Category Archives: Opioids

Worse than ever: Pain pills and heroin use

More people are dying from opioid overdoses than traffic accidents, yet no one seems to notice or want to address it. As commented on in the April 17th issue of The New York Times, “Serving All Your Heroin Needs”:


Meanwhile, the victims – mostly white, well-off and often young – are mourned in silence, because their parents are loath to talk publicly about how a cheerleader daughter hooked for dope, or their once-star athlete son overdosed in a fast-food restaurant bathroom.


Look at the numbers: 24,000 deaths from opioids. While the pain pill machine goes about its business of producing more and more addicts, no one says a thing.


For parents who do stand up and speak, the response is underwhelming. I attended an event at a large suburban high school billed as a community forum to examine the problems of recreational drug use, prompted by the drug death of a 17-year-old. Her father, Tom, spoke very movingly and passionately about his loss, but the audience was almost devoid of parents.


Why? Is it fear of hearing a contemporary bare his soul about a parent’s worse nightmare? Is it hoping that ignoring the problem will make it go away – soon they’ll be off to college anyway? Who knows? But the absence of any passion – any demand for action – was striking.

Stimulant use among 26-to-34-year-olds doubles in four years

The Sunday Times had a second story, this one on abuse of ADHD medications, titled “Workers Seeking Productivity in a Pill are Abusing A.D.H.D. Drugs.” Stimulants like Adderall, Vyvanse, and Concerta are migrating from school settings to the workplace. They’re now in play in demanding professions:


These lawyers said they and dozens of young colleagues at their firms had casually traded pills to work into the night and billed hundreds of extra hours a year in the race for partnerships.


Overuse leads to rapid heartbeat, acute anxiety, hallucinations, sleep deprivation, and addiction. Just the type of professional you want working on your case or in your firm or client base. Outside of the workplace, these pills are “Mommy Crack,” great for staying thin and multitasking on the home front.


Again, this phenomenon starts in high school, where students sell pills or give them to friends to help with academic focus and performance. They’re great for answering the four or five extra SAT questions needed to break 700 and pulling all-nighters for studying and exams. Whether it be weed, alcohol, uppers, or downer, students in every high school know who is selling or providing drugs and drinks, but are unwilling to name names out of fear of being ostracized or to protect their sources.

Silence and indifference

In any case – at the parent or student level – we have created a culture of silence and indifference not seen since the AIDS epidemic. We are beginning to make the connection between binge drinking and date rape among high school and college students, but a similar connection must be made between pharmaceutical companies’ and doctors’ profits and drug dependence and deaths. In both instances, the big businesses supplying the alcohol and pills pay less than 5% of their collateral damage and can never atone for their increasing death toll.


Not to minimize the AIDS epidemic, but what we’re dealing with here is on a very large scale. The Band Plays On, with alcohol and opioid deaths exceeding 100,000 per year. When will enough of us join together to stop this growing tragedy?

Becoming addicted to pain pills

Perhaps understanding how opioid dependency develops will be the first step in generating more public support for taking on the drug industry.


For those of you unfamiliar with how someone becomes dependent on pain pills, here is how it happens. People have an injury, surgery, or dental work and are given a prescription for 30 pain pills. After just a few days, it takes more pills to obtain the same level of effect in dampening pain. Most patients learn to tolerate their pain and supplement with over-the-counter medications. But then once they near the end of their supply, there is the problem of stopping. Stopping abruptly leads to uncomfortable physical symptoms, so most people taper off. But addicts are not like most people, and they don’t stop.


The dependency cycle


The dependency cycle begins when a person ups the dose, decides it’s too uncomfortable to quit, or in fact likes the physical and psychological effects from the pills. These narcotics can give a euphoric sensation of withdrawing from the world. Users will continue to seek prescriptions until their doctors decide to cut them off. From there, they turn to doctor-shopping and online ordering, or worse.


Switch to heroin


Many users – or addicts – switch to heroin because it’s cheaper and more readily available. It also can produce a really powerful and pleasurable body jolt the first few times. This motivates the addict to “chase the high” – trying to reproduce the feelings from that first time by increasing the amount, potency, or by mixing with other drugs. Very dangerous and a big reason for all the deaths. A similar process occurs for other narcotics.




Painkillers are meant for acute pain, not chronic pain, as are most other drugs, such as anxiety or sleeping medications. But remember, this starts with the doctor handing out the initial 30-pill prescriptions or samples provided by Big Pharma, enough to hook some patients, as the drug companies know all too well. And it’s no secret that doctors are liberal with the scripts – even doling out Norco (acetaminophen and hydrocodone) by the handful to newly-postpartum nursing mothers. It’s hard to keep saying no when it’s always offered.

Transforming public opinion and policy

Attacking the supply side seems like a good first step, but that means overcoming deeply entrenched social stigma, leaving the shadows, and finding the courage to tell our truths – namely that these problems don’t exist in a vacuum. With opioid-related overdose deaths occurring every four minutes, we can no longer pretend that these “dirty” deaths are only happening to strung-out junkies living on the streets in the inner city. They are happening to us, our families, and our friends. Fortunately, new generations are stepping forward to start conversations aimed at transforming public opinion and policy.

To Tom, the father who spoke out at the community forum, you are not alone, and we will not forget your daughter.

Pills, pot, and legalized impairment

Cautions for parents, family offices, and wealth advisors

At recent conferences in Colorado and California, several colleagues asked for my thoughts on legalizing marijuana and how it might impact families and the workplace. It’s all over the news and one everyone’s mind, but frankly, it’s not just pot that’s a concern – there’s a whole range of substances family offices and advisors should be aware of.


So it’s time to introduce a new concept into our lexicon: legalized impairment. This term refers to society-sanctioned drugs that significantly alter mood, behavior, and judgment. As they become more widespread and readily available, more and more people are using these drugs to excess. This group includes underage users, who, as we know, have easy access to all kinds of substances.


Due to their legal or quasi-legal status (often doctor-prescribed), these substances pose a significant risk to family office integrity. As a family office executive or wealth advisor, the last thing you want do is explain odd, unprofessional, or improper behavior by a colleague or employee to clients. While you may want to address the concern in family members, increased drug use is growing and impeding efficient professional-client interactions.


So, what drugs are we talking about?


Pain killers, benzodiazepines, ADHD meds, sleeping pills, e-cigs, weed, salts/herbs, and alcohol.


It’s quite the list and growing weekly. No doubt these drugs have already invaded your office and befriended your clients. As an advisor said to a friend of mine in recovery, “You mean when you wake up in the morning this is the best you will feel all day?” This question reflects the reality that in our culture, we routinely use drugs to feel better. And now we have more and more-potent options that bring with them greater risk of abuse and dependency.


Let’s look at these drugs in greater detail:

Pain killers: oxycodone, Percocet, hydrocodone

Over-prescribed in large quantities for relatively minor injuries or procedures, they are easy to get hooked on and hard to quit. When doctors do restrict refills, pills are available from dealers but are often more expensive or harder to obtain than heroin. Substituting more readily-available heroin for pills is a main reason why apparently well-off and functioning people die of opioid overdoses. (Dealers offer free samples, so why not give it a try?) Pain pills are also highly sought after by students to come down from Adderall and Ritalin and other stimulant-induced study or test-taking highs.

Benzos: Xanax, Klonopin, Valium, Librium, Ativan

Commonly prescribed for anxiety, these drugs are known as “alcohol in a pill.” Contrary to the opinions of some doctors, they do lead to increased tolerance and dependency. They’re also known for their boomerang effect: Over time, they produce the same symptoms they are designed to alleviate. Supposedly prescribed for the short-term, many are in it for the long haul, with mind-boggling withdrawal symptoms when users run out or try to ease off.

ADHD medications: Adderall, Ritalin, Vyvanse

Known as study drugs, parents seek them out for their children to give them an advantage on tests. Whether used for legitimate ADHD or just for a leg up on the competition, these drugs open the door to illegal stimulants such as cocaine, ecstasy, or meth. Coming down from the high can be a problem, and kids resort to fighting the high with depressants. Common “antidotes” include pain medication, weed, or alcohol.

Sleeping pills: Ambien, Lunesta

Touted as risk-free, when taken regularly these drugs cause restlessness, anxiety, memory loss, and occasionally bizarre nighttime behavior. When taken with alcohol in the blood stream, it can be difficult to wake up in the morning.

E-cigarettes: nicotine

E-cigs contain varying doses of nicotine – a highly addictive stimulant. They’re a go-to for people who’ve overdone it the night before and need to shake the cobwebs off in the morning. Other users believe nicotine helps them concentrate, so it can serve as an alternative to Adderall and other stimulants.


The younger generation believes it’s benign. The older generation is getting back into it (or never quit) – for medicinal purposes, of course. So what do we know about it? Marijuana can interfere with memory, perception of time, and motor function. Repeated use during adolescence can result in long-term changes to brain function. Available in increasingly higher percentages of THC (the active ingredient), drug-induced psychosis is becoming more prevalent.

Salts and herbs

Claimed to be unregulated and largely flying under the DEA’s radar, they are often as potent and destructive as the other drugs discussed here and can be highly hallucinogenic. Available online, from head shops, and from your friendly shaman, these substances run the gamut from bath salts to rue plant derivatives and ayahuasca.


Alcohol is easily the most prevalent of the legalized impairment substances. As the accepted social lubricant among the affluent, you’d be hard pressed to find a work, family, or social gathering that doesn’t serve cocktails before, during, and after the event at hand.


It’s no secret that excessive drinking is considered a major public health problem, but most of us in the affluent community would scoff at the medical definition:

  • For men, it’s five or more drinks in one sitting or 15+ in a week.
  • For women, four drinks in one sitting or eight in a week.

In our culture, these suggested limits are exceeded regularly and with little awareness that tolerance is increasing. We ultimately can become dependent, particularly as we age. After age 40 or so, alcohol takes longer to leave our system, meaning drinking the same amount will have greater effect.

What to do?

I encourage drug testing because it is the only way to truly determine actual substance use. It also has a preventive effect because people are less likely to use when they know they will be tested regularly.


For the family office:


Because of fiduciary responsibilities and client relationships, it’s important to regularly drug test all employees. There’s nothing more maddening than trying to figure out why an employee is acting strangely and mishandling client interactions. I also recommend establishing a policy for persons using prescription narcotic medications – and include marijuana as well. Of course, these procedures will need to be vetted and approved by a lawyer who is familiar with state and federal employment and disability laws.


I’d also recommend an educational program for staff on different types of narcotic prescription drugs, dosages, and their effects and side effects. This will help with self-awareness and also with client relations because many clients discuss medical conditions with their account representatives.


For clients:


Encourage your families to establish effective provisions in their policies and governing documents to address substance and behavioral health disorders (see my article, “Model Language for Addressing Substance Use Disorders [Addiction] in Trust Documents: Best Practices for Treating Substance and Other Behavioral Disorders). Educational programs are also helpful, as are discussions among the younger generation about what they would like to see happen if someone is abusing alcohol or drugs. Taking a strong stand on alcohol and drug use can set the tone for the family, especially if it is backed up by moderate, responsible drinking at family events.


For families with a history of addiction or mental health issues, a joint project such as a family genogram can help trace these disorders through the generations to the present (see: It really helps illustrate the concept of “genetic load,” meaning that when the gene linked to addiction is present, there is good chance that the next generations will be susceptible to the disease.


This may sound very controlling and Machiavellian, but drug testing young adults as a condition of receiving funding might also be appropriate, given the widespread substance use in this group. Family members don’t like to see a relative destitute, so there might be two levels of payment for compliance and non-compliance (e.g., minimum subsistence for positive test and the regular payment for passing the test).

Address legalized impairment head on it will steamroll you!

Addiction is already the primary threat to family stability and well-being. With more heavy-duty drugs legalized, legitimatized, and available, this risk is only going to increase. Your choice, as an advisor, leader, or family member is to attack this issue head-on, or it could very likely become the predominant driving force in your clients or your own family system.


Due to popular demand, a future blog will explore in detail the topic of marijuana. Before doing so, I wanted to place weed in the overall context of legalized impairment.

Pregnant women popping pills

From Tylenol to Vicodin, an uptick in opioid prescriptions during pregnancy

To do pregnancy the “right” way, to follow all the rules and recommendations, requires sacrifice on the part of the expectant mother. The list of no-nos is long: caffeine, alcohol, ibuprofen, sushi, deli meat, soft-serve ice cream, runny egg yolks, skiing, stomach-sleeping . . . just to name a few.

One of the hardest parts for me when I was wading through my first pregnancy (besides forgoing the soft-serve and stomach-sleeping), was being limited to acetaminophen for the various and sundry aches and pains I encountered as my hips widened and my ligaments stretched. Having found Tylenol to be quite ineffective in my younger years, my M.O. was to grin and bear it. Advil or bust, was my attitude. But not all pregnant women have the same tough-it-out mentality. And when they complain to their physicians, they’re getting something a lot stronger than Tylenol.

An alarming rate

Despite a dearth of research regarding the impact of opioids on fetal health and safety, doctors are prescribing opioid narcotics to pregnant women at an alarming rate, primarily to treat back pain and abdominal pain.*

In both studies, the opioids most prescribed during pregnancy were codeine and hydrocodone. Oxycodone was among the top four.

There’s speculation as to whether these script-happy doctors have done their due diligence, as fewer than 10 percent of medications approved by the FDA since 1980 have sufficient data to determine fetal risk. In fact, opioid use in the first trimester may double the risk of fetal neural tube defects. The question of addiction in just-born infants is also an issue to be addressed, as prolonged use while pregnant can lead to dependence – in mother and child.

America’s pain-averse mentality

A miracle cure in pill form has come to be expected for whatever might ail us – and that mentality doesn’t simply disappear during pregnancy. After all, taking painkillers is certainly an easier solution than suffering through it or seeking more time-consuming alternative help, such as physical therapy or acupuncture. But it still boggles the mind how women who try to be so careful in so many ways will eagerly accept an opioid prescription. “If the doctor’s giving it to me, it must be safe . . . right?”

Recklessly over-prescribed

Ultimately, this seems to be merely another manifestation of the trend of opioid painkillers being recklessly over-prescribed – and to inappropriate patients. It’s a main contributor to pharmaceutical and opioid abuse and addiction in the U.S., and now there’s yet another subgroup to whom these pills are becoming more – and more easily – available.

*For more information, see Catherine Saint Louis’s April 13, 2014, article, “Surge in Narcotic Prescriptions for Pregnant Women,” in The New York Times.

Why heroin?

Why do supposedly smart people become addicted to heroin? Why do they use it in the first place, when it has a reputation as a low-class, junkie drug? What’s the attraction? What’s the high?

With the recent death of Philip Seymour Hoffman, I asked myself those questions. As a person in recovery whose drug of choice was primarily alcohol, I experimented with cocaine, used Xanax occasionally to sleep, and smoked a joint now and then – but never, ever thought of heroin.

But it’s not just famous people who die of overdoses from the drug – it’s people I know in my circle of friends, my relatives and in our newspapers. As part of our efforts to make available an antidote to heroin overdoses to first responders (the Naloxone spray), family members came forward and told their stories of loved ones lost to the drug. Very sad. And these were middle-class young adults. It migrates into the best families, but why? Why use it when it has a reputation as a drug no one wants to mess with?

Understand the draw

First, to understand the draw of heroin, you have to understand what it does. According to Robert Aaron, the man who was arrested for providing dope to Hoffman, heroin has “good qualities”:

A lot of times you have a deadline and you to work for 24 hours. This lets you do it with no pain, no tiredness. If I have to write a book, get me high – I’ll have that book written in two weeks. You’re lucid. And emotions don’t affect you as much – your anger – it bottles up your feelings. It makes you more rational, or you think you are, anyway. I’m a lifelong insomniac. …. Everything has it good points and bad points. The bad point is the dependence.

So there you have it: the perfect study drug to pull an all-nighter on. Or to learn your lines and perform in front of the camera. Or to deliver a speech honoring a family member or friend, as a relative of mine did. It was a brilliant performance – everyone said so – but I could tell by his eyes he had used, which he confided to me while in treatment. And far too soon, he was gone.

I’ve also heard the first few times, it’s better than the perfect orgasm, better than any sex. But then, of course, the intensity lessens each time and the user begins to chase the high, hoping the next time will be like the first time. The irony is that heroin robs many users of the ability and desire to obtain an erection (see Amy Winehouse’s You Know I’m No Good, “Upstairs in bed with my ex boy / He’s in the place but I can’t get joy”).

The connection

As you probably already know, few drug users start out using heroin. In fact, many heroin users are first exposed and addicted to prescription pain medication. You may be wondering about the connection between pain medication use and heroin.

I’d always known that many people with injuries or post-surgical trauma become dependent on prescription pain medications such as oxycodone, hydrocodone and Percocet (oxycodone + acetaminophen). It’s a common phenomenon when taking these pills for only a few days, as I discovered after undergoing hip surgery. I was very aware of withdrawal symptoms when stopping after three weeks of use, and I was very conscientious about limiting the amount per day and the duration.

However, pills are different from heroin in that they numb you out, slow you down and allow you to withdraw from the world. Some people like these feelings because it helps them cope with other problems, they are pain-averse, or they can’t tolerate withdrawal symptoms. So when a pill person first touches heroin, there is a “WOW!” effect that is unlike any pills, which are all about dulling senses, not first focusing the mind and relaxing feelings and then withdrawing into the inner world of nothingness. That is the attraction of the drug, what makes it so popular, and what I never understood until Aaron came forward with his story.

Cheaper and more powerful

With increasing pressure on doctors to limit the number of prescriptions and number of pills prescribed, along with central registries for prescriptions, supply is becoming more limited. Also, copays can be high – higher, even, than the price of heroin. So users who want pills are increasingly buying over the Internet or from friends or dealers. Once they get into this illegal market, the movement to heroin is common.

Because users tend to associate with each other, word gets out that heroin is cheaper and more powerful than pills. More bang for less buck. People who use drugs encourage their friends to join them because it makes them feel better and it helps them justify their use. Dealers also will tout heroin as a better alternative, offering free samples (“One snort won’t hurt; you can control it.”).

Chasing the perfect high

All junkies believe they know how much to use without killing themselves because they successfully do it all the time. But, as we all know, this is a delusion because they are both chasing the perfect high – the one combination of drugs that will really make them feel like the first time they used – and ignoring the fact that due to increasing tolerance, they require higher-potency drugs to do so. Unfortunately, their belief is only valid until it doesn’t work. And then, they are dead.