THE RISKS OF OXYCODONE

Oxycodone is the most commonly abused opioid in America. More than 12 million people use opioid drugs recreationally in the U.S.A.

Oxycodone was the leading cause of drug-related deaths in America until 2012, when heroin and fentanyl became more widely abused. Oxycodone overdose can cause spinal cord infarction in high doses as well as ischemic damage to the brain, due to prolonged hypoxia from suppressed breathing.

Most common side effects of oxycodone include reduced sensitivity to pain, euphoria, relaxation, and respiratory depression. Other side effects of oxycodone include constipation, nausea, tiredness, dizziness, itching, dry mouth, and sweating. 

Most side effects generally decrease in intensity over time, although constipation is likely to continue throughout use. Oxycodone in combination with naloxone in timed-release tablets have been created to deter abuse and reduce “opioid-induced constipation.” 

There is a high risk of severe withdrawal symptoms if a patient abruptly discontinues taking oxycodone. In a medical context, if the drug has been taken over an extended period of time, it is to be withdrawn gradually. People who abuse oxycodone at higher than prescribed doses are at risk of severe withdrawal symptoms

Symptoms of oxycodone withdrawal may include anxiety, panic attack, nausea, insomnia, muscle weakness, fevers, and other flu-like symptoms. Withdrawal symptoms have also been reported in newborns whose mothers had been taking oxycodone orally or injecting it during pregnancy.

In high doses and in people not tolerant to opioids, oxycodone can cause shallow breathing, slowed heart rate, clammy skin, pauses in breathing, low blood pressure, constricted pupils, circulatory collapse, respiratory arrest and death. Opioids were responsible for 49,000 of the 72,000 overdose deaths in the U.S. in 2017.

Oxycodone, sold under brand names such as Roxicodone and OxyContin (the extended release form) is a strong, semi-synthetic opioid used medically for treatment of moderate to severe pain. It is highly addictive, usually taken by mouth, and is available in immediate-release and controlled-release formulations. Onset of pain relief begins within fifteen minutes and lasts up to six hours with the immediate-release tablets. 

The reformulated OxyContin has caused some recreational users to switch to fentanyl, which is cheaper and not as difficult to find (and far more dangerous). In the United Kingdom, oxycodone is available by injection. When taken by mouth, oxycodone has roughly one and a half times the effect of the equivalent amount of morphine. 

Oxycodone was first made in Germany in 1916 from thebaine, an opiate alkaloid. In 2020, oxycodone was the 54th most commonly prescribed medication in the United States with over 12 million prescriptions.

THE DANGERS OF METHAMPHETAMINE

Methamphetamine is a central nervous system stimulant used as a recreational drug and rarely as a second-line treatment for attention deficit hyperactivity disorder and obesity. It is seldom prescribed over concerns involving human neurotoxicity and potential for recreational abuse as an aphrodisiac and euphoriant. 

The highest degree of illegal methamphetamine use occurs in parts of Asia and Oceania, as well as the United States, where it has been classified as a schedule II controlled substance. Levomethamphetamine is available in the United States as an over-the-counter drug for use as an inhaled nasal decongestant. 

Recreationally, methamphetamine’s ability to increase energy has been reported to lift mood and increase sexual desire to such an extent that users are able to engage in sexual activity continuously for extensive periods during binges. At high doses, methamphetamine can induce psychosis, the breakdown of skeletal muscle, seizures and brain bleeding. Chronic high-dose intake can precipitate unpredictable mood swings, stimulant psychosis and violent behavior. 

Methamphetamine is very addictive and there is a high likelihood that withdrawal symptoms will occur when methamphetamine use ceases. Withdrawal from methamphetamine use may lead to a post-acute-withdrawal syndrome, which can persist for months beyond the typical withdrawal period. 

Methamphetamine is neurotoxic at high doses and has been shown to have a higher toxicity toward serotonergic neurons than amphetamine. Methamphetamine neurotoxicity causes deleterious changes in brain structure and function, such as reductions in gray matter volume.

A moderate overdose of methamphetamine may induce symptoms such as abnormal heart rhythm, confusion, difficult or painful urination, high or low blood pressure, high body temperature, over-active or over-responsive reflexes, muscle aches, rapid breathing, tremor, and an inability to pass urine. 

A large overdose may produce symptoms such as adrenergic storm, methamphetamine psychosis, substantially reduced or no urine output, cardiogenic shock, circulatory collapse, pulmonary hypertension, kidney failure, rapid muscle breakdown and serotonin syndrome. A methamphetamine overdose will likely also result in brain damage owing to dopaminergic and serotonergic neurotoxicity. Death from methamphetamine poisoning is often preceded by convulsions and coma.

A Cochrane Collaboration review on treatment for amphetamine and methamphetamine-induced psychosis states that about 5–15% of users fail to recover completely. The same review asserts that antipsychotic medications can aid in the resolution of acute amphetamine psychosis symptoms. 

GETTING FREE OF COCAINE

Cocaine addiction is a biopsychosocial disorder characterized by persistent cocaine use despite adverse consequences, and withdrawal symptoms upon discontinuation. The Diagnostic and Statistical Manual of Mental Disorders classifies cocaine abuse as a “stimulant use disorder”. 

Cocaine use causes euphoria and high amounts of energy, as well as mood swings, paranoia, insomnia, psychosis, high blood pressure, a fast heart rate, panic attacks, seizures, cognitive impairments and drastic changes in personality. Overdose may result in cardiovascular and brain damage, constricting blood vessels, stroke and constricting arteries, causing heart attack.

The symptoms of cocaine withdrawal are dysphoria, depression, anxiety, decreased libido, psychological and physical weakness, pain, and compulsive cravings. Cocaine is a powerful stimulant known to make users feel energetic, happy, and talkative. 

Many people who habitually use cocaine develop a condition not unlike amphetamine psychosis, the symptoms of which include paranoia, confusion and the feeling of insects crawling under the skin, also known as “coke bugs.” 

Differing ingestion techniques come with their own symptoms. Snorting coke can cause a loss of sense of smell, nose bleeds, problems swallowing and an inflamed, runny nose. Smoking cocaine causes lung damage and injecting it puts users at risk of contracting infectious diseases. Heavy users report thoughts of suicide, unusual weight loss and trouble maintaining relationships.

When used habitually, because of its highly addictive nature, coke can change brain structure and function. Circuits within the brain structure that play a part in stress levels become more sensitive. When cocaine is absent, this increases an individual’s feelings of displeasure and negative mood swings. 

Additional withdrawal symptoms are exhaustion, hypersomnia, increased appetite, restlessness, irritability, lethargy, emotional lability, poor concentration, and bowel issues. In 2019, the CDC reported over 16,000 deaths from cocaine overdose in the US alone.

A study consisting of over one thousand US residents who had used cocaine within the previous 24 months for the first time was conducted. It was found that the risk of becoming dependent on cocaine within two years of first use was 5–6%. The risk of becoming dependent within 10 years of first use increased to 15–16%. 

Among recent-onset users individual rates of dependency were higher for smoking (3.4 times) and much higher for injecting. Women were 3.3 times more likely to become dependent, compared with men. Users who started at ages 12 or 13 were four times as likely to become dependent compared to those who started between ages 18 and 20.

UNDERSTANDING FENTANYL

Fentanyl contamination in cocaine, methamphetamine, ketamine, MDMA, and certain “prescription” drugs is common. Fentanyl is often found in heroin as well as illegally manufactured opioids and benzodiazepines. Naloxone, sold under the brand name Narcan, can completely reverse an opioid overdose. Fentanyl poses an very high overdose risk, due in part to having an extremely unpredictable fatal dosage when mixed with other drugs.

A kilogram of heroin laced with fentanyl may sell for more than $100,000, but the fentanyl itself may be produced far more cheaply (about $6,000 per kilogram); this provides incentive for drug dealers to cut high amounts of it into their product. As of 2018, fentanyl was the most common opioid in overdose drug deaths, surpassing heroin. 

There were 81,230 drug overdose deaths during the 12 months from May 2019 to May 2020, the highest number of overdoses for a 12-month interval ever recorded for the U.S. In 2021, the Public Health Agency of Canada noted that 87% of accidental opioid toxicity deaths involved fentanyl. Deaths involving synthetic opioids such as fentanyl increased by a marked 22% in 2021, according to the CDC data. 

In the past, media outlets have reported stories about police officers being hospitalized after contact with powdered fentanyl, or after brushing it from their clothing. Transdermal (via the skin) and inhalative exposure to fentanyl is extremely unlikely to cause overdose (except in cases of prolonged exposure with large quantities) and first responders are at minimal risk of fentanyl poisoning through accidental contact. The effects being reported (rapid heartbeat, hyperventilation and chills) were more commonly associated with a panic attack.

A 2021 paper expressed concern that these physical fears over fentanyl may inhibit effective emergency response to overdoses by causing responding officers to spend time on unnecessary precautions, and that such media coverage could perpetuate social stigmas that people who use drugs are dangerous to be around. 

The CDC recommends the following; the need to expand distribution and use of naloxone and overdose prevention education locally; to expand access and availability of treatment for substance use disorders; to intervene early with individuals at highest risk for overdose; and to improve detection of overdose outbreaks, in order to facilitate a more effective response. 

An effective social media campaign has been put into motion by the United States DEA called “One Pill Can Kill” with the goal of spreading awareness about the prevalence of counterfeit pills, and to show the difference between counterfeit pills and real prescription pills. It also offers resources for help with drug addiction and rehabilitation.

GETTING OFF OF XANAX

Discontinuation of benzodiazepines, even after a relatively short duration of treatment, may result in withdrawal symptoms, which are the main sign of physical dependence. The most frequent symptoms of withdrawal are insomnia, gastric problems, tremors, agitation, fearfulness, and muscle spasms. Less frequent symptoms are irritability, sweating, depersonalization, derealization, hypersensitivity to stimuli, depression, suicidal behavior, psychosis, seizures, and delirium tremens.

Abrupt withdrawal can be dangerous and lead to excitotoxicity, causing damage and even death to nerve cells as a result of excessive levels of the excitatory neurotransmitter glutamate. In excitotoxicity, nerve cells suffer damage or death when the levels of otherwise necessary and safe neurotransmitters become pathologically high. Symptoms may also occur during a gradual dosage reduction, but are typically less severe and may persist as part of a protracted withdrawal syndrome for months after cessation of benzodiazepines

Approximately 10% of patients experience a notable protracted withdrawal syndrome, which can persist for many months or in some cases a year or longer. Protracted symptoms tend to resemble those seen during the first couple of months of withdrawal but usually are of a subacute level of severity. Such symptoms do gradually lessen over time, eventually disappearing altogether.

Benzodiazepines have a reputation for causing a severe and traumatic withdrawal; however, this is due largely to the withdrawal process being poorly managed. A slow and gradual withdrawal is recommended, customized to the individual, with psychological support. The time needed to complete withdrawal ranges from four weeks to several years. Alcohol is also cross tolerant with benzodiazepines and more toxic and caution is advised, in order to avoid replacing one dependence with another.

Withdrawal of benzodiazepines for long-term users leads to improved physical and mental health, particularly in the elderly; although some long term users report continued benefit from taking benzodiazepines, this is likely the result of suppression of withdrawal effects. A number of studies have drawn an association between long-term benzodiazepine use and neuro-degenerative disease, particularly Alzheimer’s disease as well as an increased risk of dementia.

PSYCHOLOGICAL DEPENDENCE

Psychological dependence is a mental disorder that involves emotional symptoms like anxiety and anhedonia after ceasing prolonged drug use. 

It involves a belief that you need the substance to do certain things like sleeping or socializing, and it develops through frequent exposure to a psychoactive substance. While previous definitions of anhedonia emphasized the inability to experience pleasure, anhedonia is now used by researchers to refer to reduced motivation, reduced desire and reduced enjoyment during activity. Psychological dependence doesn’t just result from drug use; it can also happen as a result from a behavior, like exposure to pornography

Environmental enrichment and physical activity can diminish psychological withdrawal symptoms. Environmental enrichment is the stimulation of the brain by its physical and social surroundings. Psychological dependence is not to be confused with physical dependence, though they are not mutually exclusive. Additional symptoms of psychological dependence include panic attack, dysphoria, cravings and stress.

The major difference between psychological dependence and physical dependence is the symptoms they cause. While symptoms of psychological dependence relate to emotional and motivational impairment, physical dependence entails somatic symptoms like increased heart rate, sweating and tremor. Empirical studies have shown that cravings, which are associated with psychological dependence, do involve a physiological element.

In most cases, cognitive behavioral therapy is the best way to address psychological dependence, whether it occurs on its own or alongside physical dependence. In therapy, you’ll explore patterns that trigger your use and create new patterns of thought and behavior.

Definitions surrounding psychological dependence are tricky, and not just because it’s a sensitive subject. There are a lot of terms involved that, though related, mean different things. At the end of the day, psychological dependence refers to the way some people come to emotionally or mentally rely on drugs and alcohol.

DIAGNOSING ADDICTION

If your drug or alcohol use causes significant impairment or distress, you may have a substance use disorder (SUD). Diagnosis usually involves an examination by a psychiatrist, psychologist or a drug counselor, and the most commonly used guidelines can be found in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

Parameters for the diagnosis of a SUD require impairment or distress from your pattern of abuse, and the appearance of at least two of the symptoms listed below, for over a year; using more of a substance than planned, or using a substance for a longer interval than desired; inability to cut down despite a desire to do so; spending a substantial portion of the day obtaining, using, or recovering from your substance use; cravings or intense urges to use; repeated usage contributing to an inability to meet important obligations. 

Does your usage continue despite your knowledge that it’s causing frequent problems at work, school, or at home? Are you withdrawing from important social, professional, or recreational activities because of your drug use? Are you using in dangerous situations, or is your drug use causing you physical or mental harm? 

SUDs can vary widely in severity, and there are numerous methods to measure the severity of your SUD. If you meet only two or three of the DSM-5’s criteria, you are thought to have mild SUD; if you meet four or five criteria, you may have your SUD described as moderate, and if you meet six or more criteria, your addiction qualifies as severe. In the DSM-5, the term drug “addiction” is synonymous with severe substance use disorder. 

The quantity of criteria met offers a rough gauge on the severity of addiction, but a licensed professional will also take into account certain behavioral patterns, frequency of use over time, and assess for substance-specific consequences, such as the incidence of blackouts, or arrests for driving under the influence. 

There are additional qualifiers for stages of remission that are based on the amount of time an individual with a diagnosis of a SUD has not met any of the 11 criteria (except craving).

DRUG TOLERANCE AND WITHDRAWAL

Drug tolerance describes a user’s reduced reaction to a drug after its repeated use. An increase in dosage may re-amplify the drug’s effect; however, this may also accelerate tolerance, further reducing the drug’s effects. 

One may also develop tolerance to side effects; when this concerns non-addictive, prescribed medications, tolerance may be desirable. A medical intervention that has an objective to increase tolerance (for example, allergen immunotherapy, in which one is exposed to larger and larger amounts of allergen to decrease one’s allergic reactions) is called drug desensitization.

The opposite of drug tolerance is drug sensitization, in which case the user’s reaction increases following repeated use. High tolerance may sometimes lead to drug sensitization. For example, heavy drinkers initially develop a tolerance to alcohol, which requires them to drink larger amounts to achieve a similar effect. However, excessive drinking can then cause liver damage, which puts them at risk of lethal intoxication when drinking even very small amounts of alcohol.

Drug sensitization can also occur in users of stimulants such as cocaine or meth. What had been a recreational dose may become enough to cause psychosis in regular users, or users who previously had a psychotic episode may be more likely to have one in the future and at lower doses once usage continues.

In order for symptoms of withdrawal to occur, one must have first developed a physical or psychological drug dependence, or a combination of both. Dependence develops after consuming one or more substances over a sustained period of time.

Dependence produces withdrawal symptoms that vary with the type of drug in question. For example, withdrawal symptoms from opiates include anxiety, sweating, vomiting, and diarrhea. Alcohol withdrawal symptoms include irritability, fatigue, shaking and nausea. 

There are different stages of withdrawal as well; generally, a person will start to crash, progress to feeling worse, then hit a plateau before the symptoms begin to dissipate. Withdrawal from certain drugs like benzodiazepines can be fatal. While it is seldom fatal to the user, withdrawal from opiates can cause miscarriage, due to fetal withdrawal. 

The term “cold turkey” is used to describe sudden cessation of substance use and the physiologic manifestations that follow. The symptoms from withdrawal may be even more dramatic when the drug has concealed an extended period of malnutrition, disease, or sleep deprivation, common conditions often developed as a secondary consequence of drug addiction. These conditions may resurface when the drug is removed and be confused with withdrawal symptoms.

WHAT CAN I EXPECT WHEN I ENTER REHAB?

If you are heading into rehab for the very first time, let me give you some advice, and a sense of where to set your expectations over the next 30-90 days. 

First off, I’d like to congratulate you; not only are you about to embark upon what is essentially an extended vacation, but it’s actually good for you; body, mind and soul! Like an ice cream cake made out of broccolini!

You may think I’m being funny, but I’m actually quite serious; while there are plenty of things about rehab that are challenging, what it is not about is adding to your woes, stress level, or general level of misery. You are there to find a deeper level of happiness. So kick back, put your feet up, and enjoy yourself.

The challenging “work” of rehab will be in the form of talk; specifically, talking about your feelings. If getting mushy isn’t your cup of tea, you have my sympathies. However, I am very, VERY certain it will be good for you (yes, you, in particular) to get comfortable talking about your feelings. 

It is a skill you will find incredibly useful as you re-enter life after rehab, and develop rich social, romantic and familial relationships which will inevitably require conflict resolution through emotional discussions (precisely like those you practice in therapy groups at rehab).

What else about rehab is challenging? Well, you can say goodbye to your privacy. For me, however, this was a plus; the lifestyle in which I’d found myself before I entered rehab was one of abject isolation and I was all too happy to eat, sleep and do pretty much everything else in the company of others. 

If the rehab you are headed to is a good rehab, then you are about to experience a high level of structure. If prior to entering rehab, you were living on your own and were the master of your own fate, this may require a considerable degree of adjustment. There is no easy fix to this, and the only advice I can offer you is to not be a dick about it. 

The temptation to be a dick about it will be great. Don’t succumb to it. As you mature, you will look back on your experiences being a dick about it and cringe. 

Here is my last piece of advice. It is not particularly unique or enlightening, but it is good advice. It is this: listen carefully and think things through. Don’t rush to judgements. 

Over the next 30-90 days, you are going to hear a great many people tell you their opinions and ideas. You will not agree with all of them. Deciding which opinions and ideas you agree with and which you disagree with will form the basis of your spiritual and psychological outlook moving forward. Don’t bail before it’s all had time to settle inside of yourself.

Alright, you’re ready to go to rehab! Have a blast, you rascal!

OUR COMMON WELFARE

At a gathering of our cohort last night, I found myself irritated by a particular meeting-goer. This was not the first time I have noticed him. 

Last night, he was generally rude and incoherent, and on prior occasions, he has been notably odorous. How do we deal with such members? Shall we cast them out? 

Let us look to the long form of our third tradition for a guiding principle: 

Our membership ought to include all who suffer from alcoholism. Hence we may refuse none who wish to recover.” So the only requirement is a desire to stop drinking? Well, any bum can claim to have such a desire! So this means any and everyone, from a neo-nazi to your neighbor’s niece, is welcome at an AA meeting. 

Since, in this life of AA, we are meant to deal with “life on life’s terms,” it follows that  we might view these uncomfortable situations as opportunities to grow; and indeed we should. However, there is a higher necessity to which we are obliged; and that necessity is to our own sobriety. 

If you feel uncomfortable at a meeting of Alcoholics Anonymous, it is your responsibility (to yourself) to remove yourself from that situation immediately. For the first tradition states that though “our common welfare comes first… [our] individual welfare follows close afterward.”

Allow nothing to come between yourself and your own program. While we might hope a meeting’s secretary and/or a GSR (General Service Representative) might attempt to counsel a troublesome meeting-goer, we must “accept the things we cannot control.” And this is certainly one of them.

But in that spirit: we need also “the courage to change the things we can.” And we can keep our own shares succinct; we can remain silent while others are sharing (and keep our phones similarly muted); we can be sure we are bathed and awake and, in every possible way, unoffending. 

So in the end, I say: yes, “stick with the winners.” But never count out the losers. Because, truly, “the only constant is change.”