STATS ARTICLES 2005

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Elle’s Strange Trip Into Prescription Drug Abuse and Rapid Detox
October 25 2005
Trevor Butterworth
"The Busy Woman's Detox" is a highly toxic piece of reporting

“The Busy Woman’s Detox,” in Elle’s November issue, purports to explain how growing numbers of professional women are becoming hooked on painkillers and how they might be saved from a lifetime of addiction by a “controversial process of opiate withdrawal” that takes no more than “a few hours of seemingly blissful unconsciousness.”

“Introduced to the Unites States in the mid-‘90s, rapid detox developed a bad reputation early on when seven people, all at one now-defunct clinic in New Jersey, died after undergoing the procedure. In spite of that, as many as a dozen rapid detox facilities have since opened in at least eight states… with no reported fatalities. Their promises are summed up succinctly on the website of a facility in Rochester Hills, Michigan: ‘We can help you detoxify comfortably and rapidly. You can return to your former activities without anyone knowing about the problem you once had.”

As the magazine rightfully notes, that kind of claim is “especially enticing to white-collar addicts who can afford the cost of treatment” – and who can’t afford the professional consequences of drug addiction. And the market for rapid detox is growing due to the “recent explosion of prescription painkiller addiction” part of which, the magazine avers, is a result of legitimate pain victims becoming accidentally addicted to their medicine.

Unfortunately, the idea of rapid detox seems just a little bit too enticing to the editors of Elle. Though there is some measure of skepticism reported about the procedure, it doesn’t come until the end of page three (paragraph number 24); and more importantly, it doesn’t include any mention of the most damning evaluation of the procedure, a controlled-trial study published in the peer-reviewed Journal of the American Medical Association (JAMA) in August.

This study found that despite the claims made by proponents that rapid detox condenses the opioid withdrawal process from its usual range of three to ten days to just several hours, the expensive procedure was no more effective at producing lasting abstinence or even relieving withdrawal distress than a traditional detox program.

Traditional detox also carries no risk of death: while Elle claimed that the only deaths associated rapid detox occurred among patients of one New Jersey clinic, the procedure, which involves administering massive doses of opioid-blockers and anesthesia, has been linked to roughly a dozen deaths in the U.S., Australia and England. The JAMA study also found that three of the 35 patients given anesthesia-assisted detox had serious complications, at least one of which would likely have been deadly without prompt intervention.

All of which led the editors of JAMA to write an accompanying editorial in which the journal concluded that “anesthesia assisted detox should have no significant role in the treatment of opioid dependence.”

Perhaps the long lead-in time for the magazine’s publication precluded Elle from including mention of this study, which is the kind of embarrassing and unfortunate event that haunts any monthly magazine. On the other hand, criticism of the procedure was not unknown before August: the JAMA study was just the final confirmation. But what is really telling about Elle’s strange trip is not just a failure of skeptical reporting on rapid detox, it is the errors the magazine made along the way.

First, there is the incomplete and, at times, inaccurate picture of the problem which rapid detox is supposed to address – accidental addiction to pain medications.The medical director of the Waismann Institute, a rapid detox program, is quoted by Elle as saying that “Prescription painkillers can be great for short-term problems, but they don’t work in the long term.” Elle also quoted Russell Portenoy, the chair of pain medicine at New York’s Beth Israel Medical center, as saying, “Studies [in the 80’s] seemed to indicate that people could take opiates for a long time without abusing them or developing a resistance. Unfortunately, the perspective was skewed to show that opiates were safe.”

Such comments do not acknowledge the consensus within the medical community on the treatment of chronic pain. A group of the nation’s leading pain physicians (which included Dr. Portenoy), in conjunction with the Drug Enforcement Agency, wrote the following about the use of prescription opioids for chronic pain as a guide for doctors: “The consensus now is that some patients with chronic pain should be considered as candidates for long-term opioid therapy, and some will gain great benefit from this approach.” (While the DEA did remove this document from its website when a physician accused of over-prescribing tried to use it in his legal defense, the experts stand by it.)

And Dr. Portenoy himself noted elsewhere that there is no new data to support the claim that opioids are unsafe: his own research, published in major medical journals, shows that they can be used safely in treating chronic pain without producing addiction. In fact, Elle, in a confusing move for the reader, later cites Portenoy as “admitting” that the risk of addiction in the treatment of chronic pain with opioids is “fairly small.”

It is also worth bearing in mind that data from the National Institute on Drug Abuse, finds that some 80 percent of those who abuse prescription painkillers have also taken cocaine and psychedelics - a statistic that calls into doubt the idea that there are growing numbers of naïve pain patients succumbing to addiction through carefree prescribing by their doctors.

The “Oxycontin epidemic,” for instance, only took off after the media hyped the drug’s potential for abuse and not when it was introduced as a pain medicine. In 2000, before Oxycontin hit the media’s radar, there were 2,772 “mentions” of the drug in reports from emergency rooms. But in 2001, after dozens of stories and a spate of TV segments during sweeps week (some of which helpfully noted that the drug could be abused by crushing the tablets) there were 9,998.

And there’s more: Elle also manages to get the underlying science on addiction wrong by claiming that researchers “now know that opiates plug into the brain’s endorphin receptors,” thanks to “brain imaging studies.” The implication is one of a recent breakthrough coming after the recent surge in opioid abuse, but in fact, endorphin receptors were discovered in the 1970s and long before the chemicals that activate them the brain.

They actually got their name because scientists had discovered through animal research that morphine kills pain by activating these receptors. They were named “endorphin” receptors for “endogenous” “morphine,” because researchers rightly figured that the brain was not designed to take morphine, but rather that it must have its own “endogenous” and similar substance, which morphine mimics. And this discovery was made long before today’s brain imaging techniques were invented.

Likewise, Elle’s claim that higher doses of opioids produce higher numbers of receptors and therefore, worse withdrawal is also suspect, as no one knows how the severity of withdrawal is correlated with the number of opioid receptors. Researchers do know that some people withdraw from high-dose opioid therapy with very little physical or psychological distress, while others have severe symptoms.

A swift reversal of addiction simply by loading the brain up with opioid blockers also makes little scientific sense to anyone familiar with the research. The problem with addiction is not the persistence of opioids in the brain (which can be reversed by the use of blockers), but the persistence of changes in nerve cells in response to the use of opioids. These nerve changes take weeks to occur — so there was never any reason to believe that they could be undone in hours. And that is one of the reasons why controlled research (unlike the Waismann Institute’s uncontrolled trials cited by Elle) finds that the relapse rate following rapid detox is just as high as that from other detox procedures.

The problem with addiction is craving and relapse despite negative consequences, not physical dependence — and this is of critical importance to consider in the treatment of pain. All pain patients taking opioids long- term will develop physical dependence; but existing research finds that pain patients on opioids are no more likely than the general population to suffer the self-destructive behavior involved with addiction.

In other words, if people don’t have a past history of serious drug abuse, their odds of becoming addicts when exposed to opioids are roughly one percent.

Elle quotes a patient who says that “Rapid detox makes scientific sense to me. It’s like a colonic for the brain.” It’s a pity that something similar happened to Elle’s editors when they decided to publish this article.