John M. Talmadge, M.D.

A Blog Covering Many Topics

Painkillers: New Guidlines

Federal health officials have called for doctors to stop prescribing chronic pain patients so many of the drugs. The alert has been highlighted by Statistics suggest that 1 out of every 150 patients prescribed long-term opioid painkillers die of a condition related to their prescription within three years of its start.

Opioid painkillers such as OxyContin and Vicodin are now prescribed to as much as 4% of the U.S. population — 250 million prescriptions — with their use quadrupling since 1999. Some 1.9 million Americans are now addicted to, or dependent on, the painkillers. And from 1999 to 2014, about 165,000 people died of overdoses. Almost all of the opiate-related drugs on the market for pain are as addictive as heroin.

According to the National Institute on Drug Abuse (NIDA), the abuse of and addiction to opioids such as heroin, morphine, and prescription pain relievers is a serious global problem that affects the health, social, and economic welfare of all societies. It is estimated that between 26.4 million and 36 million people abuse opioids worldwide, with an estimated 2.1 million people in the United States suffering from substance use disorders related to prescription opioid pain relievers in 2012 and an estimated 467,000 addicted to heroin. The consequences of this abuse have been devastating and are on the rise. For example, the number of unintentional overdose deaths from prescription pain relievers has soared in the United States, more than quadrupling since 1999. There is also growing evidence to suggest a relationship between increased non-medical use of opioid analgesics and heroin abuse in the United States.

Graphic: Increase in Opioid Rx 1991-2013
Increase in Opioid Prescriptions 1991-2013

Opioid medications can produce a sense of well-being and pleasure because these drugs affect brain regions involved in reward. People who abuse opioids may seek to intensify their experience by taking the drug in ways other than those prescribed. For example, extended-release oxycodone is designed to release slowly and steadily into the bloodstream after being taken orally in a pill; this minimizes the euphoric effects. People who abuse pills may crush them to snort or inject which not only increases the euphoria but also increases the risk for serious medical complications, such as respiratory arrest, coma, and addiction. When people tamper with long-acting or extended-release medicines, which typically contain higher doses because they are intended for release over long periods, the results can be particularly dangerous, as all of the medicine can be released at one time. Tampering with extended release and using by nasal, smoked, or intravenous routes produces risk both from the higher dose and from the quicker onset.

The Centers for Disease Control released a dozen opioid prescription guidelines in the Journal of the American Medical Association (JAMA). They will not have the power of law but will guide insurance company recommendations to doctors and Veterans Administration prescriptions for retired military patients, with the aim of curbing dangerous prescribing practices. "Primary care clinicians find managing chronic pain challenging," according to JAMA, and "evidence of long-term efficacy of opioids for chronic pain is limited. Opioid use is associated with serious risks, including opioid use disorder and overdose."

The guidelines are based on three principles. First, opioids should be a last option for these patients, with aspirin-related drugs and exercise preferred. Second, when given, doses should start out low and only increase slowly. Third, patients should be monitored and a plan for getting them off the drugs should start with their prescription. The guidelines also call for getting naloxone, a drug used to counteract overdoses, into the hands of more doctors, nurses, police, and emergency personnel.

Explaining Alcoholics Anonymous

Last week I attended an Alcoholics Anonymous meeting, one devoted to people who are brand new to AA. For many years I've said that we as a fellowship need to improve our outreach to newcomers. In previous posts and elsewhere on my site (as in the FAQ Frequently Asked Questions section) I state that I am not an evangelist for AA. It doesn't work for everyone. Nonetheless, AA is a powerful movement helping many alcoholics and addicts. I credit AA with helping me find sobriety over 30 years ago, when not much else was available to help alcoholics. Here are some thoughts on the subject of newcomers to AA.

Treatment centers advertising alternatives to AA, or pitching their approach to people who people who (for whatever reason) are opposed to AA, generally don't do a very good job when it comes to staying sober after rehab. Although these programs may offer all sorts of amenities like yoga, hiking, spa treatments, and leisure activities, they do almost nothing regarding follow-up and aftercare. After a few weeks that are more like a vacation than serious treatment, individuals return home with few tools and no plan for what happens next. The reason that better treatment centers endorse AA, and encourage membership, is that AA is widely available and often very helpful.

The logo of AA: Unity, Service, Recovery

In every town or city, almost without exception, AA is easy to find. In smaller communities, there is usually an AA meeting within driving distance nearby. In Dallas, for example, there are hundreds of meetings every week, and at least 20-30 every day. Some meetings have 10-20 people, and some have as many as 100 or more. I once belonged to a meeting that had fewer than 12 members, and we met every week for years.

Old-timers — recovering alcoholics who have been AA members for many years — are familiar with a statement quoted at almost every AA meeting: "ALCOHOLICS ANONYMOUS is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism."

Newcomers to the program of Alcoholics Anonymous often arrive with misconceptions about the program. With the rise of the internet, it's easy to find critical statements about AA, but unless you've attended a few meetings you may not know much about the program itself.

One common misconception is that attending a meeting means "baring your soul" or "having to talk." This is not the case. If you happen to be called on, or asked if you want to share something, you can just say, "I'd just like to listen," or "Thanks, but I'll pass." I've said this myself in many meetings.

And here is a good tip if you're flying solo rather than attending your first meetings with a friend or someone who has invited you. Show up a little early. Old-timers usually arrive early, looking forward to chatting before the meeting and welcoming newcomers. Old-timers also tend to hang around after the meeting to visit with friends and answer questions. Come a little early, and stick around a few minutes after the meeting. You will get a lot more out of the experience if you don't head for the door the minute the meeting ends.

At the end of most AA meetings, we "circle up," and most meetings end with a prayer like the Lord's Prayer or the Serenity Prayer. People gather in a circle and hold hands. If this totally turns you off, that's okay. Even if it feels awkward or doesn't fit your sense of style, it's not the worst experience in the world. It's not as bad as sitting on a barstool dreaming about the life you wish you had instead of the life you actually have.

Here are a few comments about the basics of AA, how it works, and why. The questions, quotations, and bullet points are taken from a brochure, "A Newcomer Asks," published by AA General Services. Additional comments are my own.

Newcomer Asks Pamphlet Image

• The only requirement for membership is a desire to stop drinking. There are no dues or fees for A.A. membership; we are self-supporting through our own contributions.

At every AA meeting, a little basket is passed around the room, and members put in a couple of dollars to support that particular meeting in that particular location. Although very few people arrive intoxicated, many first time visitors have had a drink in the last 24 hours. The message is simple: if you want to get sober, we can help. Honesty, having an open mind, and willingness are the keys to success.

• A.A. is not allied with any sect, denomination, politics, organization or institution; does not wish to engage in any controversy; neither endorses nor opposes any causes.

For over 70 years, Alcoholics Anonymous has remained true to this original statement. Although there is often discussion about God — "the higher power" or "the power greater than ourselves" — there is never any discussion or debate about theology. The emphasis is on recognizing that in the great scheme of things, something out there is bigger than we are, and that spiritual experience is part of human nature. Agnostics and atheists are welcome in AA, and many recovering alcoholics are not "church people." The basic idea is that if someone claims that "God does not exist," that person probably has given a lot of thought to the question. An open mind is all that is required to understand why AA's believe in a power greater than the individual.

• Our primary purpose is to stay sober and help other alcoholics to achieve sobriety.

For the better part of the past century, AA members have remained true to this simple principle. This is why members do not get side-tracked on other causes, concerns, or social projects. It's all about helping others who struggle with alcohol.

Alcoholics Anonymous asks and answers some basic questions often heard from newcomers.

Am I an alcoholic?

"If you repeatedly drink more than you intend or want to, if you get into trouble, or if you have memory lapses when you drink, you may be an alcoholic. Only you can decide. No one in A.A. will tell you whether you are or not."

Notice that the answer says you may be an alcoholic. Although there are medical and psychological definitions of addiction and alcoholism, AA takes a very practical position. If you think you have a problem, maybe you do. If other people are concerned about your relationship with alcohol, maybe that's worth thinking about. If alcohol seems always to be there when you get in trouble, it's valuable to ask whether you have a drinking problem.

What can I do if I am worried about my drinking?

"Seek help. Alcoholics Anonymous can help."

Alcoholics Anonymous is not an addiction treatment program, and the meetings are not group therapy. To our misfortune, many individuals come to AA after having a somewhat negative experience in a treatment center ("rehab"). The rehab experience is a very mixed bag. Although some treatment centers are excellent, many are not. Many treatment centers are very expensive, with a spa-like atmosphere and lots of amenities like horseback riding, indoor swimming pools, and great food. Some of these centers do not mention AA at all, and very few residential rehabs provide a smooth transition back to the real world and everyday life. Some treatment centers even advertise that they are not 12-Step based, although their success rates are poor.

AA helps in many ways, however, both "in the rooms" (at meetings) and in everyday life. Although AA does not try to explain exactly "why" the fellowship is helpful, psychologists and psychiatrists generally agree that participation in AA has many benefits.

— AA offers hope to people who are suffering because of alcohol. Our greatest enemy when we are suffering is demoralization. When we are demoralized, we consider giving up. We believe that our condition is hopeless. AA demonstrates that we can recover, and AA offers a way back to sanity and health. Hope is very powerful.

— AA encourages the alcoholic to recognize that we all have problems, that the experience of suffering is universal, and that we are all simply human beings struggling with human problems. Universality, as it's called, is fundamental to any therapeutic group process. We all have problems, and together we can forge solutions.

— Learning about the disease is essential to recovery. AA does not get into neuroscience or psychology, but the program helps people understand that the alcoholic really is powerless over alcohol (as well as drugs when it comes to those of us who have abused multiple chemicals). AA also helps us understand that alcohol affects every aspect of our lives, especially our family, our work, and what we care about most. Being a drunk doesn't make anything better in life.

— Altruism, or generously giving to others, is the foundation of the program. The old saying is "service above self, and principles are more important than personalities." In a newcomer's meeting, the attitude is welcoming, friendly, supportive, non-judgmental, and altruistic.

— Alcoholics Anonymous is like a big family. Many people form relationships in AA that help correct the damage suffered during our early years, or the trauma suffered from bad life situations. A good sponsor is like a good aunt or uncle who helps guide the process of recovery. Deep and loving friendships are forged in AA.

— Learning how to live a normal life, socializing with others in the absence of alcohol or mind-altering chemicals, is an essential part of AA. It's rather amazing for the newcomer to see that recovering alcoholics have a lot of fun, enjoy life, and know how to have a party without getting hammered.

— AA folks tend to stick together. Cohesiveness, bonding with others, makes for good health and peace of mind.

— In AA, people learn to see what works by imitating others, not in a false or phony way, but rather through the coaching process. Someone may say, "Try this. It works for me." A newcomer may develop new patterns of behavior because the newcomer sees that there's a different way to act around other people. Although you will hear "fake it until you make it," there is nothing fake or phony about AA. The old saying simply means that if you imitate someone you admire, you can change your own presentation of yourself.

— In AA, it's okay to let your true feelings come out. Sometimes people laugh, or cry, or even express anger about what's gone on during the day or during a lifetime soaked with booze. Being able to sit with a sponsor and have a good laugh or cry is a therapeutic experience. It really can help.

If I go to an A.A. meeting, does that commit me to anything?

"No. A.A. does not keep membership files, or attendance records. You do not have to reveal anything about yourself. No one will bother you if you don’t want to come back."

This is absolutely true. Alcoholics Anonymous emphasizes a philosophy of attraction, not promotion. This is why you don't see advertisements or billboards or 800 numbers for AA. It's an organization based on helping others who want what AA offers.

What happens if I meet people I know?

"They will be there for the same reason you are there. They will not disclose your identity to outsiders. At A.A. you retain as much anonymity as you wish. That is one of the reasons we call ourselves Alcoholics Anonymous.
What happens at an A.A. meeting? An A.A. meeting may take one of several forms, but at any meeting you will find alcoholics talking about what drinking did to their lives and personalities, what actions they took to help themselves, and how they are living their lives today."

Most newcomers are surprised by how many good and decent people attend AA meetings. Sometimes they run into old drinking buddies who also have decided to sober up. After a month or two, most people will have new friends in AA, and this is a powerful source of support and companionship.

How can this help me with my drinking problem?

"We in A.A. know what it is like to be addicted to alcohol, and to be unable to keep promises made to others and ourselves that we will stop drinking. We are not professional therapists. Our only qualification for helping others to recover from alcoholism is that we have stopped drinking ourselves, but problem drinkers coming to us know that recovery is possible because they see people who have done it."

As I've already said, AA is not a "treatment program," and it is not "therapy." Most people who attend AA get professional help from a therapist, psychiatrist, or counselor on a private basis outside of AA. Membership in AA is about gaining support, understanding, and the plain old love that is the power of the fellowship. I have attended AA meetings since 1983, and the friends I have made there are beyond description. These are friends from all walks of life and all sorts of backgrounds.

Why do A.A.s keep on going to meetings after they are cured?

"We in A.A. believe there is no such thing as a cure for alcoholism. We can never return to normal drinking, and our ability to stay away from alcohol depends on maintaining our physical, mental, and spiritual health. This we can achieve by going to meetings regularly and putting into practice what we learn there. In addition, we find it helps us to stay sober if we help other alcoholics."

Being "cured" of any illness is a relative concept. For example, cancer patients describe themselves as "cancer survivors," and sometimes say that their disease is "in remission." What they mean is that the disease may come back, and they continue to take care of themselves in much the same way that recovering alcoholics take care of themselves."

On a personal note, I attend AA because I have many friends there, I want to help newcomers, and I get a lot out of the meetings. There are times when I am busy or I would rather sit out on the porch in a lawn chair, but I've never come out of an AA meeting regretting that I invested the time in my health a recovery. Not everyone feels this way about AA, of course. It takes awhile to get to know people and to get the rhythm and deeper benefits of the program. In that way, it's not much different from joining any other social organization like the Rotary Club, the Lions Club, or the Elks Lodge. At first you don't know many members, and gradually you are befriended and become part of the regular crowd.

When you find a meeting that feels right, plan to attend that meeting regularly. Having a "home group" is like having a regular group for your weekly bridge game or your weekly service group. You get to know the people. Just bouncing from group to group is certainly okay when starting out, but getting a comfortable home group that feels right is an important step in staying sober.

How do I join A.A.?

"You are an A.A. member if and when you say so. The only requirement for A.A. membership is a desire to stop drinking, and many of us were not very wholehearted about that when we first approached A.A."

How much does A.A. membership cost?

There are no dues or fees for A.A. membership. An A.A. group will usually have a collection during the meeting to cover expenses, such as rent, coffee, etc., and to this all members are free to contribute as much or as little as they wish.

Is A.A. a religious organization?

"No. Nor is it allied with any religious organization. There’s a lot of talk about God, though, isn’t there?"

"The majority of A.A. members believe that we have found the solution to our drinking problem not through individual willpower, but through a power greater than ourselves. However, everyone defines this power as he or she wishes. Many people call it God, others think it is the A.A. group, still others don’t believe in it at all. There is room in A.A. for people of all shades of belief and non-belief."

Can I bring my family to an A.A. meeting?

"Family members or close friends are welcome at “Open” A.A. meetings. Discuss this with your local contact."

What advice do you give new members?

In our experience, the people who recover in A.A. are those who:
(a) stay away from the first drink;
(b) attend A.A. meetings regularly;
(c) seek out the people in A.A. who have successfully stayed sober for some time;
(d) try to put into practice the A.A. program of recovery;
(e) obtain and study the Big Book, Alcoholics Anonymous.

How can I contact A.A.?

"Look for Alcoholics Anonymous in your local telephone directory. These telephones are answered by A.A. volunteers who will be happy to answer your questions, or put you in touch with those who can. If there is no A.A. telephone service close to you, write or phone the A.A. General Service Office."

There are several websites that are specific for North Texas. For example, the Preston Group has its own website. A directory for the hundreds of AA meetings in the area can be found here at