Archive for the 'A Country Doctor Reads' Category

Broken Relationships and Sudden Social Isolation are Like Opiate Withdrawal (BOTSA via NYT)

An article in The New York Times sent me once again on a journal reading journey. Opioids Feel Like Love. That’s Why They’re Deadly in Tough Times is behind a paywall, but there are many other articles on the topic of the brain opioid theory of social attachment (BOTSA).

Falling in love involves a euphoria at least partly mediated by brain opioids. The opiate mu receptor also interacts with oxytocin, known to build emotional bonds, and dopamine, involved in reward mechanisms as well as serotonin, involved in feelings of well being. These substances build and strengthen our bonds to loved ones.

But, as with opioid use or abuse, the euphoria doesn’t last forever. It is eventually replaced with a comfortable new sense of normal. If we are then suddenly cut off from those we have bonded with, a chemical withdrawal sets in. And it is in fact partly an opiate withdrawal, albeit not usually as violent as withdrawing from heroin.

“Social pain” and “physical pain” are both mediated, at least in part, via the mu receptor. Opiates have been shown to reduce separation anxiety in puppies and opiate antagonists increase vocalization in separated puppies. Adult rodents chose to self administer opiates more if they were socially isolated.

In humans, addicts on methadone maintenance therapy indicated less anxiety about losing relationships than addicts who were sober without the help of methadone.

When we think of opiates in this context, it clarifies both the history of opiate smoking in ancient times and the rise in opiate addiction in modern times.

I can’t imagine there was a chronic pain epidemic 300 years ago, more significant than the general hardships of life in those times. And, similarly, we now know that individuals who fall victim to opiate addiction are more likely to have childhood trauma and psychiatric symptoms prior to their opiate addiction.

So, even though the term “perfect storm” is hackneyed, our current epidemic of opiate use and abuse certainly were the result of such a constellation of factors. Chronic Pain Syndrome, the presumed physical condition we thought we were treating, is not just one thing. It is a hodgepodge of suffering. And the more we learn about it, the less useful it is to try to sort out what is physical and what is psychological. The lines are not only blurred, they are probably not real at all. And the now discredited belief that pain was a vital sign and opiates would eliminate it was only a pipe dream – incidentally, a term that was coined in the era of opium dens, when people smoked the mother substance in those long, fancy pipes!

A Country Doctor Reads: Why Sweden isn’t Restricting Personal Freedom During the Covid-19 Pandemic – Svenska Dagbladet

I read in the news media that my native Sweden is not restricting personal freedoms the way other countries are. I just recently happened to subscribe to Svenska Dagbladet, one of the big Stockholm newspapers. Here is what they quote historian Lars Trägårdh saying about why:

“First, there is a deeper trust in public institutions in Sweden than in other countries. It is not blind injunctions that make us obedient citizens but faith in expert authorities who in turn trust their citizens. It is a matter of mutual trust.

Therefore, Swedish authorities believe that it is enough to make recommendations such as staying inside if you feel ill and avoid large crowds. “Use your brains“…. Classic Swedish freedom and responsibility in other words. May also be called common knowledge, common sense or sense of duty.

Secondly, the Swedish exception can be explained by the ban on ministerial rule. This is a deeply rooted rule that goes back to the 17th century when the foundation was laid for the Swedish state apparatus. This means that Sweden is governed by expert authorities and not the government. Politicians who want to show muscles in tough times should keep their paws away from apolitical institutions whose decisions are based on skill and expertise.

This is very deeply rooted in Sweden. Elsewhere in the world where they don’t have this strict rule, many politicians now take the opportunity to prove themselves as strong leaders and impose harsh prohibitions especially if it is an election year. “

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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