience of pain as prolonged, persistent, overwhelming and urgent.
And still with all of the above, clinicians still say that drug abuse is as a result of chronic opioid abuse. My point is we cannot stop after saying ‘chronic opioid abuse,’ because there is a reason for taking the opioid for a long period of time. If a clinician does not take time to understand the neurobiology of dependence and addiction of their patients, then some patients unfortunately will become addicts, after living with chronic pain for over six months. But if clinicians took time to understand their patients better, this could provide insight about their patients’ behaviours and problems. The clinicians could in turn help define realistic expectations and clarify the rationale for treatment methods and goals. In a lot of cases, clinicians prescribe these addictive opioid tablets. In addition, patients could be kept informed about the brain origins of addictions.
The brain doesn’t distinguish between dependence and addiction. But brain abnormalities do result from chronic use of heroin and other morphine-derived drugs as underlying causes of opioid addiction. The brain abnormalities that produce addiction are more complex and long-lasting. They may involve an interaction of environmental effects. For example, stress, the social context of initial opiate use and psychological conditioning.
When heroin, or and any other opiate travels through the bloodstream to the brain, the chemicals attach to specialised proteins, called mu opioid receptors, on the surfaces of opiate-sensitive neurons (brain cells). We know that opioids are prescribed therapeutically to relieve pain and when the opioids activate these reward processes in the absence of significant pain, they can motivate repeated use of drugs simply for pleasure and this can lead to addiction.
Clinicians talk about the pleasure derived from opioids’ activation of the brain’s natural reward system, promoting continued use during the initial stages of opioid addictions. I have an issue with, ‘the pleasure derived from opioids’. There is absolutely no pleasure derived from taking opioids when one is sick and having a crisis. Believe me, I know. When anyone living with SCD has a crisis, the last thing on their minds is pleasure. What the patient wants is for the pain to go away, and by any method used. So, when given some opioids, their minds are more concentrated on the pain.
Prolonged use of opioids produces more long-lasting changes in the brain that may undertake the compulsive drug-seeking behaviour and related adverse consequences that are the hallmarks of addiction. Recent scientific research has generated several models to explain how habitual drug use produces changes in the brain that may lead to drug addiction.
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