Thursday, June 07, 2007

Heroin and IBS

Kurt Cobain, the late singer/guitarist from Nirvana, had a lot of problems. Both mental and physical. He self medicated with heroin, leading to serious addiction. On an archive BBC interview earlier this year he described the dramatic relief he got from his gut pain by using heroin. He freely admitted that he had multiple other problems leading to his addiction, but the relief from abdominal pain was a significant factor. No one believed him, this was just another junkie excuse. After all, none of the doctors he had consulted for years had an explanation or any therapy for the pain so it was all in his head, wasn't it...

I mention this because I read another account of a person with abdominal pain, this time there was a diagnosis, the label being IBS. This condition varies from modestly inconvenient through to unspeakably painful, with pulsing waves of cramping visceral pain going on for hours. This guy was posting on a discussion board specialising in poppy tea. Poppy tea is a morphine like opioid mixture reported to be more addictive than heroin as judged by withdrawl severity. It is 100% absolutely illegal just about everywhere in the world and DO NOT USE THIS. I only mention it because this poor guy posted to report the dramatic relief he had obtained from his severe IBS by drinking a cup of this poppy tea. The poppy tea board is a very easy going and very supportive place on the net for opioid addicts to hang out, but they all jumped on this guy like a ton of bricks. No one would remotely accept the reality of the relief he had obtained and the universal condemnation was centered around his using IBS as an excuse to consume the opioid tea, rather than coming clean and admitting he was a straightforward addict. I was shocked at the severity of the responses. Kurt Cobain must have gone through the same thing.

Why on earth am I posting all of this?

Well, my disillusionment with the bulk of the medical profession and my journey in to nutrition began with a close friend who was suffering from severe gut problems without a specific label. Over a year or so the problem had been getting progressively worse. On medical advice she had been increasing her fibre intake. Food consisted of whole meal pasta, brown rice, lentils, chickpeas, whole meal bread and vegetables. Some meat and as little fat as possible completed it. During the final consult her doctor suggested increasing the fibre still further, without explaining quite how this might be achieved. My friend mentioned that she had found, quite by accident, that codeine produced dramatic symptomatic relief. After the doctor had been scraped off of the ceiling there followed a lecture on the constipating effects of codeine and the advice to use ibuprofen to control the pain. This was to a patient in whom a duodenal ulcer was high on the list of possibilities. Please don't do this at home either. Even if your doctor tells you to.

At this point I started reading the medical litterature for myself and we had my friend off of omeprazole and pain free within a month. She never went back to the medic, who is probably still recommending fibre and ibuprofen to her IBS patients and steadfastly refusing to think about why they don't get better.

What really struck me with all three stories was the absolute disbelief in all quarters that opioids could produce symptomatic relief in severe IBS. The impression is that people with severe gut problems are considered to use their "functional" problem as an excuse for recreational opioid abuse. Where is the "That's interesting" reaction from doctors? Nowhere.

The cure, by the way, is the elimination of almost all fibre, absolutely all grains and a marked reduction of carbohydrate consumption. She initially ate 20g/d of carbohydrate but currently anything under 70g/d seems fine for maintenance. Some people have to go a little further and eliminate starches and unfermented dairy too, but that wasn't needed in my friend's case. Grain ingestion, especially wheat, causes an immediate flare. No wonder the high fibre diet was a disaster.

So what is the link between IBS, opioids and especially grains?

Our bodies manufacture many short polypeptides for use as neurotransmitters. One specific group of them are the endorphins. These are naturally produced to control many biological processes. Gut motility and the limitation of both physical and emotional pain are two major functions under endorphin control. Morphine-like drugs, including its diacetylated derivative heroin, drop on to endorphin receptors and produce constipation and happiness. Withdrawl does the opposite. Badly.

Endorphins are produced by ourselves. Exorphins are similar peptides produced from our diet. Partially digested gluten from wheat is a major source. Eating a high gluten diet produces lots of exorphins. Constipation, often after an initial spasm reaction, is the result, just as it is from heroin. And pain too, because although exorphins do reach the brain, they never get there in the quantity needed to produce pain relief or happiness. In fact depression is common in IBS patients, but then chronic severe pain coupled with totally wrong advice tends to lead to depression!

When an IBS patient eventually has a bowel movement there is an immediate removal of the exorphins in contact with the gut wall. Acute opioid withdrawl produces diarrhoea. Remember the opening scenes of Trainspotting, with the methadone suppository and the worst public lavatory in Scotland?

So IBS is a functional problem of constipation with gut spasm alternating with diarrhoea. Eating grains is the commonest trigger. Wholegrains are the worst! Try telling that to your doctor.

BTW there are also exorphins in casein, haemoglobin and spinach but these do not seem to be as indestructible as the gluten derived peptides, although casmorphins do come a close second for many people.

Grains and heroin have a lot in common. Avoid both!



Stan Bleszynski said...

This is fascinating! Back in the 1960-ties in Poland, opium-based herbal remedies against gastric or intestinal problems were readily available. I remember, as kid, my uncle gave me a spoon of such once after some bad meal. The relief was instantanous and had nothing to do with the neurological effect. In fact as far as I know, opiates are thorughly digested int the propcess and do not get much further through the body.

There is probably more into it that we realise. Dr. Kwasniewski often refers to the sympathetic/parasympathetic stimulation. Now, as far as I know (correct me if not) opiates and marihuana are very strong parasympathetic stimulants whereas tobacco (nicotine) coffee and tea are strong sympathetic stimulants (in this order).

What has a diet got to do with? Why taking opiates brings similiar effects that a high fat diet?

Aprt from the endorphin receptor mechanism you described, I have a strong suspicion that a high fat diet also stimulates the parasympathetic system while a high carbohydrate consumption stimulates the sympathetic system.

If that's correct then logically fat consumption and carbohydrate restriction should alleviate opiate withdrawal (but not with nicotine).

Stan B.

Calvin Huang said...

Very interesting post. But I just want to correct a few things you stated.

The active ingredients in raw opium (the resin of poppy plants) are primarily morphine & codeine, though there are also small quantities of thebaine, papaverine and noscapine. So poppy tea isn't a morphine-like opioid--it _is_ morphine. However, morphine's oral bioavailability is very low (something like 10%), so when consumed orally in poppy tea it's most-likely the codeine that has the most effect.

Secondly, poppy tea is not more addictive than heroin. An opiate is an opiate. Some are more potent than others, some have a longer half-life in your body, but the long-term psychological addiction caused by each is about the same. You could argue that injecting heroin/morphine/oxycodone/hydromorphone is more addictive than drinking poppy tea, codeine syrup, or ingesting vicodin tablets, since injection provides immediate gratification, thus providing stronger positive reinforcement; but in my experience, pill-poppers can become just as addicted to opiates as IV users.

Lastly, heroin (diacetylmorphine) is a morphine derivative. It is slightly more potent than morphine (higher MEDD factor) and much more potent than codeine (when injected) while being slightly less potent than hydrocodone and oxycodone. Heroin also traverses the blood-brain barrier faster than morphine or codeine (which has to be processed in the liver first and converted into morphine).

The severity of _physical_ opiate withdrawal is dependent on mainly 2 things (excluding external variables such as individual body chemistry): speed of detoxification and level of physical dependence. Speed of natural detoxification is the same for most opiates like dilaudid, hydrocodone, codeine, morphine, heroin, hydromorphone, oyxocodone, etc. However, some opiates--such as methadone--have a much longer half-life in the body, thus the detoxification period is longer, but the withdrawal symptoms are milder. If an opiate antagonist is used to induce withdrawal, such as in rapid opiate detox, then the detox period is reduced and the severity is greatly increased (the reason rapid detox has caused a number of fatalities).

The level of physical dependence really just depends on the duration and dosage of opiate usage. You can go through just as painful withdrawals from codeine, a relatively weak opiate, as you can from extremely potent opiates such as fentanyl or carfentanyl (if you don't OD in the first place), just as you can get the same therapeutic effect or euphoria from weaker opiates as with stronger opiates by adjusting for their relative MEDD factors.

The only exception to the above are partial opiate-agonists such as buprenorphine.

Anonymous said...

Now this is fascinating! (OK so sue me, I'm a slow reader!)

My mother suffered for years with what was gradually ramped up from "neurosis" and "stress" to "IBS" and finally Crohn's disease.

During this time she was told to eat more fibre, less fibre, more fruit, less fruit etc. none of which had any effect, and was given sulphasalazine, and steroids for the flares.

Evetually they removed the diseased section of gut. This relieved her symptoms permanently (they then decided it had never been Crohn's since it didn't recur in the remaining part of her gut, so we're no further forward in knowing what was wrong).

However reducing the length of her gut (and reducing it futher over 20 years later when adhesions from the previous operation caused a blockage) left her with chronic loose bowels.

The treatment? Codeine ad lib.

She's never had any difficulty getting repeat presriptions. She uses it only when she's going out or otherwise doesn't want to be caught short.

Now her side of the family is riddled with "metabolic syndrome" and Type 2 mainly in skinny males. She's had high blood pressure for about 50 years but otherwise no specific symptoms (except her blood glucose goes up on prednisolone but returns reliably to normal when she stops it).

In all those years no-one ever told her to give up carbs, especially not grains, and extra especially not wheat. Perhaps they should have done. Wheat is my big bugbear also, spikes my BG more and faster than any other carbs except possibly pure sugar)

A couple more factors: ulcerative colitis symptoms can be treated with nicotine, a cigarette a day may be enough, though this can worsen other diseases.

I was treated with tricyclic antidepressants for gallstones (yes, really) and the anticholinergic side effect served to reduce slow muscle contraction, reducing my chronic steattorrhea and reducing the incidence of excruciating unbearable pain when I was actually passing the stones. Only removing the gall bladder actually cured the condition though.

When I was young was a standard treatment for most gut problems, but of course it's no substitute for actually finding the actual cause of the problem. Of course if the problem actually turns out to be wheat, who would dare tell you to stop eating it?

Meet the Pusher Man, in a white coat and stethoscope

Peter said...

Hi Calvin,

I don't really do humans but I thought the first pass metabolism on morphine was around 60-70% and a useful 30% gets through, hence the use of oral morphine for management of terminal cancer pain (my mum had a carrier bagful of the stuff around the house by the time she died). Of course methadone, disliked by the junkies, has the best elimination profile for sustained analgesia in man. Not the case in dogs, but probably the case in cats.

Of course blocking the cytochrome P450 system with grapefruit juice is a standard accompaniment to poppy tea, as is bypassing the liver by rectal admin. Many junkies are very very well educated people. Not all, of course.

Poppy tea withdrawal, I just go by what I've read on No one is using Omnopon, the closest medical equivalent, for sustained pain relief any more.

Bupe. Yes, buprenorphine is probably one of the strangest opioids around. It's very strange to me, and I'm an anaesthetist. Dunno much about addiction though.


Peter said...

Hi Trinkwasser,

Lutz, one of the Grand Daddies of LC eating, worked primarily as a gastroenterologist. You know his book Life Without Bread? He uses a very similar approach to Elaine Gottschall's Specific Carbohydrate Diet.

Gluten does seem to be a big part but starches in general are also players.

Smoking seems to worsen most autoimmune diseases, MS through rheumatoid, any you care to mention and PubMed. Probably why it is bad for CV health, it amplifies underlying damage. A bit strange it helps in UC..... But strange stuff happens.

A friend was having colic problems with her fully breast fed infant. She had lapsed on gluten avoidance. Re avoid gluten in the mother's diet, colic stops. Worked in less than 24h. Midwife's comment? "Oh yes, all midwives know this but none will say avoid healthy grains..." So, healthy eating for the mother and buy the Infacol for the baby.


a. said...

this is really interesting. i just discovered your blog, haven't read through too much of it yet, but i wanted to add a comment on this you may find interesting.

recently on the NY Times website's health blog (which includes a lot of bunk, crap, etc) there was a discussion of "probiotics". (probably, since now all the big ultra-globo-mega-corps are getting in on it.) the # of comments on the post seemed to be way more than i'd seen on any blog post there - clearly they hit a nerve.

most were posts from people who'd suffered from any one of many GI problems (IBS, crohn's, etc) for whom probiotics in one way or another (pills, kefir, etc) ended up being the solution. i mean, it was really amazing to read all their posts, and i just couldn't stop. at the time i was having similar stomach problems due to a way-too-strong course of antibiotics from a drug-happy doc of mine. i had never experienced stomach problems like that before, and it put me in a seriously depressive mood last summer, so i got why people were so passionate on the topic.

anyway, so my point is, as i was reading through the 100+ posts, i found one that struck me as the most bizarre yet likely true (and truth-telling) of them all. it was from a man who had been a drug addict all his life, cocaine more than heroin i think though i'm not sure, and had been in and out of jail, rehab, etc.

so this guy was almost on his deathbed when his MOTHER, who had recently discovered probiotics for her stomach problems, sent him a jar or something like that. and the guy now? completely drug-free, alive, healthy, happy, wonderful. as he tells it now, he was self-medicating for his literally DEPRESSINGLY PAINFUL stomach problems, likely due to our f'ed up modern simple-carb-loaded diets, and turned into a drug addict. probiotics literally saved his life.

now i realize this is somewhat off on a tangent - i mean, from what i've seen on your blog so far i don't see much discussion of probiotics per se. but i ended up here due to my recent weston price/nourishing traditions reading/researching kick, and one of the things sally fallon says is that traditionally humans did not eat grains unless they were lacto-fermented. so it seems to me this may be a linkage/connection creating a triangle between the three things - stomachs, carbo/grains, and good bacteria.

anyway, just wanted to share. always happy to discover blogs from people who think for themselves and are always questioning. was a science geek when i was much younger, but it's been so long that some of your more technical discussions are too much for me. argh. guess i'll just have to read up on it all! thanks.

Peter said...

Hi a,

Interesting. You might enjoy the SCD website. Elaine Gottschall was very in to home made probiotics for healing IBD/IBS etc, coupled with a starch free diet. She saw a link between autism and gut function, mostly working through the neurotoxin D-lactic acid from bacterial fermentation... I thing exorphins are involved too.

All sorts of brain issues seem to clear up when you sort out GI function.

Also Art Sayers has a lot to say about biofilms in the gut and the use of probiotics to disrupt them. Biofilms are where unpleasant bacteria hang out to hide from antibiotics while still doing lots of damage.

My own approach is to simply starve out all gut bacteria by minimal fibre, minimal starch and only digestible protein. I do eat some fermented cream but not as much as I used to.

For people not wanting to go the whole hog of sorting out their diet I can see a use for probiotics. Of course once Big Food gets in, who knows what the laws of unintended consequences will bring?

All the best


Art Sayers


Puddleg said...

a.'s comment is interesting. When I came off methadone I took probiotics to hopefully prevent diarrhoea. And I never got any. Ever since. In fact, I had more diarrhoea - like, every day - ON methadone. Fact.

Puddleg said...

Re: Stan's comment, the high-fat diet made withdrawal much easier.
The brain burning fats (yes, it does happen; however else do cell membranes turn over?) made for a quicker recovery. A little niacin (100-200mg PRN) and l-carnitine (500mg PRN) helped too.
And avoiding gluten and, temporarily, milk.
It was not only much easier than before, it was even kind of fun.