Pills and Booze—Recipe for a Cyclone

“And if I buy the cheapest vodka, and add one of my husband’s high blood pressure pills, that’s like New Year’s Eve.”

A recent email began: 

Bill,

You say it was mixing pills with gin at the end of your addictive career that landed you in two hospitals in 10 days, your kidneys too paralyzed to pee. And you always see these warnings on prescription drugs, even on cough medicine. If you take one of these, don’t drink. But I’ve found that if I have a glass of wine with just one or two Benadryl or Tylenol tablets, I get a nice little buzz. And if I buy the cheapest vodka, and add one of my husband’s high blood pressure pills, that’s like New Year’s Eve. In fact, I’ve found this the best treatment yet for my chronic lower back pain. 

If you can’t afford a lot of high-priced, prestige label alcohol, what’s wrong with taking a shot of whatever you can afford with a pill or two on top to make boredom and/or pain go away, and your dollar go further? None of this has led me to the terrible conclusion people like you warn against. Reading about your strict adherence to 12-step rules in The Fix, you sound like those government warnings against pot—a lot of puritanical people too old to have a good time, and they don’t want anyone else to have one either.

-Anna  

Anna, go to a drug wholesaler, and buy a list of chemicals that any biology teacher can supply. Allowing for inflation, the latest cost I heard was about $11.95. Add a lot of water, and you get a totally unexpected result: an incredibly complex live human being. 

The parts are greater than the whole. 

This works with chemical intoxication, too. 

Here’s how they put it when I was doing my 28-day rehab at Caron: Say a shot of booze holds three units of intoxication. And that a pill or painkiller holds three units, too. If you take them together, they don’t add up in a simple way to six units of high. 

Potentiation was the word they used back then. Nowadays, we speak of synergy: the parts multiply their effect, and you get nine units of intoxication…and it sets in a lot faster than you are ready for.  

Anna, you began your note by mixing wine and “one or two” Tylenols or Benadryls. In almost the next breath, you’ve graduated to higher voltage experiments, mixing vodka with your husband’s high blood pressure pills.

It sounds like your use is accelerating, which is one of the prime indicators of the onset of addiction. You’re playing with mysterious and dangerous chemical forces. Your nice little cheap buzz may soon turn into a cyclone. 

* *

“Opioids suppress breathing and that is why they are deadly,” says Dr. Keith Humphreys, professor of psychiatry at Stanford University School of Medicine. “When someone has alcohol and/or benziodiazepines on board as well, the risk is even greater because the drugs are synergistic. Lots of ‘opioid overdoses’ are, in fact, alcohol and opioid overdoses or benzodiazepine and opioid overdoses.”

What I find especially interesting in Anna’s note is her self-assurance in expressing a cultural fact—in 21st century America, only puritanical joy killers (like me) would see anything wrong with her refusal to bear boredom or pain. 

Many Americans today, writes Dr. Anna Lembke in The New England Journal of Medicine, “believe that any kind of pain, physical or mental, is indicative of pathology and therefore amenable to treatment…At least some segments of our society also believe that pain that’s left untreated can cause a psychic scar, leading to psychopathology in the form of post-traumatic stress; thus, doctors who deny opioids to patients who report feeling pain may be seen not only as withholding relief, but also as inflicting further harm through psychological trauma. Trauma today is seen not just as causing illness, but also as conferring a right to be compensated. No one understands this belief better than addicted patients themselves, who use their awareness of cultural narratives of illness and victimhood to get the prescriptions they want. One patient summed it up in this way: ‘I know I’m addicted to (opioids), and it’s the doctors’ fault because they prescribed them. But I’ll sue them if they leave me in pain.’”

One result, says Dr. Keith Humphreys, “is that America’s docs write a quarter-billion prescriptions for opioids a year, which is enough for every single adult in the country to be on Vicodin for a month. No society could have such a flood of opioids and not end up with higher rates of addiction and overdose. They also do it because they don’t want to be sued. The terrible thing about our health insurance system is that if you want to treat the opioid addiction you have to get on the phone and fight for hours with a managed care company. But if you want to just write the person’s next prescription for OxyContin, no one will stand in your way.”

Stand in your way? What we have today are all these new online pharmacies only too happy to help you drive along Vicodin Speedway: 

In 2011, Google Inc., agreed to pay $500 million to settle allegations by the US Department of Justice that it profited from ads purchased by online pharmacies that the computer giant knew were improperly selling prescription drugs.

“The advent of Internet pharmacies allowed the cheap and easy distribution of massive amounts of illegal prescription drugs…while allowing perpetrators to conceal their identities through the anonymity the Internet provides,” says San Francisco-based US Attorney Melinda Haag.

Let me turn directly to my readers in The Fix… people who are tempted to mix pills and booze for pain relief.

“There are many was to respond to pain other than opioids,” Dr. Humphreys told me, “both with medications and behavioral interventions. When opioids are needed, the risks can be minimized by using lower doses and not prescribing long term. There is no evidence that opioids are good at controlling non-cancer pain long-term.” 

But perhaps the last word should be left with the wise Dr. Anna Lembke: 

In previous times, she says, “doctors spoke out against the use of pain remedies. Pain, they argued, was a good thing, a sign of physical vitality and important to the healing process. Over the past 100 years, and especially as the availability of morphine derivatives such as oxycodone (OxyContin) increased, a paradigm shift has occurred with regard to pain treatment. Today, treating pain is every doctor’s mandated responsibility…It seems that the patient’s subjective experience of pain now takes precedence over other, potentially competing, considerations. In contemporary medical culture, self-reports of pain are above question, and the treatment of pain is held up as the holy grail of compassionate medical care.”

The sad fact is that for docs today, treating pain pays but treating addiction does not. This is especially true in emergency department settings, where physicians are often evaluated on the numbers of patients seen per shift. Clinicians will not take time to educate and counsel patients about addiction—even if they know how—until they get paid well to do so.  

The way we run healthcare today, it pays better to diagnose pain and quickly write an opioid prescription than to diagnose and treat addiction.