Rescuing Dorothy: Helping Women Out of the Poppy Patch of Opiate Abuse

Here’s a familiar The Wizard of Oz scene: Dorothy and her companions have overcome the forest hazards along the yellow-brick road, and just as the Emerald City finally comes into view, they step into a field of seemingly innocent flowers. Next we see the dark castle and hear the Wicked Witch intone, “And now, my beauties, something with poison in it … Poppies will put them to sleep.”

Now cut to today and see those poppies still getting in the way of Dorothy’s real-life counterparts, many also trying to get back to whatever “home” may mean. There’s no witch to blame, just the naturally occurring morphine and codeine we get from poppy seed opium, plus other related chemicals such as heroin, oxycodone, hydrocodone and hyrdromorphone.

Males are not immune—the Cowardly Lion (and Toto, too) dozed off in that poppy field—but here we’ll focus on women since their opiate problems are a little different, more than a little bad, and definitely getting worse.

A Blessing and a Curse

These chemicals are part blessing because of their extraordinary pain-relieving ability, something humans have known for at least 5000 years. More recently, 19th-century physicians used the opium tincture laudanum (from Latin, meaning “to praise,” as its users almost certainly did) for battlefield wounds (e.g., during the Civil War) and also for civilians’ headaches, coughs, rheumatism and “female troubles” (Mary Todd Lincoln was reportedly addicted). That early computer-era game “The Oregon Trail” provided frontier folk an opportunity to stock up on laudanum at the general store for the inevitable painful injuries on that arduous journey.

The curse part of opiates derives from the significant buzz that accompanies the pain relief, which often creates the need for increasingly higher doses to recapture that initial high, and possible addiction. As depressants, opiates can cause a general bodily slowing that affects the overall ability to function safely, with an ultimate risk of overdose and death.

Users’ families suffer too, sometimes even through the blood as when babies born to mothers on opiates develop Neonatal Abstinence Syndrome (NAS) and actually go into withdrawal after delivery.

Gender-Related Differences

As the undesirable effects became more widely known in the early 20th century, the government made morphine-derived heroin illegal and other opium derivatives prescription-only. Despite that, misuse and abuse have continued, and the Centers for Disease Control and Prevention have highlighted some gender-related differences.

Since 1999, overdose-related deaths are up 265% in men but up over 400% in women. And for every female death, 30 other abusing/misusing women wind up in emergency rooms. Healthcare providers are prescribing these drugs more frequently overall, but especially to women for chronic pain, and at higher doses and for longer intervals than men. Women are also more easily addicted and more likely to “doctor shop” for willing prescribers.

Depression or Physical Pain

Women more frequently have underlying anxiety and depression, as reported in 2011 in the American Journal of Drug and Alcohol Abuse. When these issues pre-date opiate misuse/abuse, opiate use may represent “self-medicating”—using a pain prescription to subconsciously treat psychiatric symptoms.

As an occupational physician, I occasionally observe severe work-related “my-back-hurts” complaints in patients whose exams and MRIs are normal. But, is the patient really saying “my life hurts”? Maybe, and there’s less stigma associated with work-related back pain than admitting to underlying depression.

In doing workplace drug screening programs, doctors have to call people with opiate-positive results to see if they have valid prescriptions. Most do, and once documented, doctors can report these tests as negative, while still exploring possible medication effects on public safety workers such as school bus drivers.

If there’s no valid prescription, doctors may hear questionable stories—“I had a prescription but lost the bottle, and my doctor retired so I can’t get a note.” Or they see genuine shock in poppy-seed-eaters—not just a Seinfeld plot since eating poppy seeds can indeed produce measurable morphine and codeine levels. Or perhaps hear babies crying in the background and imagine achingly sad scenes—what happens to that baby if the mother loses her job? Did she act irresponsibly, or is she ill?

Some gender variation may be different ways women’s brains perceive stress and seek relief, or menstrual cycle-related hormone level fluctuations. The bottom line is that women who find themselves in pop-up poppy patches may be more likely to get slowed down, implying the need to target detection and treatment efforts based on possible causes.

Fortunately Dorothy overcame the poppy-nap with outside help—Good Witch Glinda sent awakening snowflakes; “in your face” ice water to re-focus Dorothy on the Emerald City and getting home. More challenges lay ahead, but after shaking off her opiate slumbers Dorothy hears “Optimistic Voices” (the song and choir name) telling her, “You’re out of the woods … out of the dark … out of the night.” Here’s hoping that she and anyone under the poppy poison spell can finally “step into the sun, step into the light.”

Minimizing opioid problems

Fortunately, there are numerous potential solutions:

• Health care providers can explore other treatment options, discuss all risks and benefits (especially during pregnancy or when chronic pain may mean longer-term treatment), and be vigilant about unmasking underlying anxiety and depression.
• When prescribing narcotics seems appropriate, providers can avoid mixing them with tranquilizers or other potentially sedating/addictive drugs, prescribe only what’s needed, have written contracts specifying when refills will be issued, and do drug screenings to be sure the medication is being used, not sold.
• Prescribers can check Pennsylvania’s electronic prescription drug monitoring database that tracks all controlled substance prescriptions in the state in case patients have obtained the same or similar drugs elsewhere, and refer early and often to substance abuse treatment programs. In some practices, treatment only be mandated before a positive-tester can return to work.
• Patients must take responsibility, use their meds safely, embrace alternative pain management, and agree to substance abuse treatment when indicated.
• Finally, government and commercial health insurers should adequately cover behavioral health issues, especially substance abuse and any underlying psychiatric issues.

Dr. Richard Donze is the Senior Vice President for Medical Affairs and Director of Occupational Medicine Services at Chester County Hospital. He is a published medical essayist and poet, and speaks regionally and national on topics in Preventive and Occupational Medicine.