Drugs – Physiological tolerance, addiction and abuse
When I give medications to patients for neurological problems, such as attention deficit disorder or acute pain, the thing that almost everyone says is:
I don’t want to become addicted to a medication.
I don’t want a person to become addicted to a medication either.
That’s why I take an extensive history including medical along with social and family histories. The patient’s living arrangements and social situation are also an important factor in screening for patients who might be susceptible to addiction. I get more history if there is any question of addiction arising.
What the problem comes down to is that most people do not know what the definitions of addiction, physiological tolerance and abuse are.
Here we go –
When you take a medication, your body adapts to the medication by increasing the enzymes needed to break down the medication. Because of this, the dose of the drug often has to be increased in order to get the same effect that it originally produced. This is called physiological tolerance, and it is to be expected. The amount that the drug can be increased by is determined by several factors, including, but not limited to, side effects, toxicity, cost, patient history, clinical vigilance, and the doctor’s knowledge of the medication.
One of the best examples of physiological tolerance is coffee. Coffee causes some people to function better at their jobs. By modulating the release of various neurotransmitters, it causes certain blood vessels to constrict and produces an elevation in blood pressure. If you start drinking coffee every day, your body says, “Okay, since caffeine is coming in every day at 10 AM, I’m going to make sure to dilate blood vessels at 10 AM every day so that we can still have a good blood supply to the brain while drinking the coffee.” Because of this, regardless of whether you drink your coffee or not, the body is going to dilate blood vessels at 10 AM every day because it has learned that you take your caffeine drug at 10 AM every day. So, if one day, you do not take your daily dose of caffeine, your body is going to dilate the blood vessels anyway, because it had been reprogrammed to think that caffeine was coming every day at 10 AM. When that happens, you wind up getting a caffeine withdrawal headache! Additionally, if you’re a daily coffee drinker, your body has increased the enzymes to break down the caffeine and get it out of your system. So after drinking coffee for several days or weeks, you might need more cups of coffee throughout the day to give you the same effect that you had when you first started drinking it. This means that you have developed a physiological tolerance it.
Addiction is different. It’s when a person continues to do something despite the fact that it’s harmful to themselves or to others. Addiction, like many diseases, is a combination of genes and the environment. It depends on the personality of the individual and his or her surrounding influences. One person can have a sugar-free, cholesterol-free cookie every day, and that’s fine. If, one day, it turns out that they don’t have any money to buy the cookie and they can say, “Oh well. No cookie for me today,” that person is not addicted to the cookie. However, if they don’t have the money to buy the cookie, and they feel that they need the cookie so much that they have to rob a store to get the cookie, then that’s an addiction. They’re hurting others and, subsequently, themselves.
If a person feels better or happier while taking a medication, that’s not an addiction. If the person asks the doctor to increase the dose of the medication to get a better effect, that’s not an addiction either. If the doctor says that it’s unsafe to raise the dose or continue the medication for whatever reason (liver dysfunction, cardiac toxicity, etc.) and the patient decides to start “borrowing” some medication from a friend, then that’s an addiction. If they decide to start buying the medication from a dealer on the streets, then that’s an addiction. If they go to another doctor and ask for the medication without telling the new doctor that the last doctor did not want the person to get the medication anymore because it was hurting them, that’s also an addiction. The person is hurting himself and others.
Drug abuse is when a drug’s use interferes with a person’s responsibilities, health, social interactions, and/or conduct in society (legal issues), but the person’s symptoms have not met the criteria of drug addiction. Anything a person puts in his or her body that causes a pleasurable sensation has the potential for abuse. Things that are more pleasurable are more likely to be abused.
So, IN SUMMARY:
– Tolerance is a normal physiological response that a person gets to a substance, which often requires an increase in dose to get the desired effect.
– Addiction is a behavior that is governed by genes, the environment, and the coping mechanisms of a person that causes harm to the person and/or to others.
– Drug abuse is when a drug’s use interferes with certain spheres of a person’s life, but their symptoms have not met the criteria of drug addiction.
For a more in depth view of medications that are used in treatment of attention deficit disorder, please see the Sixteenth chapter, The MS ICE From Both Sides of the Desk, in my book Multiple Sclerosis From Both Sides of the Desk – Two views of MS through one set of eyes.
An excerpt from
“A Day and a Night in an MS Life”
Multiple Sclerosis From Both Sides of the Desk
The forty-minute, thirty-five-mile drive home went relatively quickly as he got off the parkway. The air conditioner was going full blast as he listened to the news declaring that the heat wave would be lasting for the foreseeable future. He had seen at least two cars on the ride home that had pulled over because of the heat. He felt lucky that his car had made it. After turning off the parkway, he followed the main road that led past his town. He made a left onto a secondary road as the trees started to outnumber the telephone poles. Traffic dropped to scant few cars as he turned onto his block. The moment Joseph saw his house, his bladder notified his brain that it had to go wee-wee. He wondered why he always, suddenly, had to go to the bathroom when he knew he was almost home. Accelerating up the hill and passing his front yard, he saw Steph and the baby playing near the sprinkler. They were both smiling.
Joseph loved his new daughter, but he was still getting used to his new position in the lineup. She was the opening act and the headliner. Her material wasn’t any better than his was, he thought. It was just that she was putting a new spin on it:
“Oh, look! She’s spitting up. Hold on. Let Mommy get your nappy and clean you up. You’re soooo cute.”
Joseph knew he had been doing mostly old material for at least several years, but he felt it was quality material. Unfortunately, somewhere, it had lost its sweet naiveté:
“Oh, great. You’re going to throw up. Here’s a bucket. Just make sure you don’t get any of it on the carpeting.”
He had always had a good sense of humor, and he hardly ever worked blue. He couldn’t remember exactly when he first heard himself saying things that were “over the line” while socializing, but Steph had noticed it often enough. It made her uncomfortable, and she let him know it. He figured she was just becoming more conservative as the years went on.
He pulled into the driveway, grabbed his bag and keys, and scooted rapidly toward the front door.
“There’s Daddy,” Steph said, holding Gabby up to look at her daddy.
“Gotta get to the bathroom,” he said in a hushed voice as he reached for the doorknob. Locked! “Dammit! Why is the door locked?” he said to no one in particular. Steph looked up.
“I have the key,” she said, pulling it out of her pocket.
“Why do you have to lock it all the time?” he asked with annoyance.
“We went out for a walk before,” she answered, handing him the key.
He got the key into the doorknob on the fourth try and then turned it. The door wouldn’t open. She had locked the deadbolt!
“Dammit!” he exclaimed as he felt a little urine get somewhere it was not supposed to be. “Why do you have to lock both the knob and the deadbolt?” he asked as he pulled out the key to put into the door handle lock.
“To be safe,” she said as she started to towel Gabby off. He turned the key, and the door opened. He raced inside, leaving the door ajar. He got to the bathroom with little collateral damage. After putting himself back together again, he went back to the front. Steph had laid the baby down in the living room and was changing her diaper.
“Thanks for helping to locate my phone earlier,” he said, trying to make up for his childish behavior.
“No problem,” she said, smiling as she lifted Gabby’s legs and tilted her up to clean her. “You’re home early. Anything go wrong at work?”
“I was feeling like crap,” he began. “Jess said I looked crummy too. I figured I should just come home and get some rest and get an early start tomorrow.” He looked at the mess in the living room and then turned and saw the lumber in the dining room. “I’ll get started on cleaning up all this stuff after I get cleaned up.”
“Okay. I was going to make some chicken for dinner. What time do you want to eat?”
“I dunno,” he said, starting to take off his jacket and tie. “Let me see how I feel after I’m done getting things cleaned up.”
He turned and lumbered up the stairs. Once in the bedroom, he turned the air conditioner on high, tossed his keys on the bed, and got out of his suit. Using his foot, he pushed around a pile of clothes that was on the floor. He picked up a pair of shorts and a faded blue T-shirt. After dressing, he turned back to the bed and saw the phone on the nightstand. He went over, picked it up, and put it in his suit so he wouldn’t forget to take it tomorrow. As the temperature in the room dropped, he began to feel a little more alert again. Steph came up the stairs with Gabby.
“Can you play with Gabby for a few minutes while I get ready to go shopping?” she asked.
“Sure,” Joseph said as he took their baby from her arms. He sat on the bed and stood Gabby up on his lap. He looked at her directly.
“Mommy says someone was tearing up copies of old magazines. Do you know anything about that?” he asked.
His daughter, seeming nonplussed by her father’s questioning, chewed on her fingers.
“Well, if you’re not going to talk, then I’m just going to have to assume you plead nolo contendere.”
Saliva started dripping out of the corner of her mouth.
“Your lack of response and flagrant slobbering force me to find you in contempt of court. You will be sentenced to tickling, which is to commence immediately.” He then placed her on her back and started tickling her tummy. She began to squeal and laugh. Watching her smile filled him with happiness and let him feel more awake and alive.
“Don’t be too rough with her,” Lauren called from the bathroom. “I just fed her, and I want her to fall asleep in the car while I do my errands.”
“I won’t,” he said. “Don’t worry,” he reassured his wife as he stopped tickling Gabby. Once free, she rolled over onto her tummy and then got to her hands and knees. She spied Joseph’s keys at the edge of the bed. Using the reaction time and unpredictable path of a mosquito on crack, she quickly scooted toward the edge of the bed. Joseph, using an outstretched-arms, soccer-goalie-styled dive, landed next to her just as Gabby’s body weight was about to carry her and the keys off the bed and onto the hardwood floor. She squealed as he grabbed her and the clump of keys fell to the floor. Steph came back into the room.
“What was that?” she asked. Joseph held Gabby in his arms.
“Nothing,” he said as he looked at his daughter. “I was just trying to demonstrate how gravity works to our little Ms. Newton.” Gabby started to chew on her fingers again.
“What are you going to do while I’m out shopping?” she asked.
“Well,” Joseph began, “I figured I would start with moving the wood out of the dining room and then cleaning the living room. After that, I’ll either start translating the complete works of John Steinbeck into Old High German or take a nap. When do you think you’ll be back?” He handed Gabby to his wife.
“Probably around four thirty. Maybe sooner if I can find everything I need to get.”
“Sounds good,” he said, kissing Gabby. He looked at Steph as he thought back to the conversation they had on the phone that morning. “I’m sorry for asking you to bring me my phone this morning. That was me being stupid.”
“It’s okay. Did you see the phone on your nightstand?”
“Yes. I already put it away in my jacket for safekeeping for tomorrow.”
“Good,” she said. They kissed good-bye. “Love you,” she said, smiling.
“Love your body, Larry,” he replied.
She went out of the room and downstairs, carrying Gabby. She didn’t even acknowledge the Fletch reference, Joseph thought. “She used to be my audience,” he said aloud to the empty room. “I was the headlining act. Then the kid arrived. Now I’m just a has-been comic working the backroom that takes out the trash and shuts off the lights after the last drunk leaves.” He pushed some clothes that were on the bed out of the way and decided to lie down to take a nap before tackling the work for the afternoon.
“Where did it all go wrong?” he asked as he tried to fall asleep.
When people start having trouble with sex, the first thing to realize is that they probably don’t know how sex works.
Actually, they might know one or two of the parts of sex but they don’t know that those parts can only work after other parts have done their job.
And I’m not talking about the rubbing and bumping parts.
The human sexual response cycle is a five-stage process. The stages are desire, arousal, plateau, orgasm, and resolution. The main rule guiding the cycle is that these stages must occur in sequence. If the sexual encounter is between two people, then both partners need to first pass through the desire stage before things can go any further. For the MSer, there are a few things that can get in the way of getting the sexual cycle going. First, let’s define desire. Desire is a strong wish in wanting something to happen. In some ways, it can be thought of as “sexual initiative.” If the MSer has trouble with initiative when the non-MSer has desire, we’re already a strike down in the count. If the stimulus presented to us by our partner is strong enough, then maybe the decreased sexual initiative can be overcome and the cycle can start. However, if the stimulus is not as enticing, then the MSer might not be able to get to the desire phase. The partner might take the MSers lassitude as sexual laziness. “Why do I have to be the one to turn you on?” they might ask. Or if they don’t say anything, they might start to think to themselves that their partner doesn’t find them appealing anymore and that the spark is gone.
The other way that the sexual cycle can get a flat is when the MSer has desire but their partner does not. In this case, the MSer can start to act like the child who cannot go to the amusement park right now. They can become impatient and force the sexual encounter, which turns their partner further away.
Both the desire (sexual initiative) and the childlike behavior are governed by the frontal lobes. Quite often treatment of attention deficit disorder, which usually involves increasing dopamine and norepinephrine levels, can help improve desire as well as helping better behaviors to surface. A thorough discussion of MS and sex can be found in the Sex chapter in my book, Multiple Sclerosis From Both Sides of the Desk.
The main point of this article is that sexual dysfunction in MS is not something that can be fixed with a drug for erectile dysfunction or vaginal lubrication. Sexual functioning starts with desire, which comes from the mind. If we think of desire as sexual initiative, we need to treat the sexual initiative first in order for the sexual cycle to start.
People have asked me, what are the symptoms of attention deficit disorder. Instead of listing a bunch of medical terms, I like to use examples. In my book, Multiple Sclerosis from Both Sides of the Desk, this is how I describe what MS attention deficit disorder is like:
AN EXAMPLE OF COMMON COGNITION
Here’s an example of cognitive functioning that goes on in many people’s lives. You’re eating breakfast when your wife tells you that she has a meeting this afternoon and the kids need to be picked up from school. You ask what time they need to picked up, and your spouse says three o’clock. You think about your schedule for the day. You remember that you have a hair appointment at the same time. You say to yourself that you have to change the time of your appointment. You make a mental note to call and reschedule your appointment when you get to work. You know that the school is on the way home from the hair place, so if you can get an earlier appointment, you’ll be able to pick up the kids after the haircut. You tell your wife, “No worries. I’ll pick them up.” You kiss her, finish your breakfast, and then leave for work.
When you get to work, you call your hair stylist and move the appointment up to 2:15 p.m. The day moves on. At two o’clock, you go for your appointment. You get your haircut. You look fantastic. You pay your bill. You pick up the kids. They comment on how great your hair looks. You return home. Life is good.
The spheres of cognition used in this example include attention (being able to focus on what your spouse is telling you), short-term memory (taking in new data), long-term memory (recalling known data), visual spatial (understanding the spatial relationship of items), executive functioning (making a decision about what to do with the data), verbal (communicating data through speech), and processing speed (doing all these things in a timely fashion).
AN EXAMPLE OF MS COGNITION
In the mind of the person with MS, the same situation commonly follows a slightly different course.
“Honey. I have a meeting today. Can you pick up the kids from school at three o’clock?”
“What?” you ask as your MS brain tries to focus on not pouring salt into your coffee like you’ve done every day since your beautiful wife bought new salt and sugar holders.
“Can you pick up the kids today for me?”
“Yeah. I guess.”
“Thanks,” she says, and turns toward the door.
“From where?” you ask.
“Three o’clock,” she answers, with disappointment in her voice.
You notice that she’s unhappy, and you try to cover up by saying, “Of course! I know they’re at school, but I just thought maybe they had an afterschool thing going on.”
She has heard this before, so then she asks, “Do you want to put it in your PDA?”
“No,” you reply. “I can remember the kids!”
She leaves, and you finish your breakfast, proud that you avoided the sugar/salt coffee conflict. As you get cleaned up, you notice your hair is long and remember that you have a haircut appointment today. You say to yourself that you can’t miss that appointment. The day goes on, and the PDA alarm that you set when you made the haircut appointment goes off, saying you have a haircut appointment at three o’clock.
It’s not until you’re halfway through your haircut, when your stylist asks how your kids are doing, that you remember that you were supposed to pick them up today. You look at your watch and see that it’s 3:27 p.m. You start to pull the hairdressing gown off as you get up and tell the hairdresser that you have to go. You rush out to your car and drive rapidly to the school to get the kids, but when you arrive, no one is there. You then call your wife, who says that she called her friend to pick them up when the school called her and said no one was there to pick up the kids. She goes on to say that she had called you first, but your phone had gone to message, so she called her friend.
In this example, we see deficits in attention (being distracted by the salt-sugar coffee confusion), immediate memory (not paying attention prevents normal memory tracks from being laid down), remote memory (forgetting about the hair appointment until seeing long hair in the mirror), and executive functioning (running out of the hair salon right away without thinking about the best way to find out what has happened to the kids). The fact that you are walking around with half a haircut and a hairdressing gown wrapped around your leg, while inconsequential in comparison to the welfare of your children, really compounds the pathos of the situation.
That is not normal functioning.
The great thing is that I have been diagnosing and treating attention deficit disorder for the last five years using a combination of:
- Getting a good history from my patient about what cognitive issues they have, their family life, their social life, their school or work environment and anything that is important to them.
- Screening them for attention deficit disorder, hyperactivity, anxiety, depression, bipolar disease and addiction.
- Having them take FDA approved computer based neurocognitive testing to see how their attention, memory judgment and processing speed are (along with a few other things)
- Treatment each patient as indicated by discussing the various therapies for treatment including, but not limited to, computer based neurocognitive training (found on home gaming systems and online), noradrenergic and/or dopaminergic (releasing and/or reuptake inhibiting) medications and behavioral therapies.
The beautiful thing about treating attention deficit disorder appropriately is that once a person can start thinking the way they did before they got MS induced attention deficit disorder other areas of their lives can get better. If they previously had anxiety about losing their job, the anxiety can get better because they can do their job again. If they were anxious about failing out of school because they couldn’t concentrate, their anxiousness can resolve as their grades go up. If they were depressed because they felt estranged from family and friends because their attention deficit disordered brain made them unreliable, the depression can improve as things get back to the way they once were.
Treating attention deficit disorder doesn’t always have the same effect on everyone, but if it does work, it can help a person to get their life back.
Many of my patients with multiple sclerosis ask me what the chances are of passing multiple sclerosis onto their children. I usually give them a two part answer:
1. The incidence of MS in the general population is about 1 in 10,000 (0.01%). The incidence between first-degree relatives (parent-child or non-twin sibling-sibling relations) where one of the relatives has MS, is around 3 in 100 (3%).
2. Since the risk is about 3 in 100 that a parent might pass on genes to their kids that MIGHT lead to MS, the chance that your kids get multiple sclerosis is still low. What I recommend to my patients is:
“Don’t have more than 15 kids.”
Next, even if they do get MS, there are going to be a whole bunch of ways to treat it. Let’s say you have a kid now. Chances are she probably wouldn’t start having symptoms of multiple sclerosis until she was in her twenties (let’s say 25). The first medication for multiple sclerosis came out in 1993 – 23 years ago. We currently have 9 disease modifying therapies for multiple sclerosis. At this rate we should have at least 18 drugs by the time your child gets multiple sclerosis and maybe even have a cure.
Moreover, a lot of computing power goes into designing many of the drugs that are used today. In 1993, the fastest computer processing speed was around 10 billion instructions per second. As of 2014, the fastest recorded speed was 10 quadrillion instructions per second. That second number is, like, a lot faster than the first number so it must mean a lot more drugs can be discovered over the next 25 years than were discovered in the last 23 years.
I’m not 100%, but I’m pretty sure.
Regardless, I believe the people who have the biggest to lose are the children of MSers who don’t get born because their folks were too worried that they might get multiple sclerosis. I have two children, Abby and Vincent. I asked my kids if they thought I shouldn’t have had them since they had a higher risk of getting multiple sclerosis. They responded just as I had anticipated. My son looked up at me from his video game and said “What?” while my daughter just stared at me and then walked away. I’m very proud of my children. My daughter will be starting college next year to become an engineer and my son is 15 years old, way taller than me and can throw a 73 mile an hour fast ball. If my wife and I did not have our children because we were afraid that they might get multiple sclerosis these are some things that might have happened:
– My wife and I would grow old and start to get sick of staring at each other. The acrimony of never having had kids would continue to increase and cause our relationship to become grotesquely hollow and warped, much like Donald Trump’s hair.
– The plumbing system for the Mars One Human Settlement Program, that would have established the first human settlement on Mars, fails because the “Abby Mac Human Groin Vacuum” device never gets invented and the human race is wiped out because the Earth’s temperature continues to rise and everyone drowns.
– The Yankees fail to win the 2031 World Series because their pitching staff never found the one reliable pitcher needed to shut down the fantastic new expansion team, the Idaho Potatoes. Because of this, everyone in New York falls into a deep depression, no one goes to work, the US economy collapses, China starts moving in, everyone except Jackie Chan, Lucy Liu and that guy from those “Harold and Kumar” movies gets thrown out of their houses, there is mass hysteria, cities around the world are burned to the ground, the Earth’s temperature rises even faster and everyone drowns.
All because I never had kids…
The point is – this is your life. Neither you nor anyone else knows what tomorrow has to offer. So if you want to have kids, have kids. Even if there is a greater chance that our kids might get multiple sclerosis, it doesn’t mean that they will. My children are two of the greatest parts of my life (the other two are my wife, Lauren, and that new candy bar that has the rice-crispies along with caramel and peanuts in it). Let your healthcare and support teams know that you want to have children. Then make a plan about how your multiple sclerosis will be handled while going through the amazing journey of pregnancy and childbirth.
And when the time comes, I’m sure your partner will demonstrate support by reassuring you that, no matter how long your labor goes on for, he or she will be in the next room, on the couch, making sure that the television still works.