Does one drug cause the user to be more annoying?
April 14, 2010
As a bit of a followup to the poll we ran on whether or not cigarettes make you high, I offer context and my thoughts. As of this writing, btw, the votes are running 44% “Yes”, 47% “No”, the balance “other” with a fair bit of commentary to the effect that “high” is not exactly the right description for nicotine.
For the background, we might as well start with the comment from SurgPA:
This started with an email from PalMD asking why doctors react much more negatively to narcotics abusers than alcohol or nicotine abusers. I hypothesized that most people view acute use of the various drugs differently. Specifically I suspected that most doctors’ gut reactions when seeing someone light a cigarette are qualitatively (and vastly) different from seeing someone shoot heroin (or snort crushed oxycontin). In short that we don’t see the act of smoking as an acute intoxication by a neuroactive substance, even if we understand it intellectually.
PalMD asked Why do doctors dislike narcotics abusers?
But narcotics are not the most frequently used addictive substances. For example, about a fifth of Americans smoke. But we as health care providers react differently to different kinds of substance use. I certainly cannot speak for all doctors, but narcotic abuse seems to push our buttons in a way that nicotine and caffeine (and even alcohol) don’t.
So I asked around to try to understand why so many of us have negative reactions to people with narcotic use disorders. After talking to a few professionals in person and via email one factor stood out: narcotic abusers often use health care providers to obtain their fix. Most of us don’t like being lied to or being involuntarily enlisted as a drug dealer.
Commenter Jon on PalMD’s thread hit very close to my take on this issue.
The cocaine and/or opiate abusers that I’ve known are much different socially that smokers and (usually) drinkers. They are generally more dishonest, manipulative, disengaged emotionally, and generally antisocial. Though, in my opionion, a lot of that difference is caused by the difficulty and danger of finding and paying for that next dose.
Let me expand, based on a number of comments I made off-line to PalMD and SurgPA. If the question is, why are those addicted to nicotine more palatable than those addicted to opiates (“narcotic” properly refers to the opiate class drugs, btw) and to a lesser extent alcohol, I point to three issues. Legality, acceptance that the drug is addicting and the impact intoxication has on behavioral function.
To start with the question of addiction, I could imagine that the nicotine dependent are least likely to deny their addiction relative to narcotics and especially alcohol. To themselves, to their family and to their medical care providers. This may be a function of age / generation but given the big tort fights, PR coverage, cancer messaging and agonist therapy marketing which all tell us that cigarettes are addictive, full stop, it is hard to imagine there are many people that debate nicotine dependence. In fact it really surprises people to see a paper like the Dierker and Donny (2007) one indicating that some 38% of individuals who have smoked at least 10 cigarettes per day for at least 10 years may not meet diagnostic criteria for dependence. (Another paper from this group describing the perhaps surprisingly low contribution of number of cigarettes smoked daily and the duration of smoking to dependence is here. )
This contrast with alcohol, for which we have much much more of an acceptance that there are social drinking patterns that are not, and never will be, a problem. The penetration of alcohol is nearly complete (upwards of 95% have at least tried it in the US population) and the repeat drinkers (weekly? monthly? however you construe it) are very salient to most observers. While the notion that alcohol does cause dependence is probably less controversial with its consumer base than, e.g. the cannabis user base, there is a great deal of understanding that addiction and dependence on alcohol are not inevitable.
Narcotics feature a bit of both- with one extra bonus factor. Remember that we’re talking about the user population that is interfacing with medical care providers. And as I said to PalMD and SurgPA it was my speculation that the legal status was a factor. I asserted that the fact that narcotics dependent folks are highly interested in scamming their medical providers for their fix was an important difference. Admittedly, since some of them started off with clinical pain management and these are pills instead of street drugs, perhaps there is a bit of denial of the dependence here. Sort of like the alcoholic. But the legality issue modulates how they have to interact with docs. I suggested that this amounted to having to lie to their care provider about all sorts of things about their health and daily lives. I concluded that this can’t help but be part of the problem; see this comment for additional support.
I also suspect that a higher order version of this dishonesty issue is at play in terms of the degree to which people dependent on the respective drugs walk around their normal lives concealing versus revealing their addiction.
This brings me to what I see as one important difference between nicotine and alcohol or narcotics is that it is not illegal or illicit or perceived as in anyway bad to be acutely intoxicated on nicotine in daily working and home life. In some senses this is the most specific point being addressed in the poll asking whether cigarettes get you “high”. Social perceptions are an important factor. Our good blog friend Anonymoustache was all over this in the comments at White Coat Underground. My formulation is that it is socially acceptable to be intoxicated on nicotine during the work day (ditto caffeine). Nobody has a problem (beyond second hand exposure issues) with a parent who is acutely nicotine intoxicated. It is not considered to make the person nonfunctional in any critical way. Therefore, there is less reason for a person to hide a nicotine addiction over an opiate, or more importantly alcohol, addiction. It is my speculation that this may shape their general honesty and skeeviness. Perhaps over time that may set up some distinct traits in a person.
So what I was getting at in my response to the medical care provider viewpoint is simple. I think that it is premature to ask if there is anything inherent about opiates that turn you into a jerk, or to assume that jerks are drawn to opiates over, say cigarettes or alcohol. We should rather ask questions about the situation of being dependent on various drugs. The social acceptability of using a given drug would seem to be a very critical determinant of the way the dependent individual interacts with others.