Addiction As It Relates To People Living With Sickle Cell Disease

Introduction

We will discuss addiction under the following terms

-Definition 

-Pleasure seeking

-Craving 

-Cue anticipations

-Withdrawal and relapse

What Is Addiction or Addictive Behavior? 

This is repeatedly taking a particular substance or performing a particular activity, despite the fact that it may be causing substantial harm to the doer because such a substance or act is continually seen as rewarding or pleasurable.

Note there are four key things in the definition that differentiates an addictive habit from a bad habit.

  1. An act.
  2. Repetition 
  3. Harm
  4. Pleasure

Bad habits do not have all of these 4 aspects. A bad habit may just be an inappropriate act as perceived by people depending on one’s age, sex, ethnicity, culture, religious belief and social environment. This is different from an addiction.

Pleasure Seeking: The brain is our most integrated and complex organ of survival. It is designed to help us develop necessary skills, learn and adapt to situations around. When you are hungry, for instance, you brain senses it and takes you on a journey to find food. This includes where to buy and how to cook. In the process your brain does something else, it stores memory of this unpleasant event called hunger and of the solution to your hunger. Finally you cook or buy some good food and while you eat you feel a certain pleasure called satiety. The brain keeps a record of all this. The next time you are hungry, and perhaps an even more intense hunger, the brain calls up the memory of how this unpleasant hunger was solved and more so how it was solved quickly. This time you know how to sort your hunger quicker. Again you are rewarded with the pleasure of satiety.

Thus the brain has formed a survival skill for you and a means to ward of an unpleasant feeling for a pleasant one in this case, hunger for satiety.

It is the same with pain, the most common challenge with SCD

When the pain of crisis starts, the brain follows a path to quickly get rid of this pain. The instant relief you get when you use some drugs creates an aura of pleasure. That instant relief is a key event here. It is euphoric, pleasurable and the brain keeps a sweet memory of it.

Mind you not all drugs cause this relief. Some pain killers that work through the brain, also have euphoric and sedating causing properties for example the opiates: Pentazocine, tramadol, Codeine, Morphine, Fentanyl, and the likes. These drugs act on the brain and cause instant relief. This explains why addiction to these drugs is commoner than addiction to Paracetamol or other NSAIDS. Paracetamol or NSAIDS do not create euphoria, sedation or instant relief as compared to opiates. This brings us to the next one. Craving

Craving

A bit of biology: There is a hormone that has been closely linked with the feeling of pleasure. This hormone is called dopamine. Dopamine acts on the Limbic system of the brain to exert its effects. Each act of pleasure is only felt because dopamine is released into the brain in certain quantities. 

Now get this, all drugs with addictive potential release some quantity of dopamine into the brain. Now, let’s say in a first crisis, a patient is given an NSAID, like diclofenac. Sure there will be pain relief but it comes slowly and undesirably so, because during a crisis the patient wants to be free quickly. In such a situation, the effect of pleasure is annulled by the slowly abating pain.

Now, let’s say this person was given an opioid instead. The drug goes acts through the brain, causes an instant pain relief, and in addition, the euphoric property of lulling into sedation, causing instant relief. This leads to the patient picking an opioid next time the patient is offered diclofenac or opioid.

On the flip side we know that drugs wear off in hours but crisis pains last for days. A typical Pentazocine prescription is given 6hrly. Imagine exposing someone to this pleasurable feeling every 6hrs for 3 to 4 days or even more frequently in some cases. A time comes when the need for pain becomes exaggerated not because of the pain itself but because of the pleasurable feeling he/she gets from it. This is called DRUG SEEKING BEHAVIOUR. When the individual does not respond to any other medication because it’s not an opioid, that individual has become Drug (OPIOID) DEPENDENT. At this stage the individual is close to becoming an addict

Now there is an argument as to whether people who crave opioid when they are in pain are truly addicts. This is because the key index of an addictive behavior is the apparent harm it causes to the person of which he/she might be in denial of. However that one needs a particular drug doesn’t make him/her and addict. It’s possible that’s just what works best. PLWSCD face a dilemma: is this drug seeking or not?

Some argue that craving opioid for pain is not an index of addiction. I like to agree. 

This is because naturally the medication is tapered off once the crisis stops and in most cases the individual is able to continue his/her normal life functions. In addictions, the addict can’t function normally if he/she does not have the addictive substance or event on a regular.

Indications that someone is becoming addicted to such drugs include:

1. Requesting higher doses for the same kind of pain: This is explained by the fact that, the brain over time gets use to dopamine release so to attain pleasurable effects, higher and higher doses of dopamine is required thus higher and higher amounts of drugs or addictive substance/events

2. Exaggeration of pain or falsified pain: just to have a drug

3. Forceful/Self administration: Ideally this is thought to be a survival skill but, it is a form of self harm. If you would rather cause yourself pain multiple times a day to get a drug when there are clearly alternatives, then it might be a sign of addiction. Not everyone is skilled in self injection. You might predispose yourself to infection or nerve damage in the process

 4. Using the drug for recreation. This means taking the drug for a reason entirely different from its medical use.

Cue Anticipation 

Okay, this means an anticipated feeling priming an anticipated response. It is closely linked to withdrawal. If you try to avoid the drug, you get unpleasant feelings. This is more experienced with addiction to alcohol, cocaine, and metamphetamines. So the craving to continue using these things in not just to feel pleasure anymore but to avoid the unpleasant feeling of withdrawal

Same thing often happens during a crisis. The pain tends to feel more when the opioid abates. That doesn’t mean it actually is, it’s just that the withdrawal from the effect of the medication is unbearable.

Impact of Addiction on The Individual and Family:

One may get into the habit of continually self injecting. This may affect his life in many ways. It may affect his family in many ways

Prevention/Cure

  • This mostly involves reconditioning the mind. 
  • Alternative sources of pain management 
  • Building a healthier outlook on life because depression is a major reason people become addicts. 
  • In established cases of addiction, mental rehabilitation might be required..

Whatsapp Discussion held on on 25th May 2018

Facilitator: Dr J. O. Agbi

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