The term “narcotics” is thrown about in daily speech, by the government, and by law enforcement professionals to refer to any illegal drug. In reality, most illegal drugs are not really narcotics and some of them, especially anabolic steroids, don’t even produce euphoria (euphoria = “high”). Let’s discuss the drugs the drugs that really are “narcotics” in the medical sense of the term – later this week I’ll touch base on other euphoria producing substances and that discussion will serve as a segue into a discussion of antidepressants next week.
WHAT IS A NARCOTIC? Narcotics are derived from opium poppies that originally grew in the wilds of Eurasian and which are now primarily cultivated for the production of heroin in Afghanistan and Myanmar. Narcotics include morphine, codeine, heroin, methadone, dilaudid, norco, percocet, and demerol – marijuana, methamphetamine, cocaine, LSD, and most of the other illegal drugs commonly listed as “narcotics” by the government are quite simply not! True narcotics function by mimicking naturally present neurotransmitters called endorphins that are important regulators of pain in the normal functioning of the human brain and body. Endorphins probably evolved, at least in part, to enable humans to function under duress without being crippled by pain — as an historical example, it would be a bad idea to stop running from the lion that was trying to eat you just because your sprained ankle started hurting really badly. A more modern example of endorphins in action can be appreciated when you watch UFC fighters kick each other in the head and then shake it off and go back to fighting without missing a beat — it’s because their brains are releasing tons of natural endorphins so that they won’t be distracted by pain and can continue fighting. Natural endorphins are also the reason why Jon Jones (UFC 205lb champion) didn’t notice that his foot was broken until someone pointed it out to him after he had won his championship fight last night if you were watching like I was! Endorphins are responsible for the runner’s high that you get after your daily jog and they are also involved in the brain’s rewards pathway, the set of neurons in your noodle that makes doing evolutionarily beneficial activities like sex feel good. The rewards pathway is very important because humans without a powerful sex drive wouldn’t be around very long! After all, what man or woman would put up with their significant other if it wasn’t for the carrot-and-stick catch-22 of sex! Another common activity that causes you to experience the power of endorphins is being in the sun. Sun exposure was evolutionarily important because your body makes vitamin D in a reaction that requires sunlight and that occurs in the skin. No vitamin D à broken bones à early death (for a caveman) à no babies à no more humans!
Thai Boxing: Courtesy of Wikimedia. Sorry, Jon Jones broken toe image is copyrighted (as is most UFC stuff, but you get the picture).
HOW DO NARCOTICS WORK? Endorphins work by binding to opiate receptors in the brain and it is the activation of opiate receptors that causes the effects (diminished perception of pain and euphoria) of these powerful neurotransmitters. Naturally occurring opiates from plants (morphine and codeine) and synthetic opioids like dilaudid, demerol, heroin, percocet, and norco are designed to chemically mimic endorphins. You can think of endorphins as being analogous to a key that fits into the opiate receptor “door” and “unlocks it,” allowing the brain to decrease the amount of pain you’re feeling and to start buzzing with euphoria. Morphine, heroin, hydrocodone, and friends all mimic the shape of the natural endorphins at the molecular level and they function to “unlock” (activate) the brain’s opiate receptors, activating these receptors to a degree that the body naturally wouldn’t have. Opiate receptors are also found in the digestive tract were they function to slow everything down. Loperamide (aka: Immodium) is a synthetic opioid that is sold over-the-counter to treat diarrhea. You can’t get high off of loperamide because unlike most other opiates/opioids it doesn’t cross the blood-brain barrier.
Heroin: Courtesy of Wikipedia.
THE HISTORY OF NARCOTICS: The extract of the opium poppy has been used for pain-control for thousands of years. By the time of the Roman Empire the medical use of opiates was already old news, which I’m sure that legionnaires who had been gravely wounded in battle greatly appreciated! The abuse of opium is probably equally ancient and many a war has been fought by a supplier nation taking offense when a weaker consumer nation decided to ban the importation of this medically important but socially destructive drug. Opium addiction most famously caused The Opium Wars between Britain and China and the scourge of narcotic addiction also scarred the early United States when a wave of morphine addiction swept the country after The Civil War, an epidemic that was partly due to wounded soldiers returning addicted to these medications and partly due to war widows becoming addicted to a drug that was less socially ostracized at the time than alcohol, the other primary chemical escape of the era. But narcotic addiction didn’t really take off until the late 1800s, when chemists synthesized heroin, a synthetic opioid that is far more potent than the naturally occurring morphine and codeine.
The Opium Poppy: Courtesy of Wikipedia.
THE USE AND ABUSE OF NARCOTICS TODAY: The wave of narcotic addiction at the beginning of the 20th century had a rather nasty, unintended consequence. Physicians began refusing to prescribe these medications even to people who clearly needed them, like patients who were lying on their death bed with metastatic bone cancer (extremely painful!) and to burn victims. Even when narcotics were prescribed, they were usually under-prescribed and many a severe burn victim from the era has publically stated that the pain was so bad that they wish that they had died, even after recovery! These horror stories led to the passage of laws that essentially forced physicians to ask patients about their level of pain and to treat them with pain medications, including narcotics, until that pain was adequately controlled. These laws have made life much more pleasant for people who are dying from terminal diseases and for those with painful injuries; however, they have also resulted in prescription drugs becoming the #1 cause of accidental drug overdose (as opposed to intentional suicidal overdose) in the United States. There are currently 100,000-200,000 heroin addicts in the U.S., and 2 MILLION prescription opioid addicts!!! Just about all of these addicts obtain their drugs legally and through their physician; indeed, opioids are the #1 prescribed class of drugs in the U.S., prescribed more often than antibiotics, antidepressants, acid reflux pills, etc. Every physician deals with at least one prescription opioid addict per day, most of whom (at least in my experience) shouldn’t be on these medications. The problem is that under the current laws there isn’t a whole lot the physicians can do about this problem—if you don’t treat someone’s reported pain you’re setting yourself up for harassment (in the form of complaints) and possibly for litigation (malpractice lawsuits).
NARCOTIC WITHDRAWAL AND OVERDOSE: Narcotic overdose kills you by depressing your respiratory drive, i.e. you quite breathing. If prompt medical assistance is available there are drugs that can reverse the effects of narcotics (naloxone, naltrexone) and mechanical ventilation can also keep the overdosed person alive until the narcotics wear off. Most people who OD on narcotics are also under the influence of another respiratory depressant, usually either alcohol or a benzodiazepine (e.g. Xanax—we’ll talk more about benzos next time). This is the reason why people who pop a few percocet and then wash them back with Budweiser are asking for an early trip to the grave. Narcotic withdrawal is unpleasant and the terms “going cold turkey” and “kicking the habit” both derive from the symptoms of morphine withdrawal that were described 100 years ago. People withdrawing from narcs become very restless, especially in their legs, and get goose bumps and chills. They also suffer from severe diarrhea, insomnia, pain, and agitation — basically withdrawing from narcotics produces the exact opposite symptoms that taking them produces. Instead of euphoric, people withdrawing from narcs feel miserable (dysphoric). The good news is that even though narcotic withdrawal might make you feel like you want to die, it won’t actually kill you. This isn’t true with alcohol withdrawal, which actually can kill serious alcoholics who suddenly quit drinking. Of course the caveat to this discussion is that many narcotic addicts are addicted to multiple drugs of abuse including alcohol — please seek medical advice from your doctor prior to making any major medical changes in your life and for assistance with rehabilitation if you happen to be addicted to narcs and contemplating quitting (and good for you if so!!!).
Mechanical Ventilation: Courtesy of Wikipedia. Property of Calleamanecer. Note: This is a highly photogenic ICU patient. Most of them have secretions, etc. dripping around the edges of their mouths and do not have their hair-combed like this attractively ventilated patient! I’m pretty sure this is a “Hollywood” version of the ICU, but it will suffice for our purposes!
A WORD ON COMBINATION PILLS: A quick word on combination pills, e.g. norco, percocet, vicodin, tylenol 3, and friends. All of these medications contain both a synthetic narcotic and acetaminophen (aka: tylenol). A common cause of unintentional overdose with combination pills is the consumption of tylenol with these medications. Acetaminophen/tylenol is toxic to the liver in doses greater than 3-4 grams per day, less in those who already have liver disease and in drinkers (and many people who abuse prescription meds are also drinkers). As an example, let’s say that you’re taking 2 pills of “generic combo pill 5-500” four times per day for your chronic back pain. The first number in the 5-500 is the narc, the second number (500) is the amount of acetaminophen in every pill of “generic combo pill 5-500.” Since you’re taking eight of them per day, that equals 4,000mg (4 grams) of acetaminophen per day—already at nearly the toxic level. Now add a few drinks or a few extra-strength tylenol on top of that and you can see why these pills are your liver’s greatest enemy. Something to think about, please!
The Abdomen of a Patient with Hepatic (Liver)Failure: Image Courtesy of Wikipedia. Propery of James Heilman, MD.
The National Institute on Drug Abuse. http://www.drugabuse.gov/publications/topics-in-brief/prescription-drug-abuse. Accessed 28 APR 2013.
Dr. Leonardo Noto
Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis.
Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 12-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).
Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!